Frequently Asked Questions
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<span style="font-size: 85%;"><br> <span style="font-size: 134%;">Nighttime Breathing Problems and Throat Infections</span><br> <br> <ul> <li><a HREF="#what">What are tonsils?</a> <li><a HREF="#why">What are adenoids?</a> <li><a HREF="#sleep">How do tonsils and adenoids affect sleep?</a> <li><a HREF="#snoring">What is the difference between snoring, sleep disordered breathing and obstructive sleep apnea?</a> <li><a HREF="#difference">What is the difference between a sore throat and tonsillitis?</a> <li><a HREF="#sore">What can be done about recurrent sore throats?</a> <li><a HREF="#carrier">What does it mean if my child is feeling better, but the strep test is still positive?</a> <li><a HREF="#risks">What are the risks of tonsillectomy and adenoidectomy?</a> <li><a HREF="#benefits">What are the benefits of tonsillectomy and adenoidectomy?</a> <li><a HREF="#need">Don't you need your tonsils and adenoids?</a> <li><a HREF="#how">How is tonsillectomy and adenoidectomy done?</a> <li><a HREF="#stay">Does my child need to stay overnight in the hospital after a tonsillectomy?</a> <li><a HREF="#eat">What can my child eat after tonsillectomy and adenoidectomy?</a> <li><a HREF="#expect">What should I expect after tonsillectomy and adenoidectomy?</a> </ul> <br> <hr> <br> <br> <span class=TitleStyle> <a name="what"> What are tonsils?</a></span> <br><br> The tonsils are two lumps of tissue, each about the size and shape of a large olive, in the back of the mouth on either side of the tongue. <br> <div align="center"><img src="images/tons_nl.jpg" width="438" height="216" hspace="10" vspace="10" border="0"></div><br> When they are small (as in young babies and many 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 are not assymetric or causing any problem (such as <a HREF="#snoring">sleep apnea</a>), the size of the tonsils alone should not be a concern. <div align="center"><img src="images/tons_big.jpg" width="415" height="216" hspace="10" vspace="10" border="0"></div> <br><br> The tonsils are <i>lymphoid</i> tissue, that is, the type of tissue that the body uses to fight infections. They are a small portion of the body's defense systems; lymphoid tissue is present all along the lining of the nose, mouth and throat (as well as elsewhere throughout the body). The tonsils are just two lumps of this tissue that happen to stick out enough to be seen in the back of the mouth. <br> <hr> <br> <br><span class=TitleStyle><a NAME="why">What are adenoids?</a></span><br><br> The "adenoid" is the name given to a third lump of lymphoid tissue that sits between the tonsils, higher up in the back of the nose. This tissue cannot be seen without special instruments or x-rays, since it is hidden behind the roof of the mouth. It is located in an area called the <i>nasopharynx</i>, and if it is large enough, it can block air from flowing through the nose.<br> The best way to understand the adenoid is just to think of it as a third tonsil.<br> <img src="images/adenoid.jpg" width="500" height="282" hspace="10" vspace="10" border="0"> <br> <hr> <br> <br><span class=TitleStyle><a NAME="sleep">How do tonsils and adenoids affect sleep?</a></span><br> <br> The path that air takes from the nose through the throat down into the lungs is called the <i>airway</i>. 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 lungs. <br> <br> Even if the tonsils and adenoids are very large, they generally do not cause significant breathing difficulties while a child is awake. They may cause lesser symptoms such as a continuous stuffy nose, "nasal" speech, drooling or a habit of keeping the mouth open. <br> <br> During sleep, however, the muscles of the throat relax. Air flowing through the narrowed space results in a drop in air pressure. The combination of relaxed muscles and low pressure causes collapse of the throat and the child will be unable to breathe (apnea). After a few seconds of struggling, the child is partially aroused from sleep (although he or she will not completely wake up), the muscle tone returns, and the throat opens- often with a gasp. A child may go through many of these cycles in an hour, resulting in a disturbance of the normal sleep patterns. This condition is known as Obstructive Sleep Apnea (OSA). <br> <hr> <br> <br><span class=TitleStyle><a NAME="snoring">What is the difference between snoring, sleep disordered breathing and obstructive sleep apnea?</a></span><br> <br> Sleep disordered breathing (SDB) is a general term, referring to any kind of disturbance of breathing that happens during sleep. Obstructive sleep apnea (OSA) is a severe form of SDB, in which breathing completely stops until the patient wakes up enough to open the airway and start breathing again. Usually, the patient does not wake up completely, but rather just goes to a lighter phase of sleep. <br> <br> Snoring is the noise of vibration in the soft tissue that lines the throat. This happens when the flow of air is disrupted, such as when the tonsils are large. Adults who snore often are overweight, or have nasal problems (such as a deviated septum) leading to obstruction. Although patients who snore often have sleep apnea, and patients with sleep apnea frequently snore, it is possible to have one without the other.