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Enlargement of palatine tonsils and adenoid lymphoid tissue that contributes to obstruction of the upper airway

  • Results in sleep disordered breathing defined as an abnormal respiratory pattern during sleep including snoring, mouth breathing, and pauses in breathing which may be symptoms of obstructive sleep apnea (OSA)


  • Volume of lymphoid tissue increases from 6 months of age to puberty; peak of OSA in preschool years, when tissue makes up greatest proportion of upper airway

  • Associated craniofacial and neuromuscular disorders and obesity increase likelihood of symptomatic adenotonsillar hypertrophy..


  • The underlying etiology of adenotonsillar hypertrophy is unknown.

  • Upper airway obstruction is multifactorial and includes hypertrophied lymphoid tissue, compliance and elasticity of pharyngeal soft tissue, facial morphology, and changes to the pharyngeal musculature during sleep.

  • Cyclic airway obstruction during sleep causes hypoxia and hypercapnia, leading to arousals to restore respiration.

  • Repeated arousals interrupt rapid eye movement sleep, which can lead to daytime somnolence.

Clinical Manifestations

  • Nighttime: Snoring, apnea, restless sleep, enuresis, nightmares

  • Daytime: Somnolence, behavioral changes, learning difficulties, nasal obstruction, mouth breathing, hyponasal speech; in severe cases, dysphagia, failure to thrive

  • Degree of tonsillar enlargement: Tonsil within fossa = 0; less than 25% obstruction = 1+; less than 50% obstruction = 2+; less than 75% obstruction = 3+; greater than 75% obstruction = 4+ (Brodsky grading scale) (Figure 25-1).

Figure 25-1

Assessing the Degree of Tonsillar Enlargement Using the Brodsky Grading Scale. Reproduced with permission from Brodsky L: Modern assessment of tonsils and adenoids, Pediatr Clin North Am 1989 Dec;36(6):1551–1569.


  • Overnight polysomnography is definitive test for OSA.

  • Lateral neck radiograph versus flexible nasopharyngolaryngoscopy (NPL) to assess adenoid size and airway caliber; however, volume of tonsils and adenoids do not always correlate well with severity of OSA.

  • ECG and/or echocardiogram in severe, longstanding OSA to rule out cor pulmonale—Right heart strain, right ventricular hypertrophy



  • Nasal corticosteroids decrease nasal turbinate and adenoid hypertrophy and may decrease severity of OSA, improve snoring, and improve nighttime symptoms such an enuresis, though long-term effectiveness is unclear. Dosage—1 spray in each nostril daily (if <2 years, give every other day)

  • Noninvasive positive-pressure ventilation (e.g., continuous positive airway pressure)

  • Weight loss for obese patients


  • Indications for adenotonsillectomy

    • ✓ Sleep disordered breathing leading to daytime and nighttime symptoms, and all children with documented OSA

    • ✓ Nasal obstruction causing discomfort in breathing and distortion of speech, or recurrent otitis media (adenoidectomy only)

    • ✓ Dysphagia or speech disturbance (dysarthria or hypernasality) due to large tonsils (tonsillectomy only)

    • ✓ Chronic tonsillitis: Seven episodes in the past year, five ...

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