When Do a Child's Tonsils and Adenoids Need to Come Out?

A child's tonsils and adenoids may need to come out when they cause repeated, well-documented throat infections or block breathing during sleep, which can show up as loud snoring, pauses in breathing and restless nights. Less often, ongoing ear fluid or a throat abscess is the reason. Most swollen tonsils do not need surgery. This article explains the main reasons, when watchful waiting is reasonable, what recovery involves, and which warning signs need emergency care.

When a child's tonsils and adenoids need to come out

Surgery to remove the tonsils (tonsillectomy), the adenoids (adenoidectomy), or both is one of the more common operations in childhood. Even so, big tonsils alone are not a reason to operate. Many children have large tonsils and adenoids during the preschool and early school years, and in many cases they shrink in proportion as the child grows.

Clinicians usually consider surgery for one of these situations:

• Repeated throat infections that are frequent, severe and documented by a clinician over a sustained period.
• Sleep-disordered breathing, including snoring with breathing pauses, that may be linked to enlarged tonsils or adenoids.
• Ongoing middle ear fluid or repeated ear infections, where the adenoids may be part of the problem.
• Complications such as a peritonsillar abscess (a pocket of pus beside a tonsil).
• Findings on examination, such as one tonsil clearly larger than the other, that call for a closer look.

The decision usually rests on your child's history, an examination, and sometimes a sleep evaluation. It is a shared decision between you and an ear, nose and throat (ENT) surgeon or pediatrician.

What tonsils and adenoids do, and why they swell

The tonsils sit at the back of the throat on each side. The adenoids sit higher, behind the nose, where you cannot see them by looking in the mouth. Both are lymphoid tissue that helps the immune system respond to germs, mostly in early childhood. MedlinePlus from the NIH describes the adenoids as tissue that can become enlarged or infected and can then block the airway behind the nose.

Several factors can contribute to swelling. Viral and bacterial infections are common ones. Allergies, irritants and normal growth patterns may also play a part, and researchers are still studying how the bacteria living in the nose and throat influence this. One cause rarely explains everything, which is why the evaluation looks at the whole picture.

Recurrent tonsillitis: how many infections are enough?

MedlinePlus (NIH) explains tonsillitis as inflammation of the tonsils, usually from a virus and sometimes from bacteria such as group A strep. Most sore throats are viral, get better on their own, and do not lead to surgery.

When children have many infections, clinicians weigh how many episodes occurred, how severe they were, and whether a clinician recorded them with findings such as fever, swollen glands, tonsil pus or a positive strep test. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline on tonsillectomy in children supports considering surgery for recurrent throat infections when a child has had at least 7 well-documented episodes in one year, at least 5 per year for 2 years, or at least 3 per year for 3 years. Ask your child's clinician how your child's history fits, since the guideline also allows for individual circumstances.

Keeping a simple record helps. Note the dates, the highest temperature, any strep test results and any antibiotics given. A written history is often more persuasive in a visit than memory alone. If you are unsure whether a given sore throat is strep, see the related article on telling strep from other sore throats.

In children who meet these criteria, surgery may modestly reduce the number of sore throats, according to the AAO-HNS guideline, but the benefit varies and some children still get them. Children with milder or less frequent episodes may do just as well with watchful waiting.

Snoring, restless sleep and breathing pauses

Enlarged tonsils and adenoids are a common contributor to obstructive sleep apnea and other sleep-disordered breathing in children. MedlinePlus (NIH) describes sleep apnea as breathing that repeatedly pauses or becomes shallow during sleep. In children, it is not always loud, and the daytime effects can look different from adults.

Signs that may suggest a problem at night:

• Loud, frequent snoring, especially with gasping or snorting.
• Pauses in breathing that you can see or hear.
• Mouth breathing, sweating, or sleeping in unusual positions, such as with the neck stretched back.
• Restless sleep, frequent waking or bedwetting that is new.

Signs that may show up during the day:

• Trouble paying attention, hyperactivity or irritability.
• Morning headaches or unusual sleepiness.
• Difficulty with school or behavior that is new.

Occasional snoring during a cold is very common and does not by itself suggest sleep apnea. Persistent snoring with pauses, or snoring with these daytime effects, deserves a visit. The clinician may refer your child to an ENT specialist or arrange a sleep study (polysomnography). If your child stops breathing and does not restart when you wake or stimulate them, or turns blue or gray, call 911. For general sleep needs by age, see the related article on how much sleep a child needs.

