By Dr. Matthew Bowen
As an ear, nose, and throat doctor, one of the most common problems I see in children are enlarged tonsils. Usually, parents and pediatricians question whether or not a child’s tonsils should be removed.
A little anatomy: The tonsils are located in the back of the throat that are made up of lymphoid tissue. Lymphoid tissue is part of the lymphatic system, which filters bacteria and viruses and builds up your immune system to fight those bacteria and viruses. The adenoids are essentially a third tonsil present behind the palate, in the back of the nose.
A little history: In the 1950s and 1960s, tonsillectomy was the most commonly performed surgery. Over the last 50 years, advancements in antibiotics allow many infections to be treated medically. Today, tonsil infections are less severe, therefore, indications for tonsillectomy have shifted away from throat infections to airway obstruction. The most recent clinical guidelines published by the American Academy of Otolaryngology – Head and Neck Surgery confirm that airway obstruction is now the most common reason for tonsillectomy.
Removing large tonsils that cause airway obstruction always made sense, but over the last 10 years, researchers learned more about the specifics of how airway obstruction and tonsil/adenoid enlargement affect a child’s health. When tonsils obstruct the airway during sleep, this creates a condition called “sleep disordered breathing” (SDB). (For example: A common type of SDB in adults is “obstructive sleep apnea.”) SDB in children can cause disrupted or interrupted sleep due to low oxygen levels or forced awakenings. If severe enough, this type of sleep disturbance, can cause symptoms such as poor concentration, behavioral problems, poor physical development, or bed wetting.
SDB is linked to specific behavioral problems, including attention deficit hyperactive disorder (ADHD). This is due to the lack of restful sleep affecting the brain and specifically concentration. In 2006, researchers at University of Michigan demonstrated improvements in ADHD symptoms after tonsillectomy. Long-term research supports similar results in children with large tonsils or adenoids, SDB and behavioral problems.
Other problems can be reversed by removing the tonsils. For example, a child who has growth delay due to airway obstruction and poor sleep may experience a period of relatively rapid weight gain, after removing the tonsils.
Of course, every patient is different, with many factors require a doctor’s evaluation, usually beginning with your pediatrician or ear, nose, and throat doctor. Other reasons for airway obstruction should be considered, and sometimes sleep disordered breathing can be caused by decreased respiratory drive rather than obstruction of the airway. Removing the tonsils and/or adenoids sometimes improves SDB without complete cure.
Should my child get a sleep study?
Sometimes, a sleep study is necessary to diagnose SDB when the diagnosis is not clear. A sleep study, formally known as a polysomnogram (PSG), is usually performed in a sleep lab with multiple pieces of equipment to monitor brain waves, eye movements, heart beats, respirations, snoring, oxygen levels and leg movements. The precise time of sleep is recorded, and the duration of sleep in the various stages of sleep is measured. Practically speaking, it is often difficult to get good results in children. A sleep study involves over 20-30 sticky electrodes with wires attached to the scalp, face, chest and legs, as well as a microphone, and a strap around the chest or abdomen.
How can my child be expected to sleep with all of those things hooked up?
Sleep lab technicians do a good job of coaching people through a sleep study, but often times the results are less reliable in children compared to adults for practical reasons. If parents witness their child gasp for breath at night or snore excessively, a sleep study may not be necessary. Sometimes, an overnight oxygen monitoring can be done at home, but this offers a limited amount of information about sleep quality.
Won’t removing my child’s tonsils affect his/her immune system?
The answer to this question is no, there is no decrease in immune function after tonsillectomy/adenoidectomy. Although the tonsils process bacteria and viruses, there are plenty of other lymph nodes to do the same job. There are about 100 lymph nodes in each side of the neck.