Adenoids and tonsils are lymphoid tissues that function as part of the immune system during childhood. Their enlargement or recurrent inflammation can affect breathing through the nose, sleep patterns, hearing, and in some cases facial-jaw development. Children who sleep with their mouths open, snore, fail to respond when called, or frequently have sore throat infections should have these tissues evaluated.
This page is prepared to help families understand the process and is a general informational text. The cause of symptoms varies from child to child; the same symptom can result from different problems. Therefore, the information presented here does not take the place of diagnosis or treatment advice. What approach is appropriate is determined by evaluating the child's history and examination findings together.
What are adenoids and tonsils?
The adenoid is a lymphoid tissue located at the back of the nasal cavity, on the upper-posterior wall of the nasopharynx. It cannot be seen when looking in the mouth; therefore its presence and size are understood only through endoscopic examination or appropriate imaging. The tonsils (palatine tonsils) are located at the back of the mouth, on either side of the base of the tongue, and can be directly visualized during examination.
Both tissues are part of the lymphoid structure called Waldeyer's ring and function at the site where microorganisms from respiratory or digestive pathways are encountered. After birth they enlarge, typically reach relatively large sizes between ages three and seven, and tend to decrease in later childhood and during puberty.
The fact that these tissues are enlarged does not by itself mean disease. Evaluation is based not solely on size but on the functional effect the tissue has in the child. Problems arise when enlarged or recurrently inflamed tissue begins to affect nasal breathing, sleep, hearing, or swallowing.
What symptoms should raise concern?
A prominent indicator of adenoid enlargement is inadequate nasal breathing. The child keeps their mouth open during the day and especially during sleep. Tonsil-related problems usually manifest as recurring throat infections, difficulty swallowing, or breathing difficulty during sleep. Symptoms often occur together.
Findings frequently noticed by families include:
- Mouth breathing during sleep, dry mouth, and sore throat in the mornings
- Snoring, restless sleep, frequent position changes, night sweating
- Observed pauses in breathing during sleep
- Nasal speech, nasal obstruction, persistent nasal drainage
- Frequent recurring throat infections, febrile episodes, neck lymph node enlargement
- Slow eating, decreased appetite, slow weight gain
- Daytime fatigue, difficulty concentrating, restlessness
- Late response when called, request for louder television volume
Effects on ears, hearing, and development
The adenoid is located near where the Eustachian tube, which connects the middle ear to the nasopharynx, opens. When the adenoid enlarges or there is persistent inflammation in the area, the Eustachian tube's ventilation function can be impaired. As a result, fluid can accumulate in the middle ear without inflammation, a condition called serous otitis (otitis media with effusion).
Serous otitis typically progresses without pain or fever, and for this reason may go unnoticed for a long time. The resulting hearing loss is usually conductive in type and resolves when the fluid is absorbed. However, persistent hearing loss during the age when speech develops can contribute to delayed speech development or difficulty concentrating in school.
Prolonged mouth breathing has been reported to have effects on upper jaw development and tooth occlusion. The degree of this relationship varies from child to child and is not solely determinative; genetics, allergies, and habits like thumb sucking also play roles. Nevertheless, when nasal breathing is continuously obstructed, evaluation of the child from an otolaryngologic perspective and when necessary, collaborative approach with a dentist or orthodontist is beneficial.
How is diagnosis made?
Evaluation begins with a detailed history. When the symptoms started, what is observed during sleep, infection frequency, and treatments used are important. Then examination of the nose, mouth, throat, and ears is performed. Tonsil size and appearance can be evaluated on examination, while adenoid status requires additional investigation.
Available methods include:
- Endoscopic examination: direct visualization of the nasopharynx with a thin endoscope; provides information about tissue size and degree of airway obstruction
- Hearing test (audiometry): measurement of hearing level using age-appropriate methods
- Tympanogram: evaluation of eardrum movement and middle ear pressure to determine fluid accumulation
- Throat culture or rapid antigen test: helps identify the causative agent in recurrent tonsil inflammation
- Sleep-related questioning and when necessary, sleep testing (polysomnography)
Monitoring and medical treatment
Not all enlarged adenoids or tonsils require surgery. If symptoms are mild and the child's sleep, hearing, and development are not affected, monitoring may be preferred initially. Because these tissues tend to decrease in size with age, symptoms improve over time in some children.
If allergic rhinitis accompanies the condition, measures to avoid allergens, intranasal corticosteroid sprays, or antihistamines may be considered through physician evaluation. Nasal cleaning with saline solution can help reduce nasal drainage and crusting. When bacterial tonsil inflammation is present, appropriate antibiotic treatment is planned; whether antibiotics are needed and their duration are determined by physician decision.
When fluid is detected in the middle ear, if there is no acute infection or significant hearing loss, an observation period is usually recommended. During this time, hearing and tympanogram are repeated at specific intervals. Cases where fluid spontaneously resolves are not rare; if it does not resolve, the treatment plan is reconsidered.
Surgical treatment and surgery decision
Surgical options include adenoid removal (adenoidectomy), tonsil removal or reduction (tonsillectomy or intracapsular tonsillotomy), and placement of ventilation tubes in the middle ear. These procedures can be planned separately or together. Adenoidectomy and tonsillectomy are performed through the mouth; ventilation tube is inserted through the ear canal and placed through a small opening made in the eardrum. All three are performed under general anesthesia in children and no external incisions are made on the face or neck.
The surgery decision is not based on a single finding but on the severity and duration of symptoms and their effect on the child's daily life. The expected benefit and risks of the procedure are weighed together, the family is informed, and a shared decision is made. Generally, conditions considered for evaluation include:
- Persistence of findings suggesting breathing pauses during sleep and significant sleep quality deterioration
- Nasal obstruction not improving despite medical treatment and monitoring
- Fluid accumulation in the middle ear lasting longer than three months accompanied by hearing loss
- Frequently recurring and documented tonsil infections; the widely accepted measure is seven episodes in the past year, five episodes per year in the past two years, or three episodes per year in the past three years
- Abscess formation around the tonsil
- Enlargement to a degree that makes swallowing or eating difficult
- Asymmetric enlargement on one side that warrants further investigation
- Evidence that continued mouth breathing is affecting jaw and tooth development
Postoperative course and precautions
Recovery varies depending on the procedure performed. Recovery following adenoid removal is usually shorter; changes in nasal breathing can be noticed early. Following tonsil surgery, however, sore throat may persist for approximately one to ten days and referred ear pain may be felt occasionally. This is an expected consequence of nerve distribution.
Formation of a whitish-gray membrane appearance in the healing area is normal; this is not a sign of infection. Early fever and mild oral odor may occur. Adequate fluid intake, nutrition with soft and warm foods, and use of pain relievers as determined by the physician support recovery. Avoidance of hard, hot, spicy, and acidic foods for a period is recommended.
Like all surgical procedures, these operations carry risks: bleeding, anesthesia-related complications, temporary changes in voice quality, and in very young children, regrowth of adenoid tissue following the procedure. Careful attention regarding bleeding must be maintained for two weeks following tonsil surgery. Fresh blood from the mouth, inability to swallow fluids, high fever, or breathing difficulty warrants prompt contact with a healthcare facility.
Results vary depending on the child's age, additional conditions, and disease severity; the same course is not expected for everyone. Which treatment is appropriate can only be determined after examination and necessary testing. For appointments and information, you may contact us.