Should my child have their tonsils removed?

Tonsillitis is a common problem. In most people, it only occurs once or twice in a lifetime. In some people however, it can recur often, resulting in multiple courses of antibiotics and time missed from school, work or other commitments.

Currently, we use the “Paradise criteria” as a guide. This criteria is met with 7 episodes of tonsillitis in one year, 5 episodes in two consecutive years or 3 episodes annually in 3 consecutive years. Importantly, there are other reasons for taking the tonsils out in children who do not reach these criteria. If your child meets these criteria or you are concerned about their tonsils you should schedule an appointment to discuss whether a tonsillectomy is the right option for them.

What do the tonsils do? What happens if they are removed?

The tonsils are part of your body’s defensive mechanism. They recognize foreign substances that you eat, drink or breathe and communicate with your immune system to defend against infections. It is likely they serve a more important role in the first year of life, however after that, there are so many other sites that detect these foreign substances that the tonsils are no longer essential. Removing your child’s tonsils will make no difference in their body’s ability to protect itself.

What are adenoids? What happens if they are removed?

Adenoids are mounds of tissue at the back of the nose. They are the same tissue type as the tonsils in your mouth just in a different location. Like the tonsils, they can detect foreign substances that we sniff in and alert the immune system. They often grow in size around the age of two and can contribute to snoring, recurrent ear problems and even recurrent sinus infections. It is for this reason that we sometimes recommend removing them. Adenoids tend to involute (disappear) in the early teenage years and so are typically a problem of childhood.

What are grommets?

Grommets (or tympanostomy tubes) are small devices we use to maintain a hole in the eardrum to allow either drainage of fluid from the middle ear (the space behind the eardrum) or to aid delivery of medication (often antibiotic drops). They are designed to be temporary and the ear will usually push the grommet out over time.

Recurrent ear infections

An ear infection can be a very painful condition. If you’ve ever had one, you are familiar with the symptoms of pain and pressure in the ear. It can be associated with a fever and often has associated hearing loss. Fortunately in most cases it is brief lasting only a few days not requiring medical intervention. Most children have had at least one ear infection. For some children these infections do not settle down or are recurrent. This can result in multiple episodes of fever and illness, time off work/school and many trips to either a GP or emergency department and courses of antibiotics. For recurrent infections, if your child has had more than 4 ear infections in 6 months or 6 infections in one calendar year, grommets may de indicated. If you are concerned about your ears and infections, you should talk to your GP about a referral to an ENT specialist for an opinion.

What is glue ear?

Glue ear is the common name for long standing, thick fluid trapped in the middle ear (the space behind the eardrum). This trapped fluid causes hearing loss, can be associated with recurrent infections, and if left untreated for long periods can result in some permanent hearing loss. Glue ear is far more common in children than adults. Although many cases will resolve after a few months, if fluid is present for more than 6 months in one ear or 3 months in both ears, grommets should be considered to aid drainage of this fluid.

My child’s nose is constantly blocked/runny

Allergies are common. Allergic rhinitis (nasal allergies) affects 1 in 5 people in Australia and New Zealand. It results in swelling of the tissue inside the nose, blockage and an increase in nasal discharge (a runny nose). If you’ve ever had a bad cold you probably know how this feels. Unlike a virus, these symptoms persist for long periods of time. Nasal allergies are also common in people with asthma. Studies show that better controlled nasal allergies improve asthma control. In many cases, nasal allergies, once diagnosed can be managed with lifestyle modifications and medical therapy. In some cases further treatment will be required.

My child has a lump in the neck

Swellings or lumps/bumps in the neck are always abnormal. While in many cases it is due to inflamed and swollen lymph nodes, it is critical to exclude a more worrying cause. A comprehensive history and physical examination by an expert familiar with paediatric head and neck problems is essential. In some cases further imaging is required, Surgery may be required to either obtain the diagnosis and/or provide a cure.

My child snores, should I be worried?

We know that between 8-12% of children snore most nights. Current evidence suggests that 2-4% of children have sleep apnoea. Sleep apnoea is the term used to describe a blockage in the airway during sleep. Untreated sleep apnoea can result in significant long term problems.  Below are 10 signs your child’s snoring may be a problem.

1. Abnormal breathing patterns – children with sleep apnoea may have periods when they appear not to breathe or have a very shallow breathing pattern, following these pauses, there is sudden movement and a deep breath and possibly a change of position in the bed.
2. Obesity – Recent studies have suggested that sleep apnoea rates may be as high as 30% in children with diabetes. Sleep apnoea causes fatigue meaning the child is less likely to exercise and can affect metabolism making it even harder for the child to lose weight
3. Thrashing around in the bed when asleep – children with abnormal breathing when asleep will roll around in the bed during the night. The sheets will be all over the place in the morning. Sometimes children will sleep with their neck extended (like they are trying to look up in the sky) to try and keep ttheir airway open.
4. Bedwetting – Is more common in children with sleep apnoea (up to 44%). Treatment of their sleep apnoea often improves the bedwetting.
5. Nightime sweating – children with sleep apnoea will not only thrash around in the bed at night but will also be warm to the touch and sweat a lot. This finding is not diagnostic of sleep apnoea abut a common finding reported with bad snoring.
6. Morning headaches – more often reported in adults and older children, this is due to lower levels of oxygen in the blood overnight and an increase in blood pressure.
7. Attention problems and hyperactivity – children with undiagnosed sleep apnea are often misdiagnosed as having attention problems or even attention defecit hyperactivity disorder ADHD. A careful sleep history can help determine whether intervention is required.
8. Children with Down’s syndrome – Somewhere between 40- and 70% of children with Down’s syndrome have sleep apnoea. It should be actively checked for and treated in this at-risk population.
9. Sleep-walking and night-terrors – Night-terrors in particular can be extremely distressing for the carer. Sleep apnoea can be potentially very dangerous (my parent’s once found me sitting on the roof having slept walked up a ladder!). Both these conditions have a strong relationship with sleep apnoea. Medical research suggests that treating the sleep apnoea can lead to resolution in many cases.
10. Elevated blood pressure (hypertension). Hypertension is something we think only affects adults. Children who have been found to have elevated blood pressure should be screened for sleep apnoea.

Sleep apnoea is becoming an ever-increasing problem. Left untreated in can result in significant long term problems with both health and development. In most children it can be cured with removal of the tonsils (and/or adenoids). If your child snores at night or you are worried about any of the problems listed above, talk with your GP about referral to an ENT specialist or paediatrician for evaluation.

My child has a hoarse voice

We’ve all had a hoarse throat at some point, either with a bad cold or after cheering too loudly. These same problems affect children too, although they may substitute cheering for screaming! Periods of hoarseness of short duration (days) are less worrying, however when it lasts for weeks or months it needs to be examined by an Ear Nose and Throat specialist. Although benign (not cancer) nodules are common in persistent hoarseness, more concerning causes like papilloma’s (similar to warts) or tumours on the voice box need to be excluded.