Editors

LauraK.Mäkinen

JohannaNokso-Koivisto

Pharyngeal and Palatine Tonsil Hyperplasia in Children

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.

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.
- See also the article Sleep disorders in children and adolescents Sleep Disorders in Children and Adolescents.
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.

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 2), 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.

If a child is found to have prolonged symptoms due to large tonsils, palatine and/or pharyngeal tonsillectomy can be considered.
If a child has constant rhinitis and nasal obstruction, before referral to a specialist a therapeutic trial with an intranasal glucocorticoid Intranasal Corticosteroids for Nasal Airway Obstruction in Children with Adenoidal Hypertrophy for 1-3 months can be performed.
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.

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.