SHOULD THEY STAY OR GO?
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.
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.