Paediatric ENT
Adenoid and Tonsil Problems in Children
Enlarged Adenoids
Background
The adenoids are located at the back of the nose and are comprised of lymphoid tissue. In childhood they are part of the immune system that fights infections. They have a tendency to increase in size during childhood in response to routine childhood nose and throat infections.
After childhood they get smaller but may still be present in young adults.
Symptoms and Signs
Children between the ages of 2 and 6 years are those most commonly affected by enlarged adenoids. Enlarged adenoids may obstruct the back of the child’s nose leading to blockage, green discharge, snoring and sometimes obstructive sleep apnoea (OSA see later). Enlarged and infected adenoids may also lead to glue ear. Long term enlargement and blockage may lead to mouth breathing which can cause the bones of the face to grow abnormally to produce a long face with a small lower jaw, doctors call this the “adenoidal facies”.
Diagnosis
Often it is possible to look at the adenoids in even small children with a flexible camera or endoscope passed through the nose. If this is not possible X-rays of the back of the nose may show enlarged adenoids but are usually not needed to make a diagnosis.
Treatment
Large adenoids in childhood are normal and for most children with minimal symptoms no treatment is required other than reassurance that they are likely to grow out of the problem.
If enlarged adenoids cause problems, they can be treated in the following ways:
- Medical - in children a trial of a steroid nose spray may be appropriate before proceeding with surgery. This is especially the case if the child has known allergies for example to pollens or house dust mite.
- Surgery - adenoidectomy may performed under general anaesthetic.
- Severe nasal symptoms that do not respond to medical treatment.
- Child with Obstructive Sleep Apnoea (usually with tonsillectomy).
- As a therapy in Glue Ear (with grommet insertion)
- As a Biopsy to rule out a cancer (mainly adults)
Adenoidectomy
Adenoidectomy is the operation to remove the adenoids. It is a common operation in children. It is performed under general anaesthetic. A pillow is placed beneath the shoulders and the neck extended. A catheter is placed through the nose to hold the soft palate out of the way and the back of the nose examined via the mouth using a mirror alternatively a thin camera or endoscope may be used. Enlarged adenoids are then removed by scraping using sharp curette or more commonly an electrical device is used to cauterise then suck away the adenoids.
Complications are unusual but may include bleeding and minor scarring. The adenoids may occasionally grow back some years later especially in children with allergies.
The Tonsils
These small organs on the sides of the throat can cause problems out of all proportion to their size. Like the adenoids they are part of the immune system and are partly responsible for the body’s response to infection. Childhood infection is common but unlike infection of the adenoids it is frequently painful.
Tonsillitis
In childhood the immune system is still developing and tonsillitis is extremely common. These infections are caused by common upper respiratory tract viruses and bacteria. It is unclear if bacterial infection follows initial viral infection. In teenagers a virus called Epstein Barr Virus (EBV) can cause glandular fever (Infectious Mononucleosis or “Mono”) with repeated sore throats.
Symptoms and Signs
The child is generally unwell with a temperature and lethargy. Both sides of the throat are sore and swallowing is often difficult. Tender, swollen lymph glands are often felt in the neck. Examination of the tonsils may show generalised redness or pus arising from the tonsils. The illness is generally self-limiting and gets better within a week. Plenty of fluids and painkillers such as paracetomol and ibuprofen are useful. Antibiotics are generally not required and should be reserved for cases that don’t get better after 72 hours.
Glandular fever is a variable illness. Tiredness, headache and muscle pain are usually worse than in straightforward tonsillitis. Enlarged lymph glands in the neck are common and are often large. Up to 10% of patients will develop jaundice.
Diagnosis
The diagnosis is usually made on the basis of a careful history. Throat swabs are not useful. During the acute episode and especially in adolescent patients a blood test looking for Glandular fever may be performed.
Treatment
Management of the severe, acute attack (i.e., a child who cannot swallow fluids and hence medication) is with anti-inflammatory medications, intravenous fluids and antibiotics. Penicillin will be effective in most cases but some bacteria are now resistant so Augmentin is also commonly used. It is important to avoid amoxycillin in glandular fever as it commonly produces a rash which may be mistaken for allergy.
Surgery
Tonsillectomy is reserved for those children with significant recurrent tonsillitis. The usual rules for considering tonsillectomy are more than 6 episodes of significant tonsillitis (requiring time off school) per year, or 4 episodes per year for 2 years.
Complications of acute tonsillitis
These may be divided into local and general complications. General complications are rare but include scarlet fever, rheumatic fever and glomerulonephritis (inflammation of the kidneys). Local complications are much more common. In smaller children especially if there is a background of obstructive sleep apnoea the swelling associated with tonsillitis may worsen snoring and breathing obstruction.
