Third tonsil (adenoid or polyps)

What kind of problems does the third tonsil (adenoid) cause?

In young children, this lymphatic tissue undergoes stimulation and often increases in size following infection by different pathogens, especially viruses. When the third tonsil enlarges, several problems may arise:
Obstruction of the nasal airway – imagine that a part of the area at the back of the nose is obstructed and the air passage is blocked.
Obstruction of the canal that connect the middle ear space to the nose.

What are the clinical signs and symptoms that children with an enlarged/obstructive third tonsil present with?

The clinical signs and symptoms may vary and often include a combination of the following:
# Obstruction of the nose and breathing through the mouth, hyponasal speech (similar to the way a person with a cold would talk), partial loss of taste, decreased appetite and insufficient weight gain.
In addition, continuous runny nose.
# “Adenoidal face” – a child with an open mouth, elongated face and high palate.
# During sleep – noisy breath that may lead to snoring and suffocation, difficulty breathing, breathing cessation, sleep apneas, broken sleep, sleep terrors, awkward sleeping positions and bed wetting. As a result of insufficient sleep during the night, sleepiness during the day may occur.
# All of these, whether they occur at the same time or separately, can eventually cause behavioural problems, attention deficit disorders and may lead to learning problems at school.
# Because of the obstruction to the ear canal, there could be a high prevalence of ear infections with effusion (ear fluid), which may later cause middle ear infection.

How can problems related to the third tonsil be detected?

This can be done with the help of a combination of characteristic history of the present illness, a suggestive physical examination, sleep lab test, lateral neck radiography and flexible endoscopy. Let’s talk about each of these separately.
Characteristic history of present illness – the experienced physician will ask questions to find out whether the child has a characteristic medical history of an enlarged third tonsil. Nonetheless, if the history is borderline suggestive of enlarged third tonsil, additional examinations will be needed to determine the diagnosis.
Characteristic physical examination – we do not have a way of assessing the size of the third tonsil in a standard physical examination. But there are other findings that may suggest enlarged third tonsil upon physical examination that I mentioned earlier. It’s worthwhile emphasizing that the size of the tonsils in the mouth do not necessarily indicate anything about the size of the third tonsil.
Sleep lab test – we used to think that sleep lab tests can give us accurate and helpful information about sleep disorders secondary to nasal obstructions. But we now know that the correlation between sleep lab tests and the severity of the problem is not very strong. Therefore, use of sleep lab tests can be helpful but are only used to strengthen a decision when the case is borderline, and the diagnosis is not clear cut.
Lateral neck radiography – this is supposed to demonstrate the relative size of the third tonsil. In practice, this is considered an outdated test and it exposes the child to radiation, it is inaccurate and is not used very often for this purpose. If you have been referred to a lateral neck radiography to assess the third tonsil, your referring physician should have a very good reason for it.
Endoscopic examination – an endoscopy is a flexible tool that has a camera in one end and it is inserted into the child’s nose for a brief period of time. This is, of course, the most accurate exam, because it allows direct visualization of the third tonsil and its size, and it allows us to see how severe the obstruction is. Nonetheless, this is an unpleasant examination, it may take time and can only be performed for this purpose by an ENT specialist in specific clinics.

So, what is the test of choice for the detection of the adenoid / third tonsil and does it always have to be carried out to determine the diagnosis?

The test of choice is endoscopy but does not always have to be carried out. Actually, when the case is clear cut, most specialists will not refer you to any additional exams while for borderline cases, sleep lab tests may be referred to, for example.
I will say this again, lateral neck radiographs are considered outdated and inaccurate tests, and are being done less frequently nowadays.
On the other hand, endoscopy is, of-course, the most accurate test but also the most invasive.

What is the treatment for enlarged third tonsils (adenoids) in children?

