Pharyngeal and Palatine Tonsil Hyperplasia in Children
Essentials
The tonsils consist of lymphatic tissue. The palatine tonsils are situated in the oral cavity, the pharyngeal tonsil in the nasopharynx.
The pharyngeal tonsil cannot normally be seen by simple oral inspection but must be examined using a mirror to visualise the nasopharynx, or by nasal endoscopy.
The size of the tonsils varies from person to person and even in the same person depending on, e.g. whether they have an infection or not.
The pharyngeal and palatine tonsils normally grow during the first years of life. At school age, the tonsils gradually start decreasing in size until in adults pharyngeal tonsil tissue is practically non-existent and palatine tonsils are small.
Nothing needs to be done about large tonsils unless they cause symptoms.
Symptoms
Large tonsils may cause symptoms such as continuous nasal congestion, mouth breathing, snoring, sleep apnoea or swallowing problems.
In this case, the need for palatine and/or pharyngeal tonsil surgery should be assessed.
If a child has constant nasal congestion throughout the year and rhinitis often but the nasal meatuses are patent and allergies have been excluded, the congestion is presumably in the area of the pharyngeal tonsil.
Workup
Establishment of the symptoms and clinical examination are the only examinations needed. X-ray examination of the pharyngeal tonsil, for example, should not be performed.
Issues to be considered in clinical examination
Mouth breathing
Speaking voice (nasal voice or slurred speech)
Occlusion
Facial shape, any structural abnormalities
Size of the palatine tonsils (picture F2), any asymmetry, and appearance of the tonsils
Anterior rhinoscopy, patency of the nasal meatuses
Assessment of the size of the pharyngeal tonsil by mirror examination of the nasopharynx, if possible considering the child's age and cooperation
An ENT doctor can perform nasal endoscopy (nasofiberoscopy) on a child under local anaesthesia to assess the size of the pharyngeal tonsil.
Tonsillectomy is performed under general anaesthesia and for basically healthy children as day surgery.
In pharyngeal tonsil surgery, i.e. adenotomy, the pharyngeal tonsil is completely removed.
If palatine tonsil surgery is performed on a child due to the large size of the tonsils, today partial removal of the palatine tonsils, or tonsillotomy, is usually performed.
In tonsillotomy, only the section causing the obstruction is removed and tissue surrounding the palatine tonsil is not touched.
After tonsillotomy, there is less pain, recovery is more rapid and there are fewer complications than after tonsillectomy.
The most common complications of tonsil surgery are bleeding and postoperative inflammation.
Criteria for referral
The child has been diagnosed with enlarged palatine tonsils and/or the pharyngeal tonsil (confirmed or suspected) and has a long history (several months) of interfering symptoms due to tonsils.
The usual symptoms in children include persistent snoring, apnoeas during sleep, persistent nasal congestion, mouth breathing and difficulty swallowing.
If only nasal congestion is the symptom, a trial of nasal glucocorticoid spray is recommended.
Symptoms often ease after the infection season, so the symptoms can well be followed-up through the summer.
Check local policies and criteria for more detailed information on referring a patient to a specialized ENT unit for assessment of the need for surgery.
References
Akcay A, Kara CO, Dagdeviren E, Zencir M. Variation in tonsil size in 4- to 17-year-old schoolchildren. J Otolaryngol. 2006 Aug;35(4):270-4.