Peri-tonsillar abscess (Quinsy)
Infection can spread outside the tonsil where it forms a painful abscess. It is usually seen as a complication of tonsillitis in young adults.
Symptoms and Signs
The patient usually gives a history of a sore throat on both sides that has become more severe and one sided. They usually feel extremely unwell and have severe one-sided throat pain which is commonly felt in the ear (referred otalgia). Examination reveals a sick looking patient who has a high temperature. They may be dehydrated. The voice may have a “hot potato” quality due to throat obstruction by the swollen tonsil. The patient is often drooling and unable to swallow their saliva; the breath usually smells foul. Examination of the throat is always difficult as difficulty opening the mouth is nearly always present.
Diagnosis
It is the general condition of the patient that gives away the diagnosis of quinsy – they feel, look, sound and smell unwell. A CT scan is sometimes performed if the quinsy does not rapidly respond to treatment.
Treatment
The infection will usually only settle down once the abscess is drained. This is done by inserting a needle into the abscess under a local anaesthetic. The patient is generally admitted to hospital for intravenous fluids, anti-inflammatories and antibiotics. The risk of a second subsequent quinsy is in the region of 20%. Most surgeons would suggest tonsillectomy following a second quinsy. This is performed once the acute infection has settled.
Unilateral (one-sided) tonsillar enlargement
Background
It is entirely normal for there to be a difference in size between the two tonsils, this is especially the case in children. However painless, one sided, tonsil enlargement cannot be ignored as it may represent more serious problems.
Causes of unilateral tonsillar enlargement include:
- Normal variant
- Recurrent tonsillitis
- Quinsy (painful)
- Lymphoma
- Squamous Cell Carcinoma (SCC)
Symptoms and Signs
Unilateral tonsil swelling is usually painless and may be noticed by chance. Except in the case of a quinsy, which is obviously quite different, it may be difficult to exclude serious disease without removing the tonsil and performing a biopsy.
Diagnosis
CT scanning may be helpful in diagnosing the cause of the swelling; it may also show associated lymph node swelling. Tonsillectomy and biopsy is however often required.
Tonsillectomy
The surgical removal of the tonsils is one of the most commonly performed surgical operations. In the past the most common reason for removing the tonsils was recurrent tonsillitis, it is now increasingly common to remove the tonsils as a treatment for obstructive sleep apnoea in a child. The main reasons for tonsillectomy are:
- Recurrent acute tonsillitis - >6 significant episodes in a year.
- Recurrent peri-tonsillar abscess - usually after second episode.
- Treatment of Obstructive Sleep Apnoea / snoring.
- Children - Adenotonsillectomy
- Adults - usually with soft palate surgery (see sleep disorders)
- Exclusion of malignancy.
- Obvious tumour of tonsil.
- Unilateral tonsillar enlargement.
The operation
Tonsillectomy is performed in a hospital under general anaesthetic. The shoulders are supported and the neck extended. The mouth is opened with a special device called a “mouth gag”. The tonsil is grasped by forceps and the tonsil dissected from the surrounding tissue using an electrical scalpel that cuts and seals blood vessels at the same time. Local anaesthetic is injected into the tonsillar area to prevent post operative pain. The operation takes around 30-45 minutes and the patient usually spends one night in hospital.
Complications of tonsillectomy
Tonsillectomy is very safe but as with all operations complications can occur.
These include:
- Pain – Pain is usual, may be severe and lasts around one week. A combination of Ibuprofen and Paracetomol is usually prescribed and should be taken regularly for the first 5 days. Adults and older children may be given stronger opiate painkillers but these are generally avoided in smaller children.
- Bleeding - Bleeding can occur immediately after the operation (primary or reactionary haemorrhage) this is rare due to the use of electrical scalpels and cautery instruments. If it happens, the patient most often requires a return to the operating theatre where the bleeding point may be identified and treated.
- Secondary haemorrhage is more common. It occurs up to 6-8 days after tonsillectomy and is often preceded by an increase in pain and temperature. It is speculated that secondary haemorrhage is the result of post-operative infection of the tonsil wound. Secondary Haemorrhage occurs in around 5-7% of patients after tonsillectomy. Giving antibiotics at the time of surgery or for 10 days after does not however seem to prevent its occurrence. It is important that post tonsillectomy bleeding is taken seriously and that medical help is obtained. Most often the patient is admitted to hospital and given intravenous antibiotics, anti-inflammatories and in older children peroxide mouth washes. Rarely, if these measures are not successful, a return to the operating theatre is required.