My eight-year-old daughter was recently referred to an ENT by her orthodontist, who felt that "mouth breathing" was contributing to her dental problem. The ENT recommended that she have her adenoids removed and also her tonsils, even though she has not had tonsillitis. My concern is: Is it necessary to remove the tonsils also? The ENT seems to be saying: "as long as we are in there we might as well take them, too." This doesn't seem like a good enough reason to me. What do you think?

M.D.

Trust your instincts. If this ENT (ear, nose and throat doctor) cannot give you a better reason to take out your daughter's tonsils, and if he refuses to remove only the adenoids, find another ENT.
Unfortunately, this ENT's attitude is not uncommon. While this habit appears to be a generational phenomenon, even some of the younger ENTs have been taught to always remove the tonsils and adenoids together. I was taught never to do ANYTHING without a good reason.

Before outlining the reasons for removing tonsils, adenoids or both, I ought to explain what these critters are. Tonsils and adenoids are "lymphoid" tissue, similar to the neck lumps one gets during a bad cold or flu. The tonsils are located on either side of the throat, near the base of the tongue; the adenoids are located high in the throat, above and behind the roof of the mouth. Lymphoid tissue is an important part of our body's immune system. Unfortunately, for many children (and adults), the tonsils and adenoids can be more trouble than they are worth.

Reasons to remove just the tonsils:

1. Frequent bouts of acute tonsillitis.
   
2. Chronic tonsillitis (persistent throat pain similar to tonsillitis pain in a patient who has had many episodes of acute tonsillitis).
   
3. Peritonsillar abscess (an "abscess" is a pus-filled hole surrounded by inflamed tissue; "peritonsillar" means behind the tonsil), particularly if it has occurred more than one time.
   
4. Tonsils that are so huge that they affect the child's ability to eat.
   
5. Concern that there may be cancer within one or the other tonsil.
   

Reasons to remove just the adenoids (assuming that enlarged adenoids have been documented, either by direct examination or by appropriate X-rays):

1. As in your daughter's case, chronic mouth-breathing, particularly if it is altering growth of the upper jaw.
   
2. Under some circumstances, frequent ear infections or persistent middle-ear fluid in a child.
   
3. Frequent problems with sinusitis (swelling of a nasal sinus) and/or rhinitis ("runny nose").
   

Reasons to remove the tonsils AND the adenoids together:

1. Obstructive sleep apnea.
   
2. Any separate, distinct reasons to have both tonsils and adenoids removed. For example, some children with recurrent acute tonsillitis will also get sinusitis/rhinitis whenever their tonsils are inflamed.
   

This is not an exhaustive list, but it covers many of the common reasons. Tonsillectomy is NOT a risk-free operation -- far from it. In my opinion, "as long as we're in there" simply does not justify the added risk of tonsillectomy.