As otolaryngologists, we are frequently asked to evaluate the upper airway especially by dentists in children undergoing orthodontic treatment or by pulmonologist in children undergoing evaluation for sleep disorders. While assessing the upper airway parents are asked few questions.
- Does your child keep his mouth open, especially while asleep?
- Does your child snore at night?
- Does he have repeated colds and coughs?
Under normal condition breathing takes place by nose. Mouth breathing or snoring should not be overlooked and proper evaluation is to be done. Mouth breathing syndrome may cause abnormal positioning of teeth, and facial deformity. It May progress to sleep disorder and poor school performance and in some cases lead to adverse effect on heart and lungs.
Mouth breathing and snoring due to adenoid is common in children but since the signs and symptoms of adenoids are so ubiquitous often the general physician or pediatrician may fail to think about adenoids.
Nose block may be of three types–
a. Organic—some mechanical obstruction –enlarged adenoids, tonsils, deviated nasal septum, allergic rhinitis, nasal foreign bodies, enlarged nasal turbinates, Nasal polyps etc.
Adenoids and Tonsils
Tonsils and adenoids are clump of lymphoid tissue, the tonsils are located on both sides of the back of the throat (Oropharynx) and adenoids are located higher in the passage that connects the back of nose to the throat (Nasopharynx).
The tonsils are visible through the mouth, but the adenoids are not directly visible. A small mirror or a nasal endoscope is used to see the adenoids.
They trap bacteria and viruses entering through the throat and nose and produce antibodies to help body fight infections. But they are not considered to be very important as body has other means of preventing infection and fighting off bacteria and viruses.
Children are born with adenoids which are quite small and usually adenoids shrink after about 5 years of age, and practically disappear by the teenage years.
Some children (and adults) are prone to develop infections of the tonsils and adenoids. These infections can be caused by different kinds of bacteria other than streptococcus( the one most people know about).
Symptoms of enlarged tonsils and adenoids
Adenoids enlarge because of repeated allergy or infection. Children with enlarged tonsils or adenoids may have a sore throat and discomfort or pain during swallowing.
Enlarged or hypertrophied adenoids can block a child’s nasal passages and result in–
- Nasal block and Difficulty breathing through the nose
- Breathing through the mouth / Keep mouth open specially during sleep
- Noisy breathing
- Snoring while sleeping
- Stops breathing for a few seconds while sleeping (called sleep apnea)
- Hyponasal voice/ as if nostrils are pinched
- Chronic ear infections, ear pain and hearing loss because of Eustachian tubes block
- Change in face (adenoid facies ) of young children
Most common cause of nasal obstruction is adenoids but nasal allergy may be contributing factor which should also be ruled out and managed.
Proper history and clinical examination is very important.
Number of episodes of sore throat during the past 1 to 3 years is more important than the size of the tonsils alone. Very large tonsils may be normal and chronically infected tonsils may be normal-sized.
Redness of the tonsils, enlargement of lymph nodes in the neck, and the effect of the tonsils on breathing is also assessed.
Parents may neglect open mouth while sleeping considering it normal or habitual but actually it may be indication of sleep apnea.
Sometimes Parents may report that child has restless sleep indicated by moving around in bed or the child stops breathing frequently during sleep.
History of Dry mouth may be found on probing. Child may be hyperactive and have poor performance in school and may be falsely labeled as ADHD (attention deficit hyperactive disorder).
Patient may have high arched palate and overcrowding of teeth, change in face called adenoid faceis.
The tonsils are visible through the mouth, but the adenoids are not directly visible.
To view Adenoids post nasal mirror or nasopharyngoscopy (Rigid or fibreoptic) is usually required. Nasenendoscopy is reliable in assessing the size of the adenoids.
X-Ray of soft tissue of nasopharynx / Occasional CT scan is done.
Observation or Video recording of child while sleeping may be helpful.
Polysomnography may be advised to see oxygen levels in the blood.
Why to remove the Tonsils and adenoids?
Tonsil surgery is less common now. The tonsils are normally large during childhood and begin to shrink in size after the age of 7-8 years.
Children who benefit from Tonsil surgery include those with the following:-
- Obstructive sleep apnea
- Extreme discomfort when talking and breathing
- lack of weight gain: Children may not eat sufficiently because of pain
- Multiple throat or ear infections (Seven or more infections in 1 year, five or more infections a year over 2 years, or three or more a year over 3 years)
- Chronic or recurrent tonsillitis associated with the streptococcal sore throat not responding to beta-lactamase-resistant antibiotics
- Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy
The only treatment for enlarged obstructing adenoids is to surgically remove them. Antibiotics and other medications do not help.