Removing the tonsils and adenoids improves breathing during sleep in many children with enlarged tissue, but some still have apnea afterward, so the clinician may repeat sleep testing if symptoms persist. For mild symptoms, watchful waiting is sometimes reasonable. Children with other contributing factors, such as obesity, allergies or differences in facial structure, may need additional treatment. The clinician will discuss this with you.

Ear problems and the adenoids

The adenoids sit near the opening of the eustachian tube, the small channel that drains and ventilates the middle ear. Enlarged or chronically inflamed adenoids may contribute to fluid that stays behind the eardrum (otitis media with effusion) or to repeated ear infections. Research, including studies of the adenoid microbiome, suggests that bacteria in the adenoids may play a role, though the mechanism is not fully understood.

Many ear infections and fluid episodes clear up without surgery. A clinician may consider adenoid removal, often along with ear tubes, when fluid persists or returns, especially if it affects hearing. See the related article on ear infection signs in toddlers for the first steps, and MedlinePlus (NIH) on ear disorders for background. If you notice that your child does not respond to quiet sounds or is falling behind in speech, tell the clinician so hearing can be checked.

Less common reasons a surgeon may recommend removal

A peritonsillar abscess causes severe, often one-sided throat pain, a muffled voice, trouble opening the mouth and drooling. It needs urgent evaluation, and drainage is sometimes needed. A surgeon may discuss tonsil removal afterward if abscesses repeat.

Very large tonsils can make chewing and swallowing hard or cause choking on food. Persistent bad breath with tonsil stones or debris is a nuisance in some children, but it is usually not a reason for surgery on its own.

When one tonsil is clearly larger than the other, a clinician may recommend removal so the tissue can be examined. Serious causes such as lymphoma are much less common than ordinary infection or normal variation in size, and a difference in tonsil size alone does not establish any of them. If you are curious about the general topic, MedlinePlus has pages on throat disorders.

When watchful waiting makes sense

Watchful waiting is a reasonable choice for many families. It tends to fit when infections are fewer or milder, when sleep problems are mild or tied to seasonal allergies, or when your child is young and the tissue may shrink in relation to the airway as they grow. During this time, a clinician may suggest treating allergies, checking for reflux or other contributors, and reviewing the situation at set visits.

Watching does not mean ignoring. If new snoring, breathing pauses, school or behavior changes, or repeated infections appear, tell the clinician so the plan can be updated.

Risks of surgery

Tonsillectomy is done under general anesthesia, and most children go home the same day. Risks include reactions to anesthesia, pain, dehydration because swallowing hurts, and bleeding, which affects a small share of children and can happen days after surgery, so ask your surgeon about the bleeding rate in their practice. A long-term review of pediatric adenotonsillectomy at one high-volume hospital in Italy reported good outcomes with low complication rates, but results at a single center do not apply to every setting. Your surgeon can explain the risks that apply to your child, including any bleeding disorders or breathing conditions that raise them.

The AAO-HNS guideline advises overnight hospital monitoring for children under 3 and for children with severe sleep apnea. Ask your surgeon whether this applies to your child.

Recovery and warning signs at home

Throat pain is expected after tonsil removal and can last several days, sometimes with ear pain that is referred from the throat. Some bad breath and a low-grade fever can also occur in the first week. The surgeon will give written instructions on diet, activity and pain relief. Follow your surgeon's written plan for pain relief. Acetaminophen and ibuprofen are commonly used, dosed by your child's weight and the product label, and the surgeon or pharmacist can tell you how much is right for your child and whether ibuprofen suits them. Do not give extra medicines unless the surgeon or pharmacist says so. Aspirin is not given to children. Drug labeling says codeine should not be given to children after tonsil or adenoid surgery, and tramadol should not be given to children under 18 after it, because either can slow breathing, especially in children who process them unusually fast.

Fluids matter most. Children who will not drink can become dehydrated, which shows as dark or little urine, dry lips, no tears and unusual sleepiness.

Bleeding can occur after tonsillectomy, most often when the scabs in the throat loosen, and it can happen in the first couple of weeks after surgery. A little pink in the saliva can happen. Any bright red blood from the mouth or nose after surgery needs emergency care now. Call 911 if the bleeding is heavy, your child is pale, faint or having trouble breathing, or if you cannot get to the ER right away. Trouble breathing, blue or gray lips, or a child who is hard to wake also needs 911. If you cannot tell whether something is serious, call 911 or the surgeon's emergency line, and call Poison Control at 1-800-222-1222 if you think your child has had too much medicine.

When to Seek Medical Care