Of adenoids and tonsils- to do or not to do?

It is indeed a difficult choice to make for any parent when the child is advised surgery. Of concern to the parents are the complications of the surgery and the impending loss of immunity. The adenoid and the tonsils indeed have a significant role in the immune defence of the child. While saying this, we imply that the gland is a healthy one and not a diseased one. A significant complication is a possibility of bleeding postoperatively. This is usually very rare, but occasionally it may be severe and may require a visit back to the operating rooms. The metaphor of the decision we subconsciously make while crossing a street every day comes handy when I guide the parents. What is to be gained by the crossing? What could be lost by doing so? What are the risks involved? Which is the best time to do so? The decision is easier now that it is a mathematical one.

The adenoid gland is strategically situated in the nasopharynx, which one could say is the crossroad where the ears, the nose and the throat meet, so essentially the crux of E.N.T.

This gland is the first to respond on exposure to infections and any allergy-causing substances in infancy and childhood. The adenoid works overtime when the child is exposed to these changes in the environment. At times the adenoid is irretrievably overwhelmed by the workload. It gets inflamed and enlarged relative to the restricted volume of the nasopharynx. It now becomes the cause of the symptoms. In addition to the discomfort of the recurrent infections, the adenoid blocks the nasal airway. The Eustachian tube, which connects the middle ear to the nasopharynx, may be compressed, leading to diseases in the ear. Some of these dreaded complications may even be life-threatening. This is a vast topic and I shall discuss it in detail in another post. A child with long-standing noisy breathing, snoring and disturbed sleep indicating a persistent nasal block, especially if associated with recurrent earaches or decreased hearing needs an E.N.T. consultation.

A few years back, I had advised adenoid surgery for the son of a colleague. I had managed to convince the parents regarding the necessity of the surgery but, the paternal grandparents of the child vehemently opposed the idea. Unfortunately, he had to undergo major surgery in the ear in addition to the one for the adenoid a few years later. The changes in the shape of the face and the protuberant teeth also needed multiple procedures for correction. Despite these, he was left with several sequelae. I was quite devastated by the unfortunate turn of events which timely surgery could have easily prevented. I have several such stories to relate, each of which had painful endings. Parents are concerned about the young age of the child but unfortunately, these are usually diseases of childhood and have to be addressed at the earliest.

 A baby must breathe through the nose for the normal development of the face. It is easy to identify a child who breathes through the mouth by observing the face. The pinched nostrils, the open mouth with the protuberant teeth and the long face are all part of what is called the adenoid facies. All these symptoms are due to the defective development of the nose and the sinuses. These changes are quite difficult to correct later in life. Truly, prevention is easier and better than a cure.

The strain to breathe through the mouth in the growing years takes a toll on the development of the body, especially the chest wall. The recurrent infections and the lack of restful sleep affects the general physical and mental health of the child. He may even miss a few growth spurts and be lagging his peers in stature. You can blame his crankiness on the sleepless nights that he has had and on the fatigue of the little body working hard to keep up. All the organs of the body are also affected by the prolonged low oxygenation. The adenoid usually stops growing and even may reduce in size as the child grows up and reaches puberty. His body is then better equipped to deal with the environment but, the damage that is already done remains as a souvenir.

Sometimes the adenoid persists into adulthood. One of my patients, a young man with pus discharge from the ears, was surprised to be told that he needed adenoid surgery before the operations in the ears. He was so habituated to the mouth breathing throughout his childhood that he knew no better. Later, this patient was a grateful one, more so because he realized the pleasures of being able to breathe through the nose, which most of us take for granted.

As for the tonsils, these are not as problematic as the adenoid due to their less strategic and more favourable location in the more roomy throat. However, the repeated painful infections can be troublesome and may lead to absenteeism, frequent use of antibiotics etc. and then, it is better to have them removed. Occasionally, these may also become so large that they meet in the midline and then these are aptly named ‘The Kissing Tonsils’. These may contribute to sleep apnoea which is essentially a serious sleep disorder when one is repeatedly woken up by breathlessness.

If the tonsils are significantly affected in a child already needing an adenoid surgery, then, of course, it would be both financially and logistically better to remove them at the same sitting.