Keep in mind that in most cases the size of the third tonsil and the partial obstruction that it is causing, if any at all, allow for watchful waiting.
Nonetheless, when the obstruction of the nose is causing significant symptoms, such as recurrent ear infections, it is reasonable to consider surgical removal. The surgery is referred to as adenoidectomy, that is, resection of the adenoid.

What are the different factors that are considered when making a decision regarding the removal of the third tonsil (adenoidectomy)?

There are several variables that are taken into consideration prior to determining whether a surgery should be performed.
The most important one is an attempt to quantify the severity of the symptoms and the ability to clearly associate them to the size of the tonsil and the obstruction it is causing.
If the child presents with suggestive signs and symptoms and has undergone endoscopy that has demonstrated an enlarged and obstructive third tonsil, then surgery is indicated.
But most of the cases are not so clear cut.
There are many other factors that may be taken into consideration, including the age of the child (because of the fact that the third tonsil typically shrinks in size after the age of 8) and even the season and time of year.
Typically, before the winter season, we expect the child to catch lots of viruses and for the third tonsil to enlarge. The opposite is true before the summer season.

What is the association between surgery for removal of the third tonsil and ventilation tubes?

Sometimes the third tonsil is one of the causes of otitis media with effusion (ear fluid), and sometimes ventilation tubes are inserted during surgical resection of the third tonsil.
The decision is made by the parents and the surgeon, depending on the medical history and findings in the child.

Do the two tonsils in the mouth need to be resected or reduced in size during surgical resection of the third tonsil?

The indications for removal of the third tonsil are different to the indications for removal of the two tonsils in the mouth. Therefore, usually, these two procedures will not be carried out at the same time.
Nonetheless, obstruction of the airway can be caused by enlargement of all the tonsils (the two tonsils in the mouth and the third tonsil), then resection of all three may be offered. Find out more about reduction or resection of the two tonsils in the following link.

What do we anticipate will happen in a child following resection of the third tonsil and does this always occur?

Any decision for surgery, no matter how common it may be in pediatrics, is a major decision that should not be taken lightly. The decision is typically made by the parents following a recommendation given by a surgeon, a specialist in pediatric ENT. You can always consult with your primary care pediatrician and ask for their opinion and experience (even though they are not the surgeons who perform the surgery).
When there is an indication for surgery, I tend to see a significant change in the children following surgery, both in the short and long term.
In the short term, their breathing and quality of sleep improve. I also tend to see a positive behavioural change later on, an increase in appetite and even an improvement in growth.
Not to mention, a reduction in the prevalence of chronic runny nose that the child suffered from, ear infections and the many courses of antibiotics that the child needed prior to surgery.
To get this kind of response, I recommend the parents seek the consult of a pediatric ENT that has lots of experience in children but is also not in a rush to perform surgery on all those cases that do not really need it. Many of these surgeries performed around the world are unnecessary, and in those children where it was not necessary to begin with, you do not see any clinical changes before and after the surgery.

What about the surgical technique?

Generally speaking there are two different surgical techniques – a “cold” resection, carried out with the help of a scalpel/scissors or a similar device and a “warm” resection, done with the use of heat (diathermy). Sometimes the two different techniques are combined.
But this is all I will say about the surgical techniques. I will not go into the details of the surgical techniques or the potential complications in this chapter. I certainly encourage parents to ask their surgeon, the pediatric ENT specialist, all these questions in a clear manner.

Did you say pediatric ENT specialist?

Yes.
When it comes to such a common procedure, that can turn into a business for the surgeon, I recommend you make sure that when you go for a consult for your precious child you are seeing a pediatric ENT specialist. Not an adult ENT specialist that also sees children. Not someone who does it because there aren’t enough pediatric specialists. But a pediatric specialist. Make sure they are specialized in pediatrics before your first encounter with them and certainly before the surgery.

In summary, this is an important topic in pediatrics and has its specific points. I hope this chapter will help you, just like other chapters on this website, receive a better consult and treatment for your child.