Though adenoids usually shrink in the second decade of life, however, blockage and sleep apnea may affect growth and development and cause permanent changes in facial or dental development.
Adenoidectomy is recommended for the following:
- Recurring nasal congestion and sinus infections
- Blockage of back of nose :- Enlarged adenoids may cause “mouth breathing”, snoring, or sleep apnea (stop breathing for brief periods during sleep). Because of blockage of upper airway Oxygen levels in the blood may be low, and children may wake up frequently and feel sleepy during the day. Rarely, obstructive sleep apnea can cause serious effects on lung and heart.
- Chronic ear infections and hearing loss: -Adenoids block eustachian tubes (tube connecting back space of nose to middle ear) resulting in fluid accumulation in the middle ear.
- lack of weight gain: -Children may not eat sufficiently because of pain or because breathing takes constant physical effort
Usually surgery is under general-anaesthesia and child will not be allowed to eat or drink minimum 6 hours before surgery start time, and patient doesn’t feel any pain during surgery.
Tonsils and the adenoids are removed through open mouth —no need to cut through skin.
Adenoids- traditional curettage method, endoscopic shaver, electrocautery or suction coagulator
Tonsil -Cold blunt dissection method, Bipolar Diathermy, LASER or Radiofrequency
Anesthetic risk -serious anesthetic complications can occur, but are very unusual. Bleeding is rare.
The Tonsillar and adenoid bed usually becomes superficially infected, and can cause 7-10 days of bad breath, but serious infections are very rare.
Adenoids should be removed with careful consideration and examination to avoid effect on speech and/or swallowing. To be avoided in patient with sub mucous cleft palate.
Bleeding is potential complication of tonsillectomy and before embarking on surgery family history of any abnormal bleeding should be excluded and patient’s coagulation profile is to be examined.
What to expect post-operatively?
Normally tonsillectomy takes half an hour to 45 min on an average.
When child wakes up he may be slow and clumsy for initial few hours.
He will be kept with head low and lying to one side post-operatively.
Child is usually discharged in 4-6 hours, child less than 2 years of age, child with obstructive sleep apnea, is admitted in hospital for 1 day
** Child may have mild soreness of throat for 7-10days, mild earache for one week or blood mixed mucus for one week.
** Child may have mild fever for few days and nausea or vomiting.
Key of post operative management is— “Good hydration” and “effective pain management”.
Pain: - Pain reception varies from person to person, Adenoidectomy typically is much less painful than a tonsillectomy. Acetaminophen is usually given for pain relief.
Ice-packs around the neck reduce pain.
Diet: - Ice cream is ideal first meal after surgery because it is soft and offers comfort for sore throat.
* lots of cold water.
*For first 24 hours child can have cold yogurt, jelly, and pudding.
*For one week soft, bland diet (should not be very hot) like meshed potatoes, oatmeal, soups.
*Avoid acidic, spicy and rough food.
*Lot of chewing-gums helps.
Medicine: – Antibiotics are often prescribed for 5-7 days to improve healing, along with analgesics.
Bad breath:-Oral-hygiene is very important so child has to do gargles every time he eats something. Fluid intake should be encouraged.
Work and physical activity: - Child can start to o to school in 7 to 10 days.
Heavy physical work is to be avoided for 14 days after surgery.
When to call/visit doctor? If significant bleeding, high fever or signs of dehydration are present consult your surgeon.
- Tonsillectomy and adenoidectomy are usually done on an outpatient basis. These operations should be done at least 3 weeks after any infection has cleared to avoid risk of complications.
- Removing adenoids can help reduce snoring but may not completely cure it because several other reasons may be responsible for snoring.
- Tonsillectomy and adenoidectomy do not appear to decrease the frequency or severity of colds or cough.
- Voice may sound different for a short while after the operation because of swelling in the area. However, this usually comes to normal within 1 or 2 week.
- Removing the tonsils or adenoids does not cause any problems with the immune system.
White patches on the tonsils are mistaken for an infection. Most often this is of no medical significance. Furthermore, large tonsils do not necessarily mean the child needs to have them removed. The most common reasons to consider removal of the adenoids and tonsils are recurrent infections and obstructive sleep apnea (OSA). Adenoidectomy has tremendous benefits for child’s health and is essential to safeguard child’s breathing and hearing.
Sleeping child with mouth open– By Daniel Dwase (http://www.child-development-guide.com) [GFDL (www.gnu.org/copyleft/fdl.html) or CC-BY-3.0 (www.creativecommons.org/licenses/by/3.0)], via Wikimedia Commons from Wikimedia Commons