After a long hiatus, I have returned with anticipation to
the blogging arena. I wish I had a great
excuse for being absent for so long. As
time has gone by, however, I realized just how quickly that time has faded into
a memory.
In reflecting on the last 8 months...yes...it has been 8
months since I last wrote... I was trying to think about a topic that I have
really needed to address during that time.
Something that I have seen frequently.
Something where trends have changed and new guidelines have been
published. Ah, yes, I know it...we will
discuss tonsils and adenoids.
First, let's discuss a little anatomy
(click link for picture). The tonsils
and adenoids are part of a surveillance system for the upper airway. The tonsils sit on either side of the throat
at the level of the soft palate and the adenoids sit above the palate at the
back of the nose. Things (antigens) that
are recognized as foreign coming into the nose or mouth are identified in these
tissues and antibodies (defenses) are made to fight them. The greatest contributions of tonsils and
adenoids to immunity are made in the early years before age 10. After that, their function decreases, perhaps
secondary to the fact that these tissues have seen most of these antigens and
do not have to work hard to produce antibodies against them. This is why the tonsils and adenoids decrease
in size, when kids get older, to nearly nothing in most adults.
So one might ask...if the tonsils and adenoids go away eventually,
why do they have to be taken out? That
is an excellent question. By the
numbers, tonsillectomy and adenoidectomy procedures have actually decreased
over the years due to changes in the criteria for candidacy for the
procedure. Back in the old days, tonsils
were frequently taken out because they looked big or for just a few
infections. The current recommendations
from the American Academy of Otolaryngology are for tonsils to be removed for
infectious reasons for 7 infections in 1 year; 5 infections per year for 2
consecutive years; or 3 infections per year for 3 consecutive years. These are strict criteria, but they do not
indicate that each of these infections has to be strep throat. Other infectious reasons for surgery could
include recurrent peritonsillar abscess.
Nearly 80% of tonsillectomies done today are done for sleep
disordered breathing or obstructive sleep apnea. This is a disease of too much tissue in the
back of the throat. When the tonsils are
enlarged, they occupy space in the throat, sometimes creating a blockage when
the muscles of the throat relax during sleep.
This can present as snoring, restless sleep, frequent awakenings, and
even pauses, choking and gasping during sleep.
This does not mean that all sleep apnea in children is caused by
enlarged tonsils, but they are frequently contributing.
Frequently parents will come into the office with a
presumption that the tonsils need to be removed purely because they are big, or
for 1 or 2 infections. Your ENT
physician will work with you to get a history of exactly how those big tonsils
are affecting your child and what other options are available for
treatment. During your evaluation, some
additional workup may be required including a sleep study, a neck x-ray, or
potentially laboratory studies. In our
next installment, we will discuss the
procedure including potential risks, surgical considerations, and
post-operative expectations. Please check out Dr. EJ on Twitter @DrEJ76 and like us on Facebook: www.facebook.com/ChildrensENT.
