Tonsils, Adenoids, Sleep Apnea and Recurrent Sore Throats
What are tonsils?The tonsils are tissue in the back of the throat which act as filters. There are two tonsils which sit on either side of the uvula, which is the structure which hangs down in the back of the throat.
When the tonsils are small (as in young babies and in most adults) they are barely visible. Between the age of two and five, the tonsils peak in size and may be large enough to touch each other. It is normal for a young child to have large tonsils, and if they appear normal and are not causing any problem the size of the tonsils alone is generally not a concern.
The tonsils are lymph tissue, one of the parts of the body that is used to fight infections. Tonsils only represent a small portion of the body's defense systems; lymphoid tissue is present all along the lining of the nose, mouth, throat and in the neck. The tonsils, due to their location in the mouth, are some of the most easily viewed lymph tissue.
|Location of Adenoids|
How do tonsils and adenoids affect sleep?
The path that air takes from the nose through the throat down into the lungs is called the airway. The tonsils and adenoids form a ring of tissue in the back of the throat. If the tonsils and adenoids are large, they narrow the airway and reduce the flow of air into and out of the mouth and nose.
The telltale signs of large tonsil and adenoids are mouth breathing, drooling in young children, snoring and, in some children, recurrent upper respiratory tract infections. When we sleep all of our muscles relax and there is impaired breathing. The relaxed muscles cause the airway to collapse down and, with large tonsils and adenoids, blockage of the breathing occurs. This is why symptoms may be mild during the day but significantly worsen during deep sleep.
What is the difference between snoring, sleep disordered breathing and obstructive sleep apnea?
Sleep disordered breathing (SDB) is a general term that refers to disruptions in sleep caused by partial to complete blockage of the breathing. Snoring is one form of SDB. Snoring occurs due to the turbulent flow of air through the respiratory system. When there is complete blockage of the breathing obstructive sleep apnea (OSA) occurs. The most common cause of OSA in children is enlarged tonsils and adenoids. The most common cause of OSA in adults is obesity and blockage of the nasal cavity from a deviated septum or blockage of the mouth from excess tissue such as a long palate or enlarged tonsils.
It is critical to distinguish between OSA and simple snoring. Studies have shown that untreated sleep apnea can lead to issues with concentration, learning and can have long term effects on IQ development in children. In both adults and children the inability to enter into REM (deep) sleep leads to poor performance during the day. The health effects of OSA in both children and adults have been studied and in its severe form OSA can lead to damage to the heart and lung and, in milder forms, can contribute to bedwetting and increases in blood pressure in children and adults. Most children with sleep disordered breathing have enlarged tonsils and adenoids; removing this tissue results in a cure of OSA in more than 90% of patients. In adults, addressing weight issues, maximizing airflow through the nose and mouth and, in some cases, considering a device to assist with breathing at night are options. In some cases, however, there are other causes of SDB which will result in persistent OSA after surgery or medical treatment. These include severe obesity, a small jaw, a big tongue, a variety of congenital skull abnormalities, or neurological problems causing poor muscle tone.
What is the difference between a sore throat, "strep throat" and tonsillitis?A sore throat can be caused by a number of problems, but is usually the result of a virus infecting the upper respiratory tract (the mouth, nose and throat). Less commonly, it can be caused by a bacterial infection. "Strep throat" is an infection by one particular type of bacteria- Streptococcus pyogenes. Although other bacteria can cause throat infections, most doctors will try to specifically diagnose the "strep" bacteria so that antibiotic treatment can be given. Doctors often try to resolve these infections more quickly, because in rare cases, these infections can result in damage to the heart, joints or kidneys.
If the tonsils are infected with a bacteria, they will usually get large, turn somewhat red, and may have some yellowish-white debris on the surface. This would be called bacterial tonsillitis, which is one kind of sore throat. Appearances can be misleading, since there are some viruses which can cause the tonsils to be red and inflamed but theses virus resolve without antibiotics. In many cases a strep test is performed to differentiate bacterial from viral tonsillitis. We have the ability to perform quick strep tests in the office. The results of these tests are available within eight minutes are fairly accurate in diagnosing strep tonsillitis. A culture is also sent to a commercial laboratory if the quick strep test is negative.
What can be done about recurrent sore throats?
