by Ann-Marie C. DePalma, RDH, BS
Upon returning home from an awesome weekend at Under One Roof in Chicago, I felt energized as both a clinical hygienist and a presenter. Those who were there know what I mean. After telling my co-workers about the fabulous courses and new friends I made, I enjoyed a few days of relative peace and quiet until my next challenge — my six-year-old son's tonsil- and adenoid-ectomy.
We are fortunate to live close to Boston and one of the best children's hospitals in the country. We had already experienced Children's Hospital through my eleven-year-old son. But since we hadn't been faced with medical issues for some time, we had forgotten about the tremendous work done there.
When we told family, friends, and patients about the impending surgery, they most often asked, "They still do that?" In fact, tonsil and adenoid surgery is undergoing a resurgence. Tonsils and adenoids are lymphoid tissues located on the sides and roof of the throat/oral pharynx.
What is normally considered "tonsil" is actually the palatine tonsil, located in the oropharynx between the anterior and posterior pillar of fauces. The adenoids are the nasopharyngeal tonsils located at the back of the nasal cavity. The lingual tonsils are located at the back of the tongue, and along with the adenoids, are not readily visible.
The tonsils and adenoids are comprised of large numbers of white blood cells that help fight infection and may contain numerous crypts that can harbor bacteria as well as white blood cells. During a bacterial or viral infection, the tonsils and adenoids tend to enlarge. Enlarged tonsils and adenoids are not usually diseased, and, as children become teens and young adults, the tissues tend to decrease in size.
Adenoid tissue is barely detectable in most people by age 20. The average age at which the adenoids begin to shrink is five, while the tonsils usually begin shrinking about age seven. The median age of T&A surgery is six to seven.
Reaching the decision to remove tonsils
Tonsils and adenoids enlarge in patients with allergies. One ear, nose and throat doctor noted that children with normal size tonsils and adenoids might see increased growth during allergy seasons. The increase in environmental allergies during the last several years has led to a growing number of T&A surgeries. Pollens, animal hair, chemicals, and other airborne particles may come in contact with the T&A tissues. If there is chronic stimulation, the tonsil and adenoid tissues become enlarged. Because of this, it is common for even adults with nasal allergies to maintain a significant amount of adenoid tissue.
Previously, tonsils and adenoids that needed to be removed were operated on at the same time. Today's procedures may or may not do this. They may be removed separately or together, depending on the patient's needs. One reason for tonsil removal only is repeated throat infections where the tonsils act as a reservoir of infection. Recent guidelines recommend tonsil removal if a person experiences seven or more sore throats or infections in one year. Another reason is that a tonsillar infection can spread beyond the tonsil tissues into the surrounding tissues, resulting in a serious infection of the neck. This type of infection is referred to as a periotonsillar abscess. Also, if one tonsil is larger than the other, it is often recommended to remove both to make sure there is not a tumor.
Indications for adenoid removal include recurrent adenoidal infections or obstruction of the nasal passage by the enlarged adenoidal tissues. In order to determine if removal of the adenoids is necessary, a doctor will perform an evaluation of the tissues at the back of the nasal passage. This can be done radiographically, or by using a long mirror with illumination placed at the back of the patient's throat. The amount of available airway space is evaluated, and, in children and adults with small throats, the tonsils may also be removed.
Sleep apnea and snoring, as well as persistent mouth odors, may also be indications for adenoid and/or tonsil removal. Some studies suggest that adenoid removal may aid in eustachian tube function and reduce the incidence of middle ear infections and fluid buildup (otitis media and otitis media with effusion), although this has not been proven. Vocal quality resulting in a hypo-nasality of speech may also be a sign for removal. Also, a post T&A patient can exhibit a hypo-nasality, either temporarily or permanently. Speech therapy can alleviate this problem.
Tonsil and adenoid surgery is not without complications. Bleeding, which may last seven to 14 days post-operatively, is the primary concern. Fever, dehydration, ear pain, stomach upset, vomiting, and mouth odor are also common. Less frequent concerns are infections and the possibility of fluids leaking back through the nose while eating or drinking.
