Clinical Reference Systems: Pediatric Advisor 10.0
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Surgical removal of the tonsils and adenoids (known as a T&A) is one of the most common operations performed on children in the U.S. Only 2 or 3 percent of children have adequate medical indications for this procedure. Parents need to be armed with enough facts to prevent any unnecessary surgery.

The tonsils are not just some worthless pieces of tissue that block our view of the throat. They have a purpose. They produce antibodies that fight nose and throat infections. They confine the infection to the throat, rather than allowing it to spread to the neck or bloodstream. Other beneficial functions of the tonsils and adenoids are being studied.

RISKS OF T&A SURGERY

T&A procedures are not without risk. Under ideal conditions, the death rate is 1 child per 250,000 operations. Approximately 4 percent of children bleed on the fifth to eighth postoperative day. A few of these children may need a transfusion or additional surgery. All children experience throat discomfort for several days. Some children whose speech was previously normal develop hypernasal speech because the soft palate no longer closes completely.

ERRONEOUS REASONS FOR A T&A

Some T&As are performed for unwarranted reasons. By all means, don't pressure a physician to remove your child's tonsils. A few physicians have difficulty saying no. You can always find someone to perform surgery on your child; in fact, this is the main risk of "doctor shopping."

1. "Large" tonsils

   Large tonsils do not mean "bad" tonsils or infected tonsils. The tonsils are normally large during childhood (called "physiological hypertrophy"). They can't be "too large" unless they touch each other. The peak size is reached between 8 and 12 years of age. Thereafter, they spontaneously shrink in size each year, as do all of the body's lymph tissues.

2. Recurrent colds and viral sore throats

   Several studies have shown that T&As do not decrease the frequency of viral upper respiratory infections (URIs). These URIs are unavoidable. Eventually your child develops immunity to these viruses and experiences fewer colds per year.

3. Recurrent strep throats

   Recent studies have shown that a child does not have fewer streptococcal infections of the throat after the tonsils are removed unless the child experiences seven or more strep infections per year (a rare occurrence). For children with 7 or more severe throat infections per year, some physicians would recommend daily penicillin for 6 months instead of a T&A, since penicillin can almost always eradicate the strep bacteria from the tonsils. The strep carrier state (which causes no symptoms and is harmless and not contagious) is not an indication for a T&A.

4. Recurrent ear infections

   This reason for a T&A was formerly controversial, but more recent studies have shown that removal of the adenoids will not open the eustachian tube and decrease the frequency of ear infections or fluid in the middle ear. The exceptions are children who also have persistent nasal obstruction and mouth-breathing due to large adenoids. Recurrent ear infections usually respond to a 3-month course of antibiotics. Persistent middle-ear fluid may require the insertion of ventilation tubes in the eardrums.

5. School absence

   If your child misses school for vague reasons (including sore throats), removing the tonsils will not improve attendance.

6. Miscellaneous conditions

   A T&A will not help a poor appetite, hay fever, asthma, febrile convulsions, or bad breath. There are few medical conditions that have not at one time or another been blamed on the tonsils.

MEDICAL INDICATIONS FOR A T&A

Yes, sometimes the tonsils should come out. But the benefits must outweigh the risks. All but the first three of the following valid reasons are rare. Once you decide a T&A is needed, the ear, nose, and throat surgeon will decide if the tonsils, adenoids, or both need removal.

1. Persistent mouth-breathing

   Mouth-breathing during colds or hay fever is common. Continued mouth-breathing is less common and deserves an evaluation to see if it is due to large adenoids. The open-mouth appearance results in teasing, and the mouth-breathing itself leads to changes in the facial bone structure (including an overbite that could require orthodontia).

2. Abnormal speech

   The speech can be muffled by large tonsils or made hyponasal (no nasal resonance) by large adenoids. Although other causes are possible, an evaluation is in order.

3. Severe snoring

   Snoring can have many causes. If the adenoids are the cause, they should be removed. In severe cases, the loud snoring is associated with retractions (pulling in of the spaces between the ribs) and is interrupted by 30- to 60-second bouts of stopped breathing (sleep apnea).

4. Heart failure

   Rarely, large tonsils and adenoids interfere so much with breathing that blood oxygen is reduced and the right side of the heart goes into failure. Children with this condition are short of breath, have limited exercise tolerance, and have a rapid pulse.

5. Persistent swallowing difficulties

   During a throat infection, the tonsils may temporarily swell enough to cause swallowing problems. Some children refuse solid foods. If the problem is persistent and the tonsils are seen to be touching, an evaluation is in order. This problem more often occurs in children with a small mouth.

6. Recurrent abscess (deep infection) of the tonsil

   Your child's physician will make this decision.

7. Recurrent abscess of a lymph node draining the tonsil

   Your child's physician will make this decision.

8. Suspected tumor of the tonsil

   These rare tumors cause one tonsil to be much larger than the other. The tonsil is also quite firm to the touch, and usually enlarged lymph nodes are found on the same side of the neck.

CALL YOUR CHILD'S PHYSICIAN DURING OFFICE HOURS IF:

• You think your child has a valid need for a T&A.
• You have other concerns or questions.

(REMEMBER: Do not give permission for a T&A unless your child has one of the preceding indications.)