It’s a common scenario in every pediatrician’s office: A mother brings in her otherwise healthy 7-year-old for a well visit, and you look in the mouth and see markedly enlarged tonsils. Does the child snore? Yes. Does the child mouth breathe? Yes. Does the child experience respiratory pauses? Not sure. But over the last year there have been two episodes of strep-positive tonsillitis, with a few days of missed school.
Removal of the tonsils and adenoids is often what I describe to parents as a quality-of-life issue. From a respiratory standpoint, loud heroic snoring with or without respiratory pauses can significantly affect the sleep cycle at night. Common behavior changes during the day such as sleepiness, irritability or hyperactivity may be present.
Often, after the initial visit with the patient and family, if I cannot determine the severity of the sleep disturbance from the parent’s report, I will ask them to keep a sleep diary or take video of their child asleep at night. Over the course of two to three weeks, I recommend going into their room after they have been asleep for one to two hours and observing their sleep for 10 minutes or so. I ask parents to report back with their observations. If it is not clear but suspicion of sleep disturbance remains, then a polysomnogram is scheduled.
Another factor in determining whether an adenotonisillectomy is warranted is duration of symptoms. If I see a child with 6 months of breathing issues and enlarged tonsils and adenoids in May, but they have had several colds during the winter, the enlargement may be a product of reactive hyperplasia from infection. I will usually wait through the summer and then re-evaluate them.
Timing is also a consideration for recurrent tonsillitis patients. Several positive throat cultures over the winter may “clear” with emergence from the typical cold and flu season. I prefer to offer surgery after a patient has had several years of difficulties. Other factors include duration of each episode, severity of symptoms, missed time at school or work and response to antibiotic treatment.
A large part of the decision-making process hinges on an accurate history from the parents. The addition of clinical notes or a letter from the primary care provider is extremely helpful in corroborating the parental report.
Greg Licameli, MD, FACS, is a pediatric otolaryngologist and director of the Cochlear Implant Program in Boston Children’s Hospital’s Department of Otolaryngology and Communication Enhancement.
Learn more about Boston Children’s Hospital’s Department of Otolaryngology and Communication Enhancement.