Tylenol with codeine is usually given to relieve pain. A soft diet that avoids dry, crusty foods for 14 days post-op is advised, along with limitation of the child's activities.
Sleeping in the chair and tardiness
My son, Christopher, had experienced chronic snoring, hypo-nasality, and a lack of deep restful sleep. We did not notice episodes of sleep apnea, but we also did not have a sleep study done. These symptoms, coupled with the ENT's finding of enlarged tonsils and adenoids, resulted in our decision for surgery. An overnight, post-operative observation hospital stay was recommended, which Christopher thought was cool because he got to sleep in the big hospital bed, while mom had to sleep in the chair "bed!"
Our surgical day actually began the previous night, when we allowed Christopher to stay up late since he was scheduled for surgery at 1:30 p.m. the next day and was NPO eight hours prior. However, he did not actually enter surgery until 4 p.m. due to medical emergencies that involved his doctor. After surgery, the doctor spoke with us regarding his findings. The adenoids were indeed large, but the tonsils were much larger than expected, with a lot of chronic infection present that had not been noted before. He and the nursing staff apologized profusely for the delays.
The apologies made me think about how often we, as dental professionals, run late and don't acknowledge it. Our tardiness is often due to lack of time to complete our clinical procedures. Dental hygienists function on a time crunch — intra/extra oral exams, medical history updates, radiographs, charting, and clinical procedures are just some of the vast clinical aspects that must be accomplished in a 45- to 60-minute appointment. We should acknowledge when we're late, because our patients' time is as valuable as ours, and acknowledging lateness can set your office apart from another.
As for Christopher's surgery, he did well initially. But several days later, he developed a slight bleeding problem and we took him back to the hospital for an evaluation. Without even looking at his throat, the triage nurses knew he was dehydrated, even though he did not exhibit the typical dehydration signs I was told to look for — lack of urine output and crying with no tears. However, he did have pale skin, dry lips, a coated tongue, and mouth odor. IV fluids, another hospital stay, and lots of new toys did the trick!
For more information regarding tonsils and adenoids, contact:
• American Academy of Otolarngology-Head and Neck Surgery, Inc., Alexandria, Va., (703) 836-4444, www.entnet.org
• Children's Hospital, Boston, Mass., (617) 355-6000, www.childrenshospital.org
Information used in this article came from the Children's Hospital Information Packets, ENT Web site, and Dental Hygiene: The Pulse of the Practice by Cynthia McKane-Wagester, RDH, Pennwell Publishing (2002).
As hygienists regarding tonsils and adenoids, what should we look for in patients who may be candidates for T&A surgery? During the intra/extra oral exam, we should evaluate the tonsillar area for signs of enlargement or infection. Is there enough space around the uvula to allow for speech production and swallowing? A reduction in the airway space does not allow normal airflow into the oral cavity.
This observation may be difficult in young children because of the high position of the tongue in the oral cavity. Visually, an idea can be obtained by the position of the uvula in relationship to the tonsils. A uvula positioned in front of the posterior faucial pillar may indicate a history of large tonsils.
Is the patient a mouth breather? This can be an indication of large adenoids and airway obstruction. Also, evaluate the texture and any cratering or fissuring along the tonsillar surface that could represent a site for bacteria collection. Scar tissue could also be indicative of frequent infections.
Ask the parent/care giver if the child has bed-wetting episodes beyond age appropriate stages, slow growth, or a struggle to get air while sleeping. These can all be subtle signs of tissue enlargement. The child may also be irritable and lack focus at the middle to end of the day due to lack of restful sleep. Sleep apnea resulting in lack of oxygen can even lead to developmental delays, and later in life, hypertension and heart disease.
Referral to an ENT physician is appropriate if conditions warrant.
Ann-Marie C. DePalma, RDH, BS is a practicing hygienist in a periodontal-implant practice.She is a graduate of the Forsyth School for Dental Hygienists, is active in the Massachusetts Dental Hygienists' Association, and is a Fellow of the Association of Dental Implant Auxilliaries and Practice Management.Ann-Marie has written articles and presents programs on dental implants, TMD, and developmental delays and can be reached at [email protected].