Enlarged Tonsils and Adenoids in Children: An Integrative Approach

Enlarged tonsils and adenoids are common in children and can significantly impact sleep, breathing, behavior, and overall well-being. For parents navigating these challenges, understanding the causes, symptoms, and treatment options – including both surgical and non-surgical approaches – can empower you to make informed choices about your child’s care. This article shares information about enlarged tonsils and adenoids, including the role of tonsils and adenoids in the immune system, what to expect at an ENT evaluation, and how to best support your child’s health, whether you’re considering surgery or seeking alternative solutions.

What Are Tonsils & Adenoids?

Tonsils are two oval-shaped lymphoid tissues located at the back of the throat, while adenoids are similar tissues situated higher up in the airway behind the nose. These tissues are part of the immune system and play a role in the immune systems of young children by capturing bacteria and viruses that enter the body through the mouth and nose (1). During early childhood, tonsils and adenoids are at their most active as the immune system learns to recognize and fight infections (1).

However, sometimes these tissues become enlarged (2). This can be due to infections (tonsillitis), allergies, or structural reasons. If the tonsils and/or adenoids are chronically enlarged, this can lead to problems that can significantly impact a child’s quality of life, and removal surgery is often performed (2). Over 500,000 tonsillectomies, adenoidectomies, or tonsilloadenoidectomy surgeries are performed on American children per year (3). 

Symptoms of Enlarged Tonsils & Adenoids

Enlarged tonsils and adenoids can lead to snoring, more frequent respiratory illnesses and middle ear infections, and more (2).

Potential Nighttime Symptoms:

• Snoring: Even when the child is not sick, snoring can occur if the airway is obstructed.
• Apneic Episodes: Pauses in breathing that last for 5 – 10 seconds (sleep apnea).
• Labored Breathing: The child may visibly struggle to breathe while asleep.
• Chronic Mouth Breathing: Often seen in children with nasal obstructions.
• Restless Sleep: Frequently waking more than twice per night.
• Sleepwalking, Talking, and Night Terrors: These may lead to the fear of falling asleep.
• Teeth Grinding (Bruxism): This can occur as the body compensates for airway obstruction.
• Bedwetting (Enuresis): Particularly in children beyond the typical potty-training age.
• Unusual Sleeping Positions: Head arched back or mouth wide open to help with breathing.

Potential Daytime Symptoms:

• Morning Fatigue and Irritability: Waking up tired or grumpy, even after a full night’s sleep.
• Daytime Sleepiness: Struggling to stay awake or alert during the day.
• Difficulty Swallowing Solid Foods: Particularly with harder foods like meat or apple peels.
• Growth Delays: Failure to thrive, delayed growth, or slow weight gain.
• Behavioral Issues: Hyperactivity, ADHD-like symptoms, mood swings, or frequent meltdowns (4).
• Learning and Concentration Problems: Difficulty focusing or performing academically (4).
• Frequent Infections: Chronic tonsillitis, sinusitis, or ear infections are common.

Chronic mouth breathing, swallowing difficulties, and inadequate sleep can interfere with a child’s development. Many parents report improvements in growth, energy, and behavior once enlarged tonsils or adenoids are addressed (4,5).

Acute vs. Chronically Enlarged Tonsils & Adenoids

It’s helpful for parents to understand the difference between acutely and chronically enlarged tonsils and adenoids.

• Acute Enlargement: Temporary infections or seasonal allergies can lead to acute inflammation of the tonsils or adenoids. In these cases, symptoms are often short-lived, resolving once the underlying cause is resolved. This is not typically a cause for concern.
• Chronic Enlargement: Chronic enlargement, however, occurs when the tonsils or adenoids remain swollen due to frequent infections, allergies, or structural issues, which can lead to persistent symptoms and complications.

Enlargement of the tonsils and adenoids is sometimes linked to chronic inflammation, driven by underlying factors such as immune dysfunction. This may explain why children with chronically inflamed tonsils and adenoids often also experience other immune-related conditions such as asthma and allergies (6).

If you or your child’s health care provider suspect that your child is dealing with chronically enlarged tonsils and/or adenoids, you will likely be referred to an ENT (Ear, Nose, & Throat) specialist.

What to Expect at an ENT Appointment for Evaluation of Enlarged Tonsils & Adenoids

If your child displays symptoms like snoring, mouth breathing, or frequent infections, your pediatrician may refer you to an ENT specialist for evaluation (2). Here’s what to expect during the appointment:

1. Medical History and Symptom Review

The ENT will start by reviewing your child’s medical history and asking detailed questions about symptoms, including:

• When symptoms began and whether they are improving or worsening
• Frequency of infections (e.g., tonsillitis, ear infections)
• Breathing issues during sleep, such as snoring or pauses
• Behavioral or learning concerns potentially related to poor sleep
• Swallowing difficulties or dietary preferences
• Family history of enlarged tonsils, adenoids, or sleep apnea

2. Physical Examination

The ENT will conduct a physical exam to assess the size of the tonsils and adenoids and check for signs of infection or obstruction:

• Throat Exam: Using a light, the ENT will examine the tonsils for redness, swelling, or pus.
• Nasal Exam: A small nasal speculum may be used to check for blockages due to enlarged adenoids.
• Ear Exam: The doctor may inspect the ears for fluid or signs of infection, as enlarged adenoids can affect the ears.

