The tonsils and adenoids are collections of immune tissue located in the throat and nasal passages. As part of the lymphatic system, they are strategically positioned to monitor the air and food entering the body. While they serve a defensive function, their location can make them prone to infection or enlargement.
Location and Role in the Immune System
The tonsils (palatine tonsils) are two oval masses of lymphoid tissue visible on either side at the back of the throat. The adenoids (pharyngeal tonsils) are a single patch of similar tissue located higher up, directly behind the nose in the nasopharynx. Because the adenoids are situated behind the soft palate, a medical professional must use specialized equipment, such as an angled mirror or a flexible camera, to view them.
These tissues function as a first line of immunological defense by sampling pathogens from the air and food passing through the upper respiratory tract. The lymphoid tissue contains specialized white blood cells, including B cells and T cells, which trap bacteria and viruses. By processing these invaders, the tonsils and adenoids help the body generate antibodies and initiate an immune response.
The activity of the tonsils and adenoids is most pronounced during early childhood, when the immune system is encountering foreign substances. They typically reach their maximum size between the ages of three and seven. As the child ages and the body develops other immunological defenses, these structures naturally begin to shrink, often disappearing by adulthood.
Recognizing Common Problems
Problems with the tonsils and adenoids generally arise from two primary issues: recurrent infection (tonsillitis or adenoiditis) and excessive physical enlargement (hypertrophy). Infection occurs when the lymphoid tissue, acting as a filter, becomes overwhelmed by bacteria or viruses. This infection can result in symptoms such as throat pain, fever, and white patches or pus (exudates) on the tonsil surface.
A common bacterial cause of tonsillitis is Streptococcus, often referred to as strep throat. Infections lead to inflammation and swelling, and repeated infections can cause the tonsils to become permanently enlarged. Even without frequent infection, these tissues can grow too large, physically obstructing the air passages.
Enlargement poses a greater problem for children because their upper airways are naturally smaller. Adenoid hypertrophy specifically obstructs the nasal airway, leading to chronic mouth breathing, a persistently runny nose, and a muffled, “stuffy-nose” voice quality. Enlarged adenoids can also block the opening of the Eustachian tubes, which connect the middle ear to the throat, resulting in chronic or recurrent middle ear infections.
When tonsillar hypertrophy is the dominant issue, the main symptom is loud snoring and disturbed sleep. In more severe cases, this physical obstruction leads to Obstructive Sleep Apnea (OSA), where breathing momentarily stops or becomes significantly shallow during sleep. The resulting poor sleep quality can contribute to daytime fatigue, behavioral problems, and difficulty concentrating, making the management of hypertrophy a priority in pediatric care.
When Surgical Removal is Necessary
The decision to surgically remove the tonsils (tonsillectomy) or adenoids (adenoidectomy) is based on clear medical criteria addressing chronic infection or airway obstruction. For recurrent infection, a tonsillectomy may be recommended based on the frequency of severe throat infections. These criteria often include:
- Seven or more infections in one year.
- Five or more in each of the preceding two years.
- Three or more in each of the preceding three years.
To meet these guidelines, a throat infection must be documented and include symptoms such as fever, pus on the tonsils, or a positive test for a bacterial cause like Streptococcus. Less frequent infections may still warrant surgery if accompanied by modifying factors, such as a history of a peritonsillar abscess or antibiotic intolerance.
Airway obstruction is the second major indication for removal, especially when leading to Obstructive Sleep Apnea. Surgery is considered if the tonsils or adenoids are significantly blocking the airway, causing difficulty breathing during sleep, or resulting in difficulty swallowing. An adenoidectomy alone may be recommended for persistent nasal obstruction, chronic sinusitis, or chronic middle ear fluid resistant to other treatments.
The overarching goal of both tonsillectomy and adenoidectomy is to improve the patient’s quality of life by eliminating the source of chronic infection or resolving the airway obstruction. Since the body has many alternative mechanisms to fight infection, the removal of these tissues does not typically compromise the integrity of the immune system. The procedures are highly effective for improving sleep, reducing the frequency of illness, and resolving associated issues like chronic ear infections.