Adenoid tonsil (polyps)

In this chapter I will try to answer questions related to that mysterious adenoid tonsil (sometimes also called polyp nasal). What is that adenoid tonsils? What is the connection between adenoid tonsil and otitis media or otitis media with exudate? When should its existence be suspected? And what is the preferred way of diagnosis and treatment?

What is the adneoid tonsil and what is its location?

The tonsils are clusters of lymphatic tissue that are scattered in several places in the body.
The first two tonsils, are the same two bumps that can be seen quite symmetrically when the child opens his mouth, see in the picture.
The adenoid tonsil is a similar tissue located in the area of the back nasal wall. It is similar in its round shape to the two tonsils in the pharynx, only less grooved.
The location of the adenoid tonsil is in the posterior nasal wall, next to the opening of a canal that connects the middle ear cavity to that area.
The importance of the adenoid tonsil, as of all other lymphatic tissue in the body is in primary protection against contaminants. Thus, it is more active in children aged 3 to 6 years. Usually after the age of 8 years this tissue recedes and decrease in size.
Let me start with the latter and say that although this tissue has a role in protecting the body, the removal of that third tonsil does not cause an immune deficiency.


What's the problem with that adenoid tonsil?

In young children, this lymphatic tissue undergoes irritation and often increase in size after infection with many contaminants, especially viral. As the adenoid tonsil grows, a number of problems can occur:
Nasal obstruction – imagine that the part in the back area of the nose is blocked and air movement is blocked.
Blockage of the canal that connects the middle ear cavity to the nose.

What is the clinical signs that can be found in children with a large / obstructive adenoid tonsil?

The clinical signs are diverse, usually a combination of:
nasal obstruction and oral respiration, hypo-nasal speech (speech like that of a person with a cold), partial loss of taste, poor appetite and insufficient weight gain.
In addition, prolonged runny nose.
"Adenoid face" – a child with an open mouth, an elongated face and a high palate.
In sleep – noisy breathing to the point of snoring and suffocation, shortness of breath, sleep apnea, restless sleep and even night terrors, strange sleeping positions and nocturnal enuresis. As a result of that unsatisfying sleep there is sleepiness during the day.
All of these, individually or all together, can later lead to behavioral problems, attention deficit disorders and cause low school outcomes.
Because of the blockage of the same ear canal, there can be a high incidence of Acute otitis media with with effusion (fluid in the ears) and later also Acute otitis media .


How can a adenoid tonsil-related problem be diagnosed?

A combination of a typical story, proper physical examination, sleep lab, a lateral neck x-ray and flexible endoscopy.
A typical story – the experienced doctor will hear from the parents a story that corresponds to an enlarged adenoid tonsil. However, in borderline cases the story is not fully suitable for this diagnosis, and further tests are needed to confirm the diagnosis.
Typical physical examination – it is not possible to check the size of the adenoid tonsil in a standard physical examination. But a physical examination of the site can find a number of suspicious findings that I mentioned earlier. I will emphasize that the tonsils in the pharynx do not necessarily indicate the size of that adenoid tonsil.
Sleep lab – a sleep lab can provide accurate and helpful information about abnormal breathing in sleep, that is secondary to the same nasal obstruction,
Lateral neck X-ray – apparently supposed to show the approximate size of the adenoid tonsil.
Endoscopy examination – an endoscope is a flexible tube with a camera at the end that is inserted into the child’s nose for a short time. This exam in performed while the child is awake, not sedated. This is of course the most accurate test because it will directly show the size of the adenoid tonsil and how significant the airway obstruction is. However, the test is unpleasant, takes time and is performed in this context only by an ENT specialist in some clinics.
There is no real answer to the question of when this or that test should be done. In unequivocal cases most specialists will not turn to auxiliary tests at all while in borderline cases a sleep lab can be used.
I will note that a lateral neck X-ray is considered an outdated and inaccurate test and is performed less and less.
Endoscopy is of course the most accurate but also the most invasive test.

What is the treatment of an enlarged adenoid tonsil?

Keep in mind that in most cases the size of the adenoid tonsil and the partial blockage it causes, if any, justify waiting and follow-up only.
However, when it comes to a blockage that causes significant symptoms as well as recurrent ear infections, there is room to consider removing the adenoid tonsil in surgery. The surgery is called an adenoidectomy, which means a resection of the adenoid.

What are the factors that are taken into account when deciding on surgery for adenoid tonsil?
Several variables are taken into account before deciding on surgery.
Most importantly, an attempt to quantify the intensity of the symptoms and the ability to unequivocally link them to the blockage and size of the adenoid tonsil.
A child with an appropriate clinical signs, who has undergone an endoscopy that demonstrates a large and obstructing adenoid tonsil, has an indication for surgery.
But most cases in life are not unequivocal.
Many other data will be taken into account, including the age of the child (since the adenoid tonsil may diminish in size after the age of 8 years) and even the season of the year. Before winter the expectation is that the child will be infected with many viruses and the adenoid tonsil will thrive. It is the oppsite case before the summer season.

What is the connection between adenoid tonsil surgery and ventilation tubes surgery?

Since the adenoid tonsil is sometimes one of the causes of otitis media with effusion (fluid in the ears), in the same operation, ventilation tubes will also be inserted into the eardrum and the adenoid tonsil will be removed.
The decision is made by the parents and the surgeon according to the anamnesis and the findings in the child’s examination.

Should a adenoid tonsil be removed is it necessary to remove or reduce the two tonsils in the mouth as well?

The indications for the removal of the adenoid tonsil are usually different from the indications for the removal of the tonsils in the pharynx. Therefore, these two procedures will usually not be performed together.
However obstruction of the airways (nose and pharynx) due to enlargement of the tonsils (the adenoid tonsil and the two tonsils in the pharynx) can happen and then parents will be offered concurrent surgery to reduce those two tonsils in the pharynx.

What is the expectation after surgery to remove a adenoid tonsil?

The decision to have any surgery, even if it is very common in pediatrics, is a major decision that needs to be seriously considered. The decision is usually made by the parents on the base of a recommendation from the surgeon, a pediatric ENT specialist. The experience of a pediatrician who is not a surgeon can be used.
In those cases where there is really an indication for surgery, I see a fundamental change in the children being operated on in the short and long term.
In the short term, breathing and sleep become better. Later, the child shows a positive behavioral change, an increase in appetite and even a jump in growth.
Not to mention a decrease in the frequency of the same chronic cold that the child suffered from, ear infections and lots of antibiotic treatments that the child received before the operation.
In order to get such a response, I recommend that parents go to an ENT consultation that also has experience in children and is not in a hurry to operate, as most of those cases do not require surgery.

In conclusion, I have not explored in this chapter the subject of surgical technique or potential complications. I recommend that parents refer these questions clearly to the surgeon, ENT specialist who specialize in pediatrics.

But hopefully the chapter will help you, like the other chapters on the site,to get more accurate advice and treatment for your toddler.