Since most sore throats are caused by viruses which are easily spread (especially in crowded day care or school settings), it would make sense to be careful about exposing a child to others who are sick. Bacterial throat infections can be treated with antibiotics, but there is no benefit to treating a virus with these drugs. If a child is having recurrent bacterial or incapacitating viral infections then a doctor may recommend a tonsillectomy and adenoidectomy. This is the removal of the tonsils and adenoids (the adenoids generally get infected along with the tonsils). Recurrent infection is a less common reason for surgery today; tonsillectomies are more frequently done for sleep disordered breathing.
What are the risks of tonsillectomy and adenoidectomy?The surgery is done under general anesthesia, and this is usually the most frightening part of the procedure for parents and in children. Modern pediatric anesthesia is extremely safe. It is given in a well monitored setting by a trained professional, in pediatric patients usually an anesthesiologist specializing in the care of children. There will be time before the surgery for patients and parents to speak with the anesthesiologist and ask specific questions. Lesser degrees of anesthesia (such as sedation) may actually be more dangerous than general anesthesia in this procedure and are inappropriate for surgery in the throat. While anxiety during the administration of anesthesia is common it is infrequently remembered by patients as anesthesia has an amnestic effect for the events surrounding surgery.
The most common risk of tonsillectomy is bleeding after surgery. It usually takes approximately two weeks for the throat to heal completely, and bleeding can be seen at any time before then. However, when bleeding does happen, it is most common between five to ten days after the operation when the scab over the healing area of the throat, where the tonsils were removed, separates. Bleeding that is enough to be noticed happens in about 2-4% of patients, and will be seen as blood in the mouth or vomiting of bright red blood. Significant bleeding after adenoidectomy alone is extremely rare.
Bleeding after tonsillectomy that requires intervention is rare. Any significant bleeding after tonsillectomy or adenoidectomy should be evaluated in a controlled setting such as an emergency room. If significant bleeding does occur in the post-operative period please contact your doctor and proceed to the emergency room as directed by your physician or to the nearest ER in a significant emergency. This type of bleeding occurs in less than 1% of patients but is more common in older patients and adults.
You may see a change in the quality of your child’s voice after surgery. Usually this results in a high pitched quality to the voice which is at its worst at three weeks and usually resolves by 12-14 weeks after surgery. This occurs because the muscles in the back of the throat become weakened from being stretched by large tonsils and take time to strengthen up after surgery. In very rare causes speech therapy may be required to improve the vocal quality after surgery.
Occasionally, a child will have pain after surgery that is so severe that he or she will not be able to drink enough liquid and will become dehydrated. If this happens, the child may need to be readmitted to the hospital overnight for stronger pain medication and intravenous fluids. Other risks such as excessive bleeding during surgery, scarring of the throat and infection are extremely rare.
What are the benefits of tonsillectomy and adenoidectomy?In the case of an otherwise normal child with enlarged tonsils, the cure rate of sleep disordered breathing is greater than 90%. While this usually is obvious immediately after surgery, some children will not show the full benefit of an improved airway until 10-14 days after surgery when the majority of the swelling has resolved
In the case of a child with recurrent tonsillitis, removing the tonsils and adenoids will result in fewer episodes of sore throat. However, the operation can not prevent colds or other virus, and occasional illnesses with throat pain may still occur.
There are a few unusual reasons for tonsillectomy and adenoidectomy apart from sleeping problems and recurrent infections. Children who have an abscess (a collection of pus) around the tonsil may require surgery to drain the infection. A tonsillectomy is usually not done at that time, since bleeding is more likely if the tonsils are removed during an infection. These children may be referred for a T&A in 6 -8 weeks after the inflammation has resolved. Even more infrequently, a child with one tonsil that is growing much larger than the other will be referred for surgery. The tonsil is removed to make sure that it does not contain a tumor or other growth.
Don't you need your tonsils and adenoids?Everything in our body is put there for a reason and in their healthy state the tonsils and adenoids are filters. However like any filter when they become unhealthy or “dirty”, like an air conditioning filter might, they need to be removed. In their healthy state the tonsils and adenoids trap bacteria, viruses and other contaminants which enter the body on their surface and then transport them to the center of the tonsil or adenoids and kill them. When the tonsils and adenoids become too large they act like sponges not filters and can be reservoirs of infection rather than filters. Since adenoids disappear naturally by 10-15 years of age and tonsils shrink down significantly during adolescence they have only a small part in our immune function as adults. The other areas of lymph tissue in the head and neck pick up the filter function that the tonsils and adenoids previously performed.
