My daughter is nine years old and has very large tonsils. When she opens her mouth to say "ahh," one of the tonsils covers over half of her throat and the other is right along side it. Her voice is very "husky" sounding. She prefers soft foods such as pasta, and she doesn't like to eat meat. Our doctor says she's fine, but the tonsils seem to be getting larger and larger. I worry that she won't be able to breathe. Am I overreacting?

B.

Here's what you need to do. Listen to her when she sleeps. Does she snore? If so, does it sound as if she is struggling for air? Sometimes, a child will snore for a while, and then there will be a quiet period, followed by a loud snort or gasp. The quiet period may represent an "apneic pause," meaning that the child is NOT BREATHING during this interval. If your daughter does this often enough, she has obstructive sleep apnea (OSA), a condition in which an anatomical obstruction (in this case, big tonsils) blocks the airway, resulting in frequent apneic pauses.
Obstructive sleep apnea is a serious problem. If your daughter has this problem, she needs to have her tonsils and adenoids removed. (The adenoids are made of tissue very similar to the tonsils. Adenoids are located high in the throat, above the soft palate and behind the nasal cavities. In this location, big adenoids can cause obstruction of the nasal airway, contributing to obstructive sleep apnea. They may also account for part of her "husky voice.")

How can you know for certain if she has OSA? If she breathes comfortably during sleep, with little or no snoring, then she probably does not have OSA. If she snores loudly but does not have apneic pauses, she probably does not have OSA. Nevertheless, you may want to make a tape recording (or better still, a videotape) of your daughter while she sleeps and play it for your daughter's doctor.

You may also want to see an ear, nose and throat doctor (ENT) for a second opinion. Fortunately, most ENTs are not "cut-happy." Don't assume that an ENT will recommend a tonsillectomy just because the tonsils are big! The doctor will question you and your daughter carefully about whether she snores, what her snoring is like, the frequency and severity of her sore throats and so forth. An ENT could watch the videotape and have a very good idea whether your daughter has OSA.

Occasionally, if the situation is very ambiguous, a sleep study (called "polysomnography") is necessary to make the diagnosis of OSA. Your daughter would be connected to a variety of monitors to follow her heart rate, the electrical activity of her heart and brain, her respiratory rate, the oxygen saturation of her blood and several other parameters. A doctor would review all of this data to determine whether or not she has OSA, and if she does, the severity of the problem.

What if she does not have OSA, and her only problem is a husky voice and difficulty eating certain foods? In this case, you and your daughter should have an in-depth discussion of surgical risks with an ENT. Many ENTs would NOT remove a child's tonsils for reasons such as these. If you find an ENT willing to perform this operation, you and your daughter need to have a very clear understanding of the risks of this operation.