TALK­ING TON­SILS

SHOULD THEY STAY OR GO?

Your Baby & Toddler - - Front Page - BY LORI CO­HEN

My daugh­ter Stella snored from birth. She was like a lit­tle granny, snuf­fling her way through the night. As she got older, she got louder – we could tell she was sleep­ing (and was alive) from the com­fort of the couch. It was only af­ter her teacher rec­om­mended that we get her hear­ing tested that we be­came aware that not only did she have glue ear (with only 50 per­cent hear­ing), but also needed her ton­sils (the lit­tle bumps on both sides in the back of the throat) and ade­noids (hid­den up in the throat be­tween the nose and the mouth) re­moved. So we headed to theatre and af­ter both were re­moved, and grom­mets in­serted, we were pre­sented with a new and im­proved lit­tle girl. She slept through the night. Soundly.

Our at­ti­tude was quite laid back, but re­search shows that swollen ton­sils and ade­noids are a ma­jor cause of sleep dis­tur­bances among chil­dren, in­clud­ing sleep ap­noea (ab­nor­mal pauses in breath­ing dur­ing sleep). It’s also been found that an ade­no­ton­sil­lec­tomy (the sur­gi­cal pro­ce­dure to re­move them) can im­prove day­time func­tion­ing, en­ergy lev­els, hy­per­sen­si­tiv­ity to smells, bal­ance prob­lems and be­hav­iour – in­clud­ing in chil­dren suf­fer­ing from ADHD. But that doesn’t mean a busy tod­dler nec­es­sar­ily war­rants surgery.

WHY DO THEY GO VROT?

They may be a pain in the neck, but ton­sils and ade­noids do serve a pur­pose. “They are lym­phoid tis­sue (like the glands in your neck, armpits or groin), and form part of a ring of tis­sue in the throat and nose called the Waldyer ring,” says ENT sur­geon Dr Ben Ver­maak. Any­thing that you breathe in or swallow has to pass the ring so that the body can learn what’s com­ing into the body, and build im­mu­nity. How­ever, “even if ton­sils and ade­noids are re­moved, there is still enough lym­phoid tis­sue in the Waldyer ring to aid the im­mune sys­tem for it not be com­pro­mised by tak­ing them out,” says Dr Ver­maak.

Some­times the for­eign in­vaders are just too much for them to han­dle and they be­come in­fected. Most cases of ton­sil­li­tis are caused by a virus, in which case flu­ids and rest will be enough to help your child heal. “Sec­ondary bac­te­rial in­fec­tions of­ten oc­cur sub­se­quently, re­quir­ing an­tibi­otics,” ex­plains Dr Ver­maak. The strep-throat bac­te­ria can also cause it. Doc­tors pre­fer to do a swab to iden­tify the cause of the in­fec­tion, but this can take two days for re­sults, so many give a broad-based an­tibi­otic such as peni­cillin, to which most bac­te­ria are sus­cep­ti­ble.

But in­fec­tion is not al­ways be­hind swollen tis­sue. “Any ir­ri­ta­tion, be it al­lergy, re­flux or in­fec­tion, can cause en­large­ment. If the tis­sue is ob­struc­tive to air­flow it should be re­moved. Re­mov­ing ade­noids and ton­sils will not treat the al­lergy but will im­prove air­flow and the pa­tient will be less symp­to­matic,” says Dr Ver­maak.

MAK­ING THE CALL

Fifty years ago doc­tors didn’t

think that ton­sils served much of a pur­pose, so chil­dren with fre­quently sore throats would have them re­moved with­out a spe­cific cause. How­ever, their role in build­ing your baby’s im­mune sys­tem is now con­sid­ered im­por­tant. And be­cause surgery is also as­so­ci­ated with risks, th­ese days your doc­tor may only con­sider it if your child has had four to seven in­fec­tions in a year, five in­fec­tions per year for the past two years, or three per year for the past three years. In­di­vid­ual doc­tors will have their own cri­te­ria.

Other fac­tors they will con­sider in mak­ing this de­ci­sion are breath­ing prob­lems dur­ing sleep, growth de­lay, pro­longed bed­wet­ting and be­havioural prob­lems.

SIZE MAT­TERS

In young chil­dren, lym­phoid tis­sues are very sen­si­tive and can be­come en­larged even af­ter a sim­ple cold. Ade­noids and ton­sils can be­come so big that they cause ob­struc­tion sim­ply be­cause they are crammed into a rel­a­tively small space. Ade­noids sit next to the open­ing of the ear, and if they be­come in­fected reg­u­larly they can cause ear in­fec­tions. If your child has re­cur­rent ear in­fec­tions, or de­vel­ops a con­di­tion known as glue ear, your doc­tor may con­sider putting in grom­mets (small tubes in the ear drum to re­lease fluid), and re­mov­ing the ade­noids at the same time if they are en­larged and ob­structed (re­cov­ery af­ter this op is two to three days). “Chil­dren with glue ear and in need of grom­mets of­ten have ade­noidal en­large­ment. This ade­noidal tis­sue of­ten har­bours or­gan­isms that cause in­fec­tions. Stud­ies have shown that if ade­noids are re­moved when do­ing grom­mets, the in­ci­dence of hav­ing a sec­ond set of grom­mets later on is dramatical­ly less,” ex­plains Dr Ver­maak.

If there are also in­di­ca­tions to do a ton­sil­lec­tomy, it can be done at the same time but with a re­cov­ery time of a week to ten days, he ex­plains. En­larged ton­sils and ade­noids can also cause chil­dren to breathe through their mouths (that poor nose is blocked!). If this oc­curs over many months it leads to mouth dry­ness and this can in­crease the risk of get­ting cav­i­ties.

WHAT’S THE RISK?

You might be plead­ing with your doc­tor to get those suck­ers taken out, but al­ways con­sider that all surgery comes with risk. Com­pli­ca­tions that could oc­cur in­clude bleed­ing dur­ing the re­cov­ery pe­riod and ini­tial changes in voice. “The op­er­a­tions are done us­ing steel sur­gi­cal in­stru­ments, by laser or by cold ab­la­tion. There isn’t much dif­fer­ence ex­cept that with cold ab­la­tion re­cov­ery is less painful in the first three days,” says ENT sur­geon Dr Gary Kroukamp.

It’s all about weigh­ing up the rel­a­tively small risk against the pos­si­ble benefits. Your doc­tor will try to avoid surgery be­fore your child is a year old be­cause of the in­creased risk of com­pli­ca­tions, but once they are age two, or weigh more than 12kg, it is an op­tion. “How­ever if the in­di­ca­tion for surgery is met, age should not be a de­ter­rent,” says Dr Ver­maak.

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