<br> <br> When it is severe, obstructive sleep apnea can result in serious conditions such as heart strain, abnormalities in heart rhythm, and changes in the blood flow to the lungs. These problems are very rare in children, unless they are obese. More common complications of OSA in children include poor growth, behavioral problems, concentration difficulties, bedwetting, or daytime sleepiness (since the sleep that they are getting is not as restful as it could be). Sleep disturbance can also occur even without complete apnea, if the child is struggling to breathe against resistance and airflow is reduced. <br> <br> Most children with sleep disordered breathing have enlarged tonsils and adenoids, and removing this tissue results in a cure of OSA in greater than 90% of cases. Snoring may persist, but if there is no more apnea, the snoring itself does not require any treatment. In some cases, however, there are other causes of SDB which will result in persistent OSA after surgery. These include obesity, a small jaw, a big tongue, a variety of congential skull abnormalities, or neurological problems causing poor muscle tone. <br> <br> It is important to remember that SDB is mainly a sleep problem, and not usually a breathing problem. That is to say, the risk of SDB is that a child will not get a good night's sleep, and that this may affect daytime behavior and performance. Patients with SDB are not at risk of suffocation, the brain is always working and rouses a child to shallower levels of sleep before the oxygen level gets too low. Unfortunately, this continual partial awakening fragments the normal sleep rhythms and causes inefficient, insufficient sleep. <br> <hr> <br> <br><span class=TitleStyle><a NAME="difference">What is the difference between a sore throat, "strep throat" and tonsillitis?</a></span><br> <br> 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- <i>Streptococcus pyogenes</i>. Although other bacteria can cause throat infections, most doctors will try to specifically diagnose the "strep" bacteria so that antibiotic treatment can be given. This is to help the symptoms resolve more quickly, and because in rare cases, these infections can result in damage to the heart or kidneys. <br> <br> If the tonsils are infected with a bacteria, they will usually get large, turn somewhat red, and may have some yellowish-white debris of 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 make the tonsils look like this (as in mononucleosis). On the other hand, the "strep" bacteria can be present in a normal looking throat. The only way to be sure is to do a throat culture, although there are other tests which may suggest a bacterial infection. <br> <hr> <br> <br><span class=TitleStyle><a NAME="sore">What can be done about recurrent sore throats?</a></span><br> <br> 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. <br> <br> As in recurrent ear infections, some doctors try to prevent sore throats with a low dose of a mild antibiotic for a prolonged time (weeks to months). There is some concern, however, about using too many antibiotics- a practice which can result in the germs developing a resistance to the drugs, as well as in side effects in children such as allergic reactions. Therefore, this approach is not commonly used. <br> <br> If a child is very severely affected with recurrent sore throats, particularly if they involve tonsillitis, a doctor may recommend a T&A, or 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, and tonsillectomies are more frequently done for <a HREF="#snoring">sleep disordered breathing</a>. <br> <hr> <br> <br><span class=TitleStyle><a NAME="carrier">What does it mean if my child is feeling better, but the strep test is still positive?</a></span><br><br> There is a condition known as the "carrier state", in which the child is feeling fine, but a throat culture still shows the presence of the "strep" bacteria. While this is somewhat controversial, most pediatricians do not treat children who are carriers with antibiotics except in unusual circumstances. They do not seem to be at very high risk for developing heart or kidney damage, and are generally not considered to be very contagious. <br> <hr> <br> <br><span class=TitleStyle><a NAME="risks">What are the risks of tonsillectomy and adenoidectomy?