If your child snores very loudly and appears to stop breathing when they are asleep at night, or if they suffer very frequent sore throats, you have probably wondered “Do their tonsils and adenoids need to come out?” This is one of the most common questions that we hear as Ear, Nose and Throat Surgeons, and it is a very reasonable one: tonsillectomy and adenoidectomy are two of the most frequently performed operations in children.
Removal of tonsils and adenoids is a significant operation and one that should not be undertaken unnecessarily.
The good news is that there are well established, evidence based guidelines that help provide guidance, rather than it coming down to guesswork. This guide explains in simple terms what the guidelines actually recommend.
What are Tonsils and Adenoids and What Do They Do?
Tonsils and adenoids are similar tissue on either side of the throat and at the back of the nose. They are a part of a system that helps protect against infections.
Fortunately, since they are such a small part of that system, their removal appears to have no detrimental effect with regards to immunity. There is identical tissue elsewhere in the throat, back of tongue, lungs and intestines, all of which perform the same function.
The Two Main Reasons Children Have Tonsils and/or Adenoids Removed
In general, tonsillectomy (removal of the tonsils) or adenoidectomy (removal of the adenoids) often done together as “adenotonsillectomy” is offered for two different reasons:
- Obstructive sleep apnoea – which means stopping breathing during sleep. This is the most common reason for this surgery in children.
- Recurrent throat infections – recurring bouts of tonsillitis.
Each of these indications has its own set of guideline backed criteria, which is important. Just because a child has large tonsils, does not mean that they have to be removed. Similarly, not all sore throats are due to tonsillitis.
Snoring and Sleep Apnoea: When Are Enlarged Tonsils a Problem?
Occasional snoring during a cold is common and usually not a concern. Loud, regular snoring especially associated with pauses in breathing, gasping, restless sleep and sweating at night occurs when big tonsils and adenoids block the sleep airway.
The reason this happens is that whereas the tonsils are held apart from one another with muscle tone while awake, in sleep, the muscles of the throat relax and the tonsils can potentially block the airway. The American Academy of Pediatrics Clinical Guideline on childhood sleep apnoea recommends that all children should be screened for snoring at routine check-ups.
All children that snore and have signs such as high work of breathing while asleep ,restless sleep, gasping or daytime concerns that may reflect poor sleep quality should be assessed further, either by an Ear, Nose and Throat Surgeon or a Paediatric Sleep Physician. These guidelines also state that adenotonsillectomy is the first line of treatment for most children with confirmed sleep apnoea that is related to large tonsils and adenoids.
If the diagnosis can be made clinically, then no further investigation is necessary.
On the other hand, if there is uncertainty as to whether or not a child is stopping breathing while asleep at night, we generally may recommend polysomnography (sleep study) to determine whether or not treatment is necessary.
Polysomnography is also recommended for all children that have suspected sleep apnoea who are under two years of age,or are obese or have congenital conditions such as Down syndrome or craniofacial abnormalities. These children have a high chance of complications of sleep apnoea and/or its treatment, and may need extra monitoring after surgery.
Why This Matters For Your Child:
Untreated sleep apnoea is not just about sleeping poorly with the daytime consequences of fatigue. Untreated it may affect your child’s growth, behaviour, concentration and thus school performance. If moderate or severe it may even affect your child’s brain development and lead to problems to do with the heart and lungs. This is why the guidelines support treating significant sleep apnoea proactively, rather than “waiting for them to grow out of it.”
Recurrent Tonsillitis: “How Many Infections is Too Many?”
There are clear guidelines as to when a child should undergo tonsillectomy for recurring tonsillitis. Often referred to as the Paradise criteria, tonsillectomy should be offered if a child has:
- Seven or more documented episodes of tonsillitis in the last year.
- Five or more infections per year for two years.
- Three or more infections per year for the last three years.
Each infection needs to be properly documented and confirmed by your General Practitioner, rather than simply a parent’s recollection of “lots of sore throats.” Again, tonsillectomy is a significant operation, and should only be undertaken if necessary. Children who suffer tonsillitis less frequently than described above, will commonly outgrow tonsillitis without having to resort to surgery.
So, Does My Child Need Their Tonsils or Adenoids Removed?
As a general (not individual) guide, based on the current evidence it may be reasonable to consider this surgery if your child has:
- Loud frequent snoring with pauses in breathing, gasping or very disrupted sleep and has big tonsils.
- A sleep study confirming obstructive sleep apnoea linked to enlarged tonsils.
- Frequent, well documented throat infections meeting the frequency thresholds described above.
- Alteration in the growth of the face, in particular the upper jaw that your dentist documents as being a consequence of nasal obstruction.
Watchful waiting is usually recommended if:
- Snoring is mild and not associated with pauses in breathing, satisfactory quality sleep and no daytime symptoms to suggest that a child is tired.
- Throat infections are recurring but less than the guideline thresholds.
- Sleep study showing that there is no requirement for surgery.
FAQs About Tonsillectomy and Adenoidectomy in Children
How many throat infections does my child need before surgery is recommended?
Guidelines generally support surgery once a child has had seven or more infections in a year, five per year for two years in a row or three per year for three consecutive years, provided each episode was properly documented by a doctor and shown to be due to tonsillitis. Fewer infections than this usually means that watchful waiting is advised.
Is snoring in children always a sign that they need surgery?
Absolutely no. Mild, occasional snoring especially with a cold is common and not necessarily concerning. Loud snoring throughout the night with pauses in breathing, gasping or daytime symptoms warrants assessment by an Ear, Nose and Throat Surgeon and if necessary a sleep study to confirm whether obstructive sleep apnoea is present before surgery is considered.
Will my child need to stay in hospital overnight after surgery?
Most children undergoing surgery for sleep apnoea are monitored in hospital overnight. Selected older children and adults may elect to go home the same day as the surgery.
When should I see an ENT Specialist?
It is worth booking to see a Paediatric ENT Surgeon if your child has:
- Loud and frequent snoring, especially with pauses in breathing or gasping.
- Restless sleep, unusual sleeping positions or daytime tiredness, problems with emotional regulation and irritability.
- Frequent sore throats or tonsillitis over the last year.
- Any concerns about growth, behaviour or school performance thought by your doctor to be linked to poor quality sleep.
Evidence Based Paediatric ENT Care in Sydney
At Sydney Adult and Children’s ENT Surgery Centre our recommendations for tonsillectomy and adenoidectomy are guided by the same evidence based criteria outlined above.
We will talk you through exactly where your child fits amongst the guidelines, what the options are and what to expect at every stage. If you are concerned about your child’s snoring, sleep or sore throats, please contact our Clinic to arrange a consultation.
This article is general information only and is not a substitute for advice from your own doctor. Every child is different so please discuss your child’s specific situation with your family doctor or treating specialist.