3. Flexible Nasopharyngoscopy (If Needed)

A flexible nasopharyngoscopy may be performed to get a closer look at the adenoids. This involves inserting a thin tube with a camera into the nose. A numbing spray may be used for comfort.

4. Sleep Study Referral (If Sleep Apnea is Suspected)

If sleep apnea is suspected, the ENT may recommend a sleep study (polysomnography) to monitor breathing, oxygen levels, brain activity, and heart rate during sleep. This test may be conducted at home or in a sleep clinic.

5. Hearing Test (If Ear Infections Are Frequent)

Recurrent ear infections may prompt a hearing test to check for hearing sensitivity and evaluate any impact from fluid buildup or infections.

6. Swabbing (If Infection is Suspected)

Swabbing provides valuable information about whether bacteria or viruses contribute to swelling, guiding treatment choices.

• Throat Swab: A throat swab may be used to detect bacterial infections like strep throat.
• Nasal Swab: A nasal swab may be done to check for respiratory, bacterial infections, or allergens.

Remember, you know your child best, and as their advocate, you have the right to ask questions and ensure they receive the thorough evaluation they deserve. If there are tests or assessments you believe would be beneficial but were not conducted, don’t hesitate to discuss this with the ENT. Similarly, if any procedure or test feels unnecessary to you, it’s entirely appropriate to ask for more information or even seek a second opinion. Follow your gut!

What You Should Know About Surgical Removal (Tonsillectomy and Adenoidectomy)

For children with severe symptoms, tonsillectomy and adenoidectomy are common treatments, especially for those with obstructive sleep apnea or frequent infections. Here’s what parents should know about these procedures.

Potential Benefits of Surgery:

• Improved Breathing and Sleep Quality: Studies show that surgery often resolves snoring, apneic episodes, and labored breathing, which leads to better sleep quality (7).
• Behavioral and Cognitive Impacts: Improved focus, mood, and behavior are commonly reported after surgery, likely due to improvements in sleep (8).
• Some Reduced Infection Frequency: Research shows that cases of tonsillitis often decrease following surgery (8). However, the study suggests that while tonsillitis risk is lowered, there is an increased long-term risk for other respiratory and allergic diseases, such as asthma, sinusitis, and chronic obstructive pulmonary disease (COPD) (9). 

Potential Risks of Surgery:

• Pain and Recovery: Post-surgery pain typically lasts 1-2 weeks.
• Bleeding and Infection Risks: This is rare, but as with all surgeries, there is a risk of infection and bleeding in the days immediately following the procedure.
• Anesthesia Risks: There are some risks associated with general anesthesia, and the surgical team will review these with you before the procedure.
• Potential Impact on Immune Function: Since tonsils and adenoids are part of the immune system, removing them can reduce some aspects of immune defense in the upper respiratory tract (9).
• Increased Long Term Risk of Infection: Research has shown that removing the tonsils and adenoids can increase the risk of developing respiratory and allergic conditions later in life, including asthma, sinusitis, and COPD (9). This suggests that while surgery may reduce tonsillitis risk, it could leave children more susceptible to other infections and inflammatory conditions over time.

To learn more about detoxing from general anesthesia, read this article: Detoxing Kids From General Anesthesia: A Guide for Parents

The Immune Role of Tonsils and Adenoids

A 2018 study involving nearly 1.2 million children (10) highlights the potential long-term effects of removing the tonsils and/or adenoids. While the study confirmed that tonsillectomy and adenoidectomy can reduce the risk of tonsillitis, the findings also suggest that removing these tissues may more than double the risk of other respiratory and allergic conditions later in life (10).

Beyond educating on the potential risks and benefits of these surgeries, these findings also offer valuable insights for managing the health of children who have undergone tonsillectomy and/or adenoidectomy, indicating that extra immune support may be beneficial for them.

Non-Surgical Alternatives to Enlarged Tonsils

For children with mild to moderate symptoms of enlarged tonsils and adenoids, non-surgical options can help alleviate occasional discomfort and address some of the potential underlying causes. It is important to note that these strategies may not always be enough, and surgery may become necessary. Here are some integrative approaches to consider:

• Anti-Inflammatory Diet: A nutrient-dense, anti-inflammatory diet can reduce systemic inflammation and support overall immune health (11). Emphasize whole foods, fresh fruits, vegetables, quality proteins, and healthy fats like omega-3s.
• Allergy Management: Identifying and addressing allergens can help reduce inflammation. An elimination diet is often a good place to start.
• Nasal Sprays: Saline or short term steroid nasal sprays can decrease swelling and improve airflow.
• Humidifiers: Adding moisture to the air can relieve symptoms, especially in dry environments.
• Myofunctional Therapy: Exercises that strengthen facial muscles, improve airway health, and reduce mouth breathing may be helpful for children with mildly enlarged adenoids and/or tonsils.