</a></span><br> <br> The surgery is done under general anesthesia, and this is usually the most frightening part of the whole process, for children and for parents. Modern pediatric anesthesia is extremely safe. It is given by a trained professional in a well monitored setting. Usually, this will be an anesthesiologist specializing in the care of children. There will be time before the surgery for 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 a healthy child, and are inappropriate for surgery in the throat. Even though children may become frightened during the administration of the anesthetic, after the operation they usually do not remember anything about the time just before they went to sleep. <br> <br> The most common significant risk of tonsillectomy is bleeding after surgery. It usually takes about 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 usually about five to ten days after the operation when the "scab" in the tonsil bed separates from the wall of the throat. Bleeding that is enough to be noticed happens in about 2-4% of patients, and will be seen as blood in the mouth. Significant bleeding after adenoidectomy alone is extremely rare. <br> <br> Postoperative bleeding from the tonsillectomy site often stops by itself. However, if it persists, it is usually managed in children by returning them to the operating room for a brief procedure under anesthesia, in which the open blood vessel is found and cauterized. Some adolescents and adults may allow this to be done without anesthesia, but most children will not permit a thorough examination and cautery while awake. <br> <br> The soft palate (roof of the mouth) keeps air from flowing backwards from the mouth to the nose during speech and swallowing. Sometimes, removing the adenoids and/or tonsils can result in an inproper seal of the palate against the wall of the throat, with "escape" of air or liquid around the back of the nose. Many patients have a high, nasal voice, different from the "clogged up" sound that they had before surgery. Usually, this does not last long, but sometimes it takes a few weeks or even months before the palate can stretch enough to make a good seal again. In rare patients (such as those with palate abnormalities), this voice problem may persist, requring special therapy or even further surgery. <br> <br> 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. <br> <hr> <br> <br><span class=TitleStyle><a NAME="benefits">What are the benefits of tonsillectomy and adenoidectomy?</a></span><br> <br> 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 improved airflow until several days have passed and the swelling has gone down. <br> <br> 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 anyone from getting a cold or other virus, and occasional illnesses with throat pain may still occur.<br> <br> There are a few unusual reasons for T&A 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 surgery is done during an infection. These children may be referred for a T&A in 6 weeks or so after the inflammation has resolved. Even more infrequently, a child with one tonsil that is much larger than the other and growing will be referred for surgery. The tonsil is removed to make sure that it does not contain a tumor or other growth. <br> <hr> <br> <br><span class=TitleStyle><a NAME="need">Don't you need your tonsils and adenoids?</a></span><br> <br> This has been a concern over much of the 20th century, especially when tonsillectomy was done more commonly. Since the tonsils are immune tissue, it would seem logical to think that removing them would somehow reduce the body's ability to fight infection and tumors. However, many studies have been done over the years to look at rates of lymphoma, polio, and other infections with and without tonsils. There have <i>not</i> been any consistant findings of decreased immune function or increased rates of disease following T&A. It seems that the tonsils and adenoids are the "tip of the iceberg" with regard to the immune system, and that removing them does not significantly reduce the overall amount of immune tissue in the body. <br> <hr> <br> <br><span class=TitleStyle><a NAME="how">How is tonsillectomy and adenoidectomy done?</a></span><br> <br> Tonsillectomy and adenoidectomy is done through the mouth, and there are no cuts or sutures anywhere on the skin. The tonsils may be removed with a knife and scissors, or with an electric cautery (my preferred method). While some surgeons use a laser for this procedure, I do not feel that the additional risk of using this device is balanced by any major decrease in pain or bleeding after surgery. Lasers are useful in many types of surgery where cutting needs to be done in an area that is difficult to reach and there is no good alternative (such as on the vocal cords or deep in the windpipe). However, few surgeons perform tonsillectomy using this instrument. There are several other new approaches currently under investigation, but at the present time, I still feel that the electrocautery is the most appropriate tool for this operation. <br> <br> The tonsils are visible when the mouth is opened, and are removed while looking directly at them. They are also encapsulated, which means that they