Introduction
Many children have enlarged tonsils or adenoids, which can narrow their airways, leading to snoring, short periods of stopped breathing, and long-term poor sleep. Because of these issues, doctors often suggest surgery to remove the extra tissue.
Some kids have enlarged palatine tonsils (commonly called "tonsils") located on the left and right sides at the back of the throat. Others have enlarged adenoids (also known as the pharyngeal tonsil), located at the back of the nose. The medical terms for these conditions are "tonsil hypertrophy" and "adenoid hypertrophy."
Sometimes, both tonsils and adenoids are enlarged. Enlarged adenoids or tonsils do not cause problems for many children. About 7 percent of kids snore all the time, and around 2 percent experience nighttime breathing pauses and obstructive sleep apnea. These issues are often due to enlarged tonsils or adenoids, especially in children aged 3 to 6. This article explains the causes, symptoms, and treatment of tonsillar hypertrophy.
What Is Tonsillar Hypertrophy?
Tonsillar hypertrophy refers to enlarged tonsils. Hypertrophic tonsils can result from recurrent pharyngitis and local inflammation, particularly in children and young adults. When inspecting the oral cavity, one might notice hypertrophy of the palatine tonsils, sometimes referred to as “kissing tonsils” when they meet in the midline or overlap.
Tonsilloliths may also be found lodged in the tonsil crypts. While tonsillar enlargement can be asymptomatic, severely enlarged tonsils can sometimes fall back and block the oropharynx, especially when the patient is lying down. Most cases of obstructive sleep apnea in children are linked to hypertrophic tonsils.
Tonsillitis is one of the most common infections family physicians encounter. Patients typically experience a sore throat, acute fever, and swallowing pain. A physical examination usually shows pharyngeal swelling, tonsillar erythema and exudates, and tender anterior cervical lymphadenopathy. While viruses are the most common cause of tonsillitis, group A beta-hemolytic streptococcus accounts for 5 to 30 percent of cases. Streptococcal infections require treatment with antibiotics.
What Causes Tonsillar Hypertrophy?
Tonsillar hypertrophy can be caused by acute and chronic infections such as recurrent infection, inflammation, or underlying conditions. Besides acute or chronic infection, other factors can cause tonsillar and adenoid hypertrophy. If one tonsil is enlarged, it is crucial to check for potential neoplastic processes like lymphoma or human papillomavirus-associated squamous cell carcinoma of the tonsil. Though rare, autoimmune lymphoproliferative syndrome is also a possibility. Some lysosomal storage diseases, such as mucopolysaccharidoses, are also linked to tonsillar and adenoid hypertrophy.
What Are the Symptoms of Tonsillar Hypertrophy?
Signs of enlarged tonsils or adenoids can include:
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Snoring.
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Pauses in breathing during sleep.
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Mainly breathing through the mouth.
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Strained breathing.
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Restless sleep, frequent waking, bedwetting.
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Unusual sleeping positions (head bent back, knees drawn up to the chest while lying on the stomach).
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Trouble swallowing, "hot potato" speech.
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Frequent colds.
The main symptoms vary depending on whether the palatine tonsils or adenoids are enlarged. Enlarged adenoids primarily affect nasal breathing, while enlarged palatine tonsils mainly cause pauses in breathing during sleep.
When children do not get a good night's sleep, they often do not feel rested during the day. Instead of appearing tired, they might be fidgety or "wired." However, they can suddenly become exhausted, especially during car rides. Extreme tiredness is more noticeable in older children and teenagers. Frequent pauses in breathing and waking up at night can lead to obstructive sleep apnea (OSA), which results in very little deep, restful sleep.
What Are the Complications of Tonsillar Hypertrophy?
Enlarged tonsils or adenoids can cause several issues:
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Respiratory Tract Infections: Constant mouth breathing due to enlarged adenoids can increase the risk of respiratory tract infections, such as the common cold.
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Middle Ear Infections and Glue Ear: These can occur if enlarged adenoids block airflow to the middle ear, leading to fluid buildup. Chronic glue ear may cause hearing and speech problems.
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Jaw Misalignment, Open Bite, and Altered Tongue Position: These can result from constant mouth breathing.
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Severe, Long-term Sleep Apnea: Enlarged palatine tonsils can lead to sleep apnea, which can affect a child’s physical development and increase the risk of cardiovascular disease.
The impact of enlarged adenoids or tonsils depends on how much they narrow the child's airways, whether they cause breathing pauses during sleep, and how long these issues persist. Sometimes, symptoms resolve on their own. Sleep apnea is more likely to cause additional medical problems than snoring, but regular, loud snoring and mouth breathing can also have consequences. Occasional, quiet snoring, such as from a cold, is usually harmless.
What Is the Treatment for Tonsillar Hypertrophy?
Tonsillar hypertrophy generally only needs treatment if it affects the ability to sleep, eat, or breathe. If an infection causes it, antibiotics might be necessary. For allergies, the doctor might suggest a nasal corticosteroid spray or antihistamines to alleviate the symptoms. Tonsillectomy and adenoidectomy (T&A) is the second most common surgery in the United States. The two main reasons for a tonsillectomy are sleep-disordered breathing (SDB) and severe recurrent throat infections.
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Tonsillectomy- T&A is increasingly being done for obstructive issues rather than infections. It is recommended for patients with sleep-disordered breathing (SDB) who also have related conditions such as growth restriction, poor school performance, nocturnal enuresis, or behavioral problems.
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Adenoidectomy- The primary reason for performing an adenoidectomy alone is severe nasal obstruction. Symptoms of severe nasal obstruction include mouth breathing, hyponasal speech, and reduced sense of smell. These symptoms should be present for over a year and continue despite conservative treatments like antimicrobial therapy and nasal corticosteroids to rule out infections or allergies. Relative indications for adenoidectomy include persistent chronic sinusitis, recurrent acute ear infections, and chronic otitis media with effusion in children who have not benefited from tympanostomy tube placement.
Conclusion
Tonsillar hypertrophy can be resolved by itself. It generally occurs in children and is caused by several factors. Enlarged tonsils are common; treatment depends on their size and whether they interfere with eating, sleeping, or breathing. Often, no treatment is needed. However, a doctor might prescribe medication to shrink the tonsils or recommend surgery (a tonsillectomy) to remove them. Sometimes, someone with sleep apnea might need to wear a special mask at night to aid breathing. The prognosis for tonsillar hypertrophy is good.
