Say Aaa! Then Zzz: Tonsillectomy Helps Kids Sleep

NPR

Tyler Scorza, 7, had his tonsils removed last year to help with his snoring.

Published: March 14, 2011

by Nancy Shute

Getting your tonsils out used to be just part of childhood — a rite of passage for children in the 1950s and '60s. Then it fell out of favor.

But tonsillectomy is back.

Today, the most common reason for the surgery is "sleep disordered breathing," a broad diagnosis that includes sleep apnea and snoring. About 10 percent of elementary-school-age children snore.

Doctors say snoring can cause bed-wetting, behavior problems, short stature and poor school performance. That's a far cry from the 1950s and '60s, when tonsillectomy was used to fight frequent sore throats.

Back then, it was the most popular surgery in the United States. In the 1960s sitcom Leave It to Beaver, Beaver Cleaver was so impressed by his dad's tales of ice cream and pretty nurses that he schemed to have his tonsils out, even though he didn't need it.

Turning Point For Tonsillectomies

The tonsils are two glands that sit at the base of the tongue and are part of the body's immune system. The premise of tonsillectomies, back in their heyday, was that tonsils get infected themselves and no longer help fend off germs.

Then doctors started noticing that kids were still getting sore throats, even after having their tonsils taken out. But it wasn't until clinical trials were completed in the early 1980s that there was proof that tonsillectomy really only helped children with severe, recurrent throat infections.

"It was becoming unacceptable to just take tonsils out because they were there or you had a few infections," says Richard Rosenfeld, an ear, nose and throat doctor at SUNY Downstate in Brooklyn, N.Y. "People were growing up with their tonsils."

But growing up with tonsils can create another problem: snoring. Lisa Moran of Takoma Park, Md., remembers what it sounded like when her son ,Tyler Scorza, now age 7, slept.

"It was loud," Moran says. "You could hear him through he closed door, down the hall, snoring, and he would occasionally stop breathing."

At first, Tyler's pediatrician thought he'd outgrow the snoring. But he wasn't sleeping well and often didn't have any energy. The doctor recommended a head X-Ray, and the radiologist said that though Tyler's adenoids were enlarged, they weren't that bad.

By then, Tyler had been dealing with this for almost three years. He started getting frequent nasal infections. So his parents took him to an ear, nose and throat doctor. He said, sure, the adenoids are swollen.

"But the real problem is the tonsils!" Moran recalls. "He showed us on the X-ray that there was a tiny passage between the tonsils and the back of his throat — very small."

Enlarged tonsils (and adenoids) are the most common cause of sleep-disordered breathing in children. So the doctor recommended tonsillectomy.

Complications From Surgery

But Tyler's parents were worried about the surgery. It's usually done as an outpatient procedure now, but with general anesthesia. That's never without some risk.

"Your child is under," says Moran, "completely under. This is not a local."

Other complications include pain after surgery and the risk of bleeding; about 4 percent of people have complications that require readmission to the hospital.

Despite hundreds of studies, there's still surprisingly little research on whether tonsillectomy really helps reduce the risk of sore throats. The operation continues to be controversial.

No less a personage than President Obama dissed tonsillectomy when he was stumping for health care overhaul in July 2009. In a prime time news conference, Obama said that doctors may think: " 'You know what? I make a lot more money if I take this kid's tonsils out.' "

Rosenfeld disputes Obama's claim, saying insurers usually pay a surgeon $200 to $300 for tonsil surgery.

Sleep Study Before Tonsillectomy

The picture is further clouded because not all children with big tonsils have sleep-disordered breathing or frequent throat infections. Because of that, in 2002 the American Academy of Pediatrics recommended that children have a sleep study before surgery is considered.

About 530,000 tonsillectomies are performed in the United States each year. Obviously, parents could use some help in deciding whether surgery is needed. In January, the American Academy of Otolaryngology issued its first guidelines on tonsillectomy in children.

With sore throats, the ENTs recommend waiting (and treatment with antibiotics, if needed), unless a child has more than seven infections in a year. They'd recommend surgery if a child has five or more throat infections a year for two years, or three or more in three years.

There have been very few randomized studies on the effects of tonsillectomy for sleep-disordered breathing. Most of the researchers have asked parents or children whether they noticed improvements, and looked at a single measure, like behavior or quality of life. Still, the ENTs recommend tonsillectomy for sleep-disordered breathing, saying it reduces symptoms in most children.

Tyler's family decided to go ahead with the surgery; they went to the hospital at 5 a.m., and Tyler was home by noon. The doctors said he would be out of school for a week, but a throat infection kept him home a second week. His classmates sent him get-well cards.

A year later, Tyler is feeling great. And his snoring is gone. "Completely gone," his mom says. "You can hear a pin-drop quiet when he sleeps."