come out of their beds in the wall of the throat as one piece of tissue. The adenoids, on the other hand, are not visible directly and must be seen with a mirror placed in the back of the throat. They are <i>not</i> encapsulated, so they are usually "shaved" down with a curette, and come out in pieces. Enough tissue is taken to unblock the back of the nose, but there is <i>always</i> a small amount of adenoid tissue left at the end of the surgery. Any attempt to remove all of the adenoids would not only be unsuccessful, but would risk damage to nearby structures and severe scarring of the back of the throat. Therefore, we speak of "shaving down" the adenoids rather than removing them completely. It is extremely rare for the little bit of adenoid tissue left after surgery to grow back enough to cause problems. <br> <hr> <br> <br><span class=TitleStyle><a NAME="stay">Does my child need to stay overnight in the hospital after a tonsillectomy?</a></span><br><br> In the past, all children undergoing this surgery stayed overnight for observation. Most managed care plans and other third party payers today will not allow this expense unless there is an exceptional reason for admission (such as severe obstructive sleep apnea, age less than 3 years old, or underlying medical problems). In fact, this should not reduce the safety of the operation, since the most common complication (bleeding) does not usually occur until at least five days after surgery. If a child is breathing, sleeping, and drinking well after a few hours in the recovery room, they are generally safe to go home. Certainly, any child may be admitted to the hospital from the recovery room if- in the surgeon's opinion- there is any problem requiring observation. <br> <hr> <br> <br><span class=TitleStyle><a NAME="eat">What can my child eat after tonsillectomy and adenoidectomy?</a></span><br><br> In the past, many surgeons followed strict dietary guidelines after surgery. Liquids only were allowed, and milk or citrus juices were prohibited. While this is an individual practice preference, I do not advise any restrictions except to avoid "sharp" foods for the first two weeks (such as pretzels or chips, which might cause bleeding). Immediately after anesthesia, the child may feel some nausea, and rich foods like milk may cause vomiting. However, this feeling usually goes away after a few hours. Ice cream is an ideal food, since it is cold (which reduces throat pain), liquid (which prevents dehydration) and rich in calories (which is important since a child may not be eating too well after the operation). <br> <hr> <br> <br><span class=TitleStyle><a NAME="expect">What should I expect after tonsillectomy and adenoidectomy?</a></span><br> <br> Tonsillectomy and adenoidectomy can be a fairly painful procedure, and a bad sore throat may linger until healing is complete in about two weeks. Some children, particularly young children, bounce back fairly quickly, but older children, adolescents and adults usually have a more difficult time. The pain seems to peak after a few days, and then gradually subside. Patients also may have a bad taste in their mouths and bad breath as the scab breaks up and falls off. Ear pain is very common, since the same nerves bring sensation to the throat and the ears. This does not mean that the ears are infected. <br> <br> Pain medicine will be prescribed by the surgeon for use after the operation. The most commonly used drug is acetominophen (Tylenol™), with or without codeine. Codeine should be avoided if possible, since it is a narcotic, and can result in stomach upset, constipation and suppression of breathing (particularly of concern in patients with obstructive sleep apnea). Most other non-prescription pain medicines (such as aspirin, or Ibuprofen containing drugs like Motrin™ and Advil™) have the disadvantage of potentially interfering with the clotting of blood. This can make bleeding more likely, and therefore they are not used for two weeks before or after T&A. <br> <br> 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 child 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, some doctors may wish to admit the patient for overnight observation. For this reason it is very important not to travel far from hospital access in the first two weeks- no more than 30 minutes from the nearest hospital. Activities such as air travel, camping and hiking are not allowed. School does not need to be restricted, and a child can return to class as soon as he or she is feeling well enough to go back (usually a day or two). <br> <br> If a child is not drinking enough after surgery, they may become dehydrated. 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 liquids such as milk shakes to the extent that they are tolerated. A dehydrated 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 admission to the hospital for intravenous fluid therapy.
© 2005 Michael Rothschild, MD
Frequently Asked Questions