How is tonsillectomy and adenoidectomy done?The tonsils and adenoids are removed through the mouth. There are no external incisions on the skin. My technique utilizes a device that removes the tissue and seals the tissue at the same time. This is called an electrocautery and is the most common method for removal of tonsils in the United States. It has a minimal risk of bleeding post-operatively and the vast majority of patients less than 14 years of age may return to school within one week. Older children and adults, due to the higher incidence of scarring of the tonsils, may require a much longer recovery.
The adenoids are also removed through the mouth using a mirror and a special device that removes the majority of the adenoid tissue. A small amount of adenoid tissue is left to help decrease the chance of speech problems post-operatively. This small amount of adenoid tissue does not interfere with breathing or predispose to infections.
A newer procedure is the partial tonsillectomy. In this procedure a shaver is used to remove 80-90% of the tonsils. A small amount of tonsil tissue is left behind to help with healing. The advantage of this procedure is that it decreases post-operative pain. Studies have shown that children return to a normal diet 1-2 days earlier and require less pain medication. The disadvantages to this procedure are that there is an approximately 10% risk of regrowth of the tonsils and an approximately 5-10% risk of future recurrent infections in the pieces of tonsil which are left behind. I will discuss with you or your family which procedure is right for you or your child.
Does my child need to stay overnight in the hospital after a tonsillectomy?The vast majority of children and almost all adults can be discharged home after surgery. If there are underlying medical problems or severe OSA and obesity than an overnight admission will be recommended. In very young children, i.e. two years of age or less, please plan to stay overnight and your child will be reassessed as the day progresses for the need for admission.
What can my child eat after tonsillectomy and adenoidectomy?A soft diet is recommended for the first 7-10 days after surgery. Foods such as pasta, rice, scrambled eggs, soggy french toast or pancakes are perfect. Drinks such as fruit punch, herbal ice teas, Kool Aid, and white grape juice are also well tolerated. Stay away from rough foods such as cookies, apples, potato chips, apples or popcorn for two weeks as they may promote bleeding. Please avoid citrus containing products such as real orange juice, grapefruit juice, cranberry juice and tomato sauce for the first 10-14 days . Foods and drinks with a high salt level such as Gatorade and French fries should be avoided. Our grandmothers were right, milk does thicken the mucous. Please limit the amount of milk consumed and avoid lots of ice cream for the first 10 days after surgery. Ice pops and sorbet are better tolerated.
What should I expect after tonsillectomy and adenoidectomy?Each person heals differently. Overall, there is pain associated with a tonsillectomy and adenoidectomy. The vast majority of patients require narcotic pain medication in the post-operative period. Narcotics should be used to control pain but have side effects such as upset stomach, constipation and, in rare cases, suppression of breathing (particularly of concern in patients with severe obstructive sleep apnea). Most other non-prescription pain medicines (such as aspirin, or Ibuprofen containing drugs like Motrin™ and Advil™) can interfere with the body's clotting ability. This can make bleeding more likely, and therefore they can not be used for two weeks before or after T&A. Vitamins can also affect blood clotting and should be avoided for two weeks before and for two weeks after surgery.
Patients may swallow some blood during surgery, and it is not unusual to see a small amount of old, dark red blood after vomiting on the first day. However, any active bleeding (with bright red blood) is abnormal and the patient should be immediately taken to the emergency room for evaluation. Even if the bleeding has stopped by the time the child is in the hospital, there may be a reason to admit the patient for overnight observation. For this reason it is very important not to travel more than one hour from home for the first 10 days after surgery. Activities such as air travel, camping and hiking are not allowed during this time. Physical activity should be restricted, and a child can return to class usually within one week after surgery. However, no gym or after school activity should be undertaken for the first two weeks after surgery. Adults and older children may require a longer recovery time and this should be discussed with your surgeon.
If you or your child are not drinking enough after surgery, dehydration may occur. As long as they are taking in enough fluids, eating is less of a concern in the first week after surgery. Calories can be supplemented by giving drinks which are high in sugar. A dehydrated adult or child may feel excessively tired or dizzy, have a dry mouth, and urinate less often. If this is the case, they should be seen by their pediatrician or surgeon, who may recommend evaluation in the emergency room for intravenous fluid therapy and pain management.