How to Support Your Child’s Health if They’ve Had Their Adenoids or Tonsils Removed

Following your child’s recovery from adenoid and/or tonsil removal, a few proactive measures can support their overall health, strengthen their immune system, and address underlying inflammation.

1. Focus on an Anti-Inflammatory Diet

A diet rich in whole foods like fresh fruits, vegetables, whole grains, and quality proteins can provide essential nutrients while supporting a healthy inflammatory response.

2. Support Gut Health

Since much of the immune system resides in the gut, maintaining a healthy gut microbiome is important for all of us (12). Eat fermented foods, such as yogurt and kefir, that offer natural probiotics, or you may consider a supplement to help balance gut bacteria. This may be especially relevant if your child had several rounds of antibiotics prior to surgery to address frequent infections

3. Ensure Adequate Vitamin Levels

Key vitamins, including vitamin D and zinc, play essential roles in immune function. Sunlight exposure, nutrient-dense foods, and supplements can help maintain these levels.

4. Use Immune-Supportive Herbs

Herbs like elderberry, echinacea, and astragalus may support immunity and are gentle enough for daily use.

5. Implement Healthy Lifestyle Habits

Good hydration, restful sleep, and plenty of active outdoor time support a resilient immune system. Encouraging these habits helps maintain overall health and boost the body’s natural defenses.

Summary

Enlarged tonsils and adenoids can impact your child’s sleep, breathing, behavior, and overall health, which can be challenging for both kids and parents. Surgery can improve sleep, behavior, and frequent tonsillitis. However, these tissues play an important role in the immune system, and removal may carry some long-term risks. For many families, exploring non-surgical options, like dietary changes and allergy management, can be effective in managing mild symptoms. If surgery becomes necessary, rest assured that there are steps to support your child’s health and resilience post-procedure.

References:

1. Masters, K. G., Zezoff, D., & Lasrado, S. (Updated 2023 Jul 17). Anatomy, Head and Neck, Tonsils. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539792/
2. Germany: Institute for Quality and Efficiency in Health Care (IQWiG). (Updated 2023 Jan 17). Overview: Enlarged tonsils and adenoids. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536881/
3. Bohr, C., & Shermetaro, C. (Updated 2023 Jun 26). Tonsillectomy and Adenoidectomy.  Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536942/
4. Amiri, S., AbdollahiFakhim, S., Lotfi, A., Bayazian, G., Sohrabpour, M., & Hemmatjoo, T. (2015). Effect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy and sleep disordered breathing. Int J Pediatr Otorhinolaryngol. Aug;79(8):1213-7. doi: 10.1016/j.ijporl.2015.05.015. Epub 2015 May 27. PMID: 26066853.
5. Fasunla, A. J., Totyen, E. L., Onakoya, P. A., & Nwaorgu, O. G. (2020). Short-term effect of adenotonsillectomy on growth and nutritional anthropometric parameters of children with obstructive adenotonsillar enlargement. Egyptian Pediatric Association Gazette, 68(1). https://doi.org/10.1186/s43054-019-0016-4
6. Evcimik, M. F., Dogru, M., Cirik, A. A., & Nepesov, M. I. (2015). Adenoid hypertrophy in children with allergic disease and influential factors. International Journal of Pediatric Otorhinolaryngology, 79(5), 694–697. https://doi.org/10.1016/j.ijporl.2015.02.017
7. Chinnadurai, S., Jordan, A. K., Sathe, N. A., Fonnesbeck, C., McPheeters, M. L., & Francis, D. O. (2017). Tonsillectomy for Obstructive Sleep-Disordered Breathing: A Meta-analysis. Pediatrics. Feb;139(2):e20163491. doi: 10.1542/peds.2016-3491. Epub 2017 Jan 17. PMID: 28096514; PMCID: PMC5260158.
8. Fidan, T., & Fidan, V. (2008). The impact of adenotonsillectomy on attention-deficit hyperactivity and disruptive behavioral symptoms. Eurasian J Med. Apr;40(1):14-7. PMID: 25610016; PMCID: PMC4261322.
9. Byars, S. G., Stearns, S. C., & Boomsma, J. J. (2018). Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood. JAMA Otolaryngol Head Neck Surg. Jul 1;144(7):594-603. doi: 10.1001/jamaoto.2018.0614. PMID: 29879264; PMCID: PMC6145787.
10. Byars, S. G., Stearns, S. C., & Boomsma, J. J. (2018). Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood. JAMA Otolaryngol Head Neck Surg. Jul 1;144(7):594-603. doi: 10.1001/jamaoto.2018.0614. PMID: 29879264; PMCID: PMC6145787.
11. Scheiber, A., & Mank, V. (Updated 2023 Oct 28). Anti-Inflammatory Diets. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK597377/
12. Wiertsema, S. P., van Bergenhenegouwen, J., Garssen, J., & Knippels, L. M. J. (2021). The Interplay between the Gut Microbiome and the Immune System in the Context of Infectious Diseases throughout Life and the Role of Nutrition in Optimizing Treatment Strategies. Nutrients. Mar 9;13(3):886. doi: 10.3390/nu13030886. PMID: 33803407; PMCID: PMC8001875.