Tyler still hears snoring at night, he says. But he knows that the culprit is not him, or the family dog. It's Dad. [Copyright 2013 NPR]

TRANSCRIPT:

RENEE MONTAGNE, host:

Now to kids and their breathing problems. Up until the mid-1900s, having your tonsils out was a routine part of childhood. And according to NPR's Nancy Shute, that's becoming more frequent again. She tells us why.

NANCY SHUTE: Tonsillectomy was the most common surgery in the '50s and '60s, even for kids in sitcoms like "Family Affair."

(Soundbite of TV show, "Family Affair")

Mr. BRIAN KEITH (Actor): (As Uncle Bill Davis) Sometimes, little kids have to have their tonsils sort of taken out. And in order to do that, you have to...

Ms. ANISSA JONES (Actor): (As Buffy) Go to the hospital?

Mr. KEITH: (As Uncle Bill Davis) That's right.

SHUTE: Doctors used to prescribe tonsillectomy as the treatment for frequent sore throats. But then they started noticing that kids were still getting sore throats, even after the surgery. Richard Rosenfeld is an ear, nose and throat doctor - an ENT - at SUNY Downstate in Brooklyn, New York.

Dr. RICHARD ROSENFELD (ENT, SUNY Downstate): It was becoming unacceptable to just take tonsils out because they were there, or you had a few infections. People were growing up with their tonsils.

SHUTE: But growing up with tonsils can create another health problem.

Dr. ROSENFELD: When you lay down at night and go to sleep and your tongue falls back a little bit, it's going to land right on those two big tonsils.

SHUTE: And that causes sleep-disordered breathing.

Sleep apnea, like you just heard about, is a more severe form. But in kids, plain-old snoring can cause problems, too - like poor school performance, behavior problems and bed-wetting.

Lisa Moran remembers what it sounded like when her son, Tyler Scorza, snored. She and Tyler, who's 7, talk about what she would hear when she stood outside his bedroom door at night.

Ms. LISA MORAN: It was loud. You don't remember a thing, how loud it was?

TYLER SCORZA: No, I don't.

Ms. MORAN: You could hear him through the closed door, down the hall, snoring. That's how loud it was. And so he would exhale...

(Soundbite of exhaling)

Ms. MORAN: ...and there'd be that long pause, and you'd stand there and wait, and he'd go...

(Soundbite of exhaling)

SHUTE: At first, his pediatrician thought he'd outgrow it. But Tyler wasn't sleeping well, and he often didn't have any energy.

TYLER: Sometimes, I did wake up, even by my own snoring.

SHUTE: His parents, who live in Takoma Park, Maryland, took him for an X-ray. The thought was maybe his adenoids was causing trouble.

Ms. MORAN: So he had a head X-ray, and the radiologists report was, well - and we were looking specifically at the adenoids at that point. They said well, no, the adenoids were swollen or enlarged, but it's not that bad.

SHUTE: By now, Tyler had been dealing with this for almost three years. He started getting a lot of nasal infections, so his parents took him to an ENT.

Ms. MORAN: The ENT there took a look at the X-ray and said well, they're right about the adenoids. They are swollen, but the real problem is the tonsils. And he showed us on the X-ray that there was a very tiny passage between the tonsils and the back of his throat very small.

SHUTE: The doctor said: Those tonsils are just too big; they've got to go. But Tyler's parents were worried about tonsillectomy. The surgery is now usually done outpatient, but with general anesthesia. That's never without some risk.

Ms. MORAN: Your child is under completely under. This is not a local.

SHUTE: To help parents decide if a child needs a tonsillectomy, the ear, nose, and throat doctors have issued new guidelines. With sore throats, they recommend watchful waiting, unless a child has more than seven infections in a year.

There's less evidence on tonsillectomy and sleep-disordered breathing. The guidelines say it helps most children, but not all. Tyler's family decided to go ahead.

TYLER: I went over to the hospital with my mom, at about 5 o'clock in the morning.

SHUTE: By lunchtime, Tyler was back home, eating popsicles. Over the next two weeks, his classmates sent him get-well cards.

TYLER: Dear Tyler, I hope you get well soon. Did the surgery hurt? Your friend, Rachel.

SHUTE: A year later, Tyler's feeling great, and his snoring is gone.

Ms. MORAN: Completely gone. Absolutely, 100 percent completely gone. He sleeps like his older brother now. You can hear a pin-drop quiet when he sleeps.

SHUTE: But Tyler and his brother Joe agree: At night, the house is still not completely quiet.

TYLER: Dad snores, and he wakes me up a lot.

JOE SCORZA: Yeah. Definitely.

SHUTE: Which makes them wonder if maybe Dad needs his tonsils checked, too.

Nancy Shute, NPR News, Washington. Transcript provided by NPR, Copyright NPR.