Tonsils and adenoids
Tonsils and adenoids are not removed just because they are large. They are removed when they block breathing during sleep, when they affect hearing, or when infections keep coming back often enough to meet specific criteria. Size on its own is not a reason, and this is the first thing we clarify at the appointment.
Tonsils or adenoids?
They are 2 different things, in 2 different places, and they cause different problems.
The tonsils sit on the right and left at the back of the mouth. When they get inflamed, they cause bouts of fever and a very sore throat. When they are very large, they narrow the airway in the throat and make eating difficult.
The adenoids, sit further back and higher up, where the nose meets the throat. You can't see them by looking in the mouth. When they get large, they block the nose and close off the opening of the Eustachian tube, which leads to mouth breathing and ear problems.
They are often enlarged together, which is why we tell them apart by examining your child, not from the symptoms.
Why do they get bigger in childhood?
Both are lymphatic tissue, placed exactly where the air your child breathes in passes through. Their job is to come into contact with germs and train the immune system in the early years, so it is normal and expected for them to grow.
The tissue is most active roughly between the ages of 4 and 10. With the adenoids, growth slows after age 6 while the space behind the nose keeps growing, so the proportions improve on their own. Something similar happens with the tonsils: they peak in the preschool and early school years and become smaller relative to the throat as the child grows. With both, real shrinking starts after puberty.
So the question is never whether your child has large tonsils or adenoids, but how much of a problem they cause and whether it can be managed without surgery.
How can you tell?
In sleep and breathing. Snoring on its own doesn't mean much. What matters are the moments when your child stops breathing, the effort you can see in the chest and neck, sleeping with the head tilted back and the mouth open, and waking up again and again. In children a bad night doesn't show up as sleepiness the next day, it shows up as irritability and trouble concentrating.
In infections. Bouts of fever, a very sore throat, pain when swallowing and swollen glands in the neck, with your child perfectly fine in between. What counts here is not how unpleasant each episode was, but how many there were and whether they were documented.
In hearing. When the adenoids block the Eustachian tube, fluid collects behind the eardrum. Your child is not in pain and doesn't complain, they simply hear less: they ask you to repeat things, turn up the TV, don't turn around when you call them, or are late to talk..
In eating and in the voice. They eat slowly, avoid solid food, keep drinking water to wash each bite down. The voice sounds muffled with large tonsils, or nasal, as if they always had a cold, with large adenoids.
In mouth breathing. Persistent bad breath, dry lips and a mouth that stays open during the day too, not only in sleep.
What happens at the appointment?
We start with the history, because most of the answers are found there: how your child sleeps, how they breathe, how many episodes they have had and when, and what treatment they received.
Examining the tonsils
They can be seen directly with a simple look in the mouth, nothing more. What we assess, though, is not their absolute size but how much space they leave in the throat. Large tonsils in a child who sleeps quietly and eats normally don't need any treatment.
We also look for signs of chronic inflammation, for tonsil stones, which often explain persistent bad breath, and for symmetry. A tonsil that is clearly larger than the other and can't be explained by a recent infection is looked into separately.
During an active episode, a strep test is useful in 2 ways: it guides treatment and it documents the episode, which matters especially if surgery is discussed later.
Checking the back of the nose
The adenoids can't be seen this way. We start with a small mirror held at the back of the mouth, which gives an answer in seconds without putting anything into your child's nose. When a more precise view is needed, we use an endoscope. An X-ray is only needed in very young children who can't cooperate with anything else.
Hearing test and tympanogram
Since the question is not how big they are but what they block, hearing is tested at the same visit. The tympanogram shows in seconds whether there is fluid behind the eardrum. Without these, half the picture is missing.
When is a sleep study needed?
In most cases it isn't. It comes up when sleep problems are marked but don't match the findings of the examination, or in children with particular conditions where the decision needs objective evidence.
Treatment
When is monitoring enough?
When sleep is quiet with no pauses in breathing, when there is no fluid in the ear and no drop in hearing, and when infections are below the criteria, monitoring is an evidence-based choice and not inaction.
In practice this means we set a specific interval and see your child again, not that we leave things open. If breathing pauses appear or hearing drops in the meantime, we revisit the decision sooner.
When are the tonsils operated on (tonsillectomy)?
When the reason is repeated infections, the criteria are numerical and refer to documented episodes: 7 a year, or 5 a year for 2 years in a row, or 3 a year for 3 years in a row. Documented means recorded with fever, swollen glands in the neck, pus on the tonsils or a positive strep test. Very often the number the family remembers and the number that has been documented are not the same.
Regardless of infections, surgery is considered when large tonsils contribute to blocked breathing during sleep. This is a reason in its own right, and frequent tonsillitis doesn't need to be present as well.
When are the adenoids removed?
Η Adenoid removal is considered when the nose is constantly blocked and breathing during sleep is affected, when fluid in the ear persists with a documented drop in hearing, or when ear infections keep coming back despite treatment.
If surgery on the tonsils or the adenoids has already been recommended to you and you would like a second opinion these are the criteria we go through from the beginning, so we can give you a clear picture of whether it is better to monitor your child for a while or whether surgery is needed now.
The procedure
Η Tonsillectomy (tonsil removal) and Adenoid removal are 2 separate operations, which are often scheduled together so your child only has anesthesia once. This is not a rule, and having the adenoids out doesn't mean the tonsils must come out too.
Both are done under general anesthesia, through the mouth, with no cuts on the outside, at IASO Children's Hospital (IASO Paidon). With the tonsils, full removal is not the only option: when the problem is blocked breathing rather than infections, partial removal (tonsillotomy) is an option with an easier recovery and a lower risk of bleeding. Recovery after adenoid removal alone is usually short, while after full tonsil removal the sore throat lasts several days.
Frequently asked questions
There is no evidence that removal has a meaningful effect on the immune system or makes a child more prone to infections. They are 2 parts of a ring of lymphatic tissue around the entrance to the throat, and around them there are dozens of other lymph nodes doing similar work.
On their own, usually not. Tonsil stones are debris that gets trapped in the small pockets of the tonsils and they explain the bad breath, but they are not a reason for surgery by themselves. They become part of the discussion when other criteria are also met or when they seriously affect your child's daily life.
Often yes, as the space around them grows with age. That doesn't mean every case can wait, though. When sleep or hearing is affected, the assessment is done now.
It depends on what is causing the problem. Some children need only adenoid removal, others only tonsil surgery, and others both. When there are reasons for both, they are usually done at the same time.
A small amount of tissue may remain and grow again, but this is not the rule and a second operation is rarely needed. If symptoms come back, the case is looked at from the beginning.
It depends on what was done. After adenoid removal alone, children recover quickly. After full tonsil removal, the sore throat lasts several days and often gets worse around day 3 to 5 before it starts to ease. You receive written instructions when your child is discharged.
When should you not wait?
Immediately
Pauses in breathing during sleep
When you see your child stop breathing and then take a deep breath, they need to be assessed right away.
Immediately
Severe pain on one side with difficulty opening the mouth
A sore throat on one side, with a muffled voice, drooling because saliva can't be swallowed and difficulty opening the mouth, needs urgent assessment, not waiting.
Soon
Drop in hearing or speech delay
We don't wait for the adenoids to shrink with age, because the cost of waiting is paid by speech.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Mitchell RB et al., Clinical Practice Guideline: Tonsillectomy in Children (Update), AAO-HNSF, 2019 · Rosenfeld RM et al., Clinical Practice Guideline: Otitis Media with Effusion (Update), AAO-HNSF, 2016.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
