Surgery for enlarged tonsils or adenoids

Photo of little boy in a hospital bed (PantherMedia / Monkeybusiness Images)

Tonsil surgery can improve or get rid of breathing and sleep problems such as snoring or breathing pauses in children. But surgery isn’t always necessary.

Enlarged palatine tonsils can affect children's sleep. It is common for children who have enlarged palatine tonsils to have enlarged adenoids too. The palatine tonsils, often simply referred to as "tonsils," are the lumps of tissue you can see on the left and right sides at the back of your throat. Adenoids, also known as the pharyngeal tonsil, are found at the back of the nose. Children with these enlarged areas of tissue may snore all the time, mainly breathe through their mouth and even stop breathing for a few seconds at a time while sleeping (sleep apnea). This can disturb their sleep, making them feel tired and restless during the day. It can also affect their development. If enlarged tonsils or adenoids are having this effect, surgery might be considered.

There are various surgical approaches:

  • Partial tonsillectomy (sometimes called tonsillotomy): Partial removal of the enlarged palatine tonsils.
  • Total tonsillectomy: Complete removal of the palatine tonsils (rarely done nowadays when treating enlarged palatine tonsils).

If the child also has enlarged adenoids, they can be removed during the same operation. If only the adenoids are removed, it is called adenoidectomy. Sometimes enlarged adenoids lead to frequent middle ear infections with a build-up of fluid in the middle part of the ear (“glue ear”). Small ear tubes known as grommets can then be implanted during the operation too. This improves the exchange of air between the middle and outer ear.

If a child is having their tonsils completely removed (total tonsillectomy), they have to stay in hospital. The other operations can be done as a day procedure. But hospital stays are often recommended if the child is having surgery on their palatine tonsils and adenoids at the same time. Depending on how much care is needed after the surgery, the children stay in hospital for about 2 to 7 days.

When is it possible to wait and see at first?

Because operations are never pleasant and they are also associated with risks, doctors often suggest waiting for a while to see whether the symptoms of enlarged tonsils improve on their own. Depending on things like how severe the symptoms are, this could take weeks or months. Particularly in the winter months, common colds can make existing symptoms worse. If you decide to wait and see at first, the child should have regular check-ups with an ENT (ear, nose and throat) doctor.

If a child has enlarged adenoids as well as enlarged tonsils, a steroid nasal (nose) spray may relieve the symptoms. This medication can reduce the size of the adenoids, which might be enough to make it easier for the child to breathe through their nose and sleep better. Steroid nasal sprays don’t relieve the symptoms of enlarged palatine tonsils, though. The spray has been approved for use in children aged three years and above. It shouldn’t be used for longer than six months. Although it is generally well tolerated, it can sometimes lead to minor nosebleeds or fungal infections in the membranes lining the mouth.

If the child only snores quietly, only every now and then, or mainly when they have a cold, the snoring is probably harmless and doesn’t need to be treated. But if they have very large tonsils or adenoids that are really affecting their sleep, it is unlikely that the symptoms will improve on their own.

How effective is surgery?

Many children can already breathe a lot better soon after surgery, and they also no longer have breathing pauses while sleeping. They snore less or stop snoring altogether, and generally get a better night's sleep. Research suggests that this also has a positive influence on their behavior: For instance, they are then less fidgety during the day.

But sometimes these positive effects of surgery don’t last, and the sleep problems come back. The success of surgery will also depend on whether the breathing difficulties are caused by other things too, such as jaw problems or being overweight.

What are the pros and cons of only partially removing the tonsils rather than taking them out completely?

Based on a number of studies, there is reason to believe that partially removing the palatine tonsils is about as effective as removing them completely.

The main advantage of partial tonsillectomy is that it’s less unpleasant for the child. Compared to those who have their tonsils removed completely, children who have had this operation are in a lot less pain in the first two weeks afterwards, and can start eating again sooner.

The risk of bleeding after surgery is probably lower too because parts of the tonsils that have a lot of blood vessels in them are left intact.

But the tonsils sometimes grow larger again after being partially removed: About 5 out of 100 children have surgery again within a few years because the breathing problems return. If that happens, doctors often recommend removing the tonsils completely.

What are the possible side effects?

Surgery on the palatine tonsils is a more major procedure than surgery to remove the adenoids. The wound can hurt, and swallowing can be painful in the first few days after the operation too. People sometimes feel sick or vomit. As with any type of surgery, the wound can become infected and there are other general risks (for instance, related to the anesthetic).

Bleeding after surgery occurs in less than 1% of children whose tonsils are partially removed. This type of bleeding can happen shortly after the procedure, but delayed bleeding is also possible – often after about one week. If severe bleeding isn’t discovered in time, it can become life-threatening.

Because tonsils play a role in the immune system, some parents are concerned that tonsil surgery could weaken their child’s immune system in the long term and, for instance, increase the risk of allergies or respiratory tract infections. There hasn’t been enough research in this area to say whether these concerns are well founded. But it is known that tonsils play a more important role in the immune system during the first few years of life than later on in life.

Things to remember after the surgery

In the first two to three weeks after surgery, children should avoid physically strenuous activities – for instance, they shouldn’t do sports and should avoid “rough-and-tumble” play. They are also advised not to take very warm baths. In order to protect the wound, it’s a good idea to make sure that they eat soft, low-acid foods in the first ten days. It’s best to avoid acidic drinks like fruit juices, too. Pain can be relieved with medication such as ibuprofen or acetaminophen (paracetamol).

Take bleeding after surgery seriously

The wound usually takes two to three weeks to heal. Before it has healed properly, it might start bleeding again. If that happens, blood typically comes out of the nose or mouth. Although this kind of bleeding is rare, it can lead to the loss of a lot of blood because the tonsils have a very good blood supply. But after-surgery bleeding sometimes goes unnoticed because children tend to swallow the blood. So it’s important to look out for less obvious signs of bleeding, such as the child swallowing more often than usual. After some time the child might start vomiting blood, or blood might get into their windpipe.

If you notice signs of this kind of bleeding, it’s important to immediately go to a hospital or call the emergency services (112 in Germany and many other countries, 911 in the U.S.) – even if the bleeding seems to have stopped on its own. The doctors in the hospital will decide whether a further operation is needed.

A second medical opinion may help

Whether or not tonsil surgery is worth considering will depend on various factors: How bad are the symptoms? How likely are they to go away on their own? Do other illnesses make them worse? How large are the tonsils? How effective is surgery likely to be?

There hasn’t been enough research to be able to say when the advantages of tonsil surgery clearly outweigh the disadvantages, and when it’s best not to have surgery. As a result, different doctors may give different advice. If your child’s doctor recommends tonsil surgery, it may be a good idea to seek a second medical opinion – in other words, to talk with a doctor in a different practice or hospital. Our decision aid may be helpful, too. It provides a brief summary of the main pros and cons of the different treatment options.