If you’ve never heard of turbinates before then you’re not the only one! As long as they’re working well then the subject is unlikely to ever come up; they are also not something that your regular doctor (GP) is able to review – finding out there’s a problem first requires a referral to an Ears Nose Throat (ENT) specialist because of the symptoms you are experiencing.

Your turbinates can have a surprisingly large impact on your quality of sleep; this is especially true in young children and the problems are even more exacerbated if they also have troubles with their ears, adenoids, and tonsils.

What are turbinates?

Turbinates are bony structures (covered in moist tissue called the nasal mucous membrane). Inside your nose there are three sets of turbinates: upper (superior), the middle, and the lower (inferior).

Why do we need turbinates? What do turbinates do?

The turbinates have several important functions:

• Help warm and moisturize air as it flows through the nose.
• Protect the openings into your paranasal sinuses.
• Help create airflow through your nose (important for your sense of smell!).
• Trap micro-organisms (like viruses) and pollutants (like pollen).
• Help the voice to resonate (i.e. they affect how we sound).
• Produce mucous to help clean out the nose and assist the cilia in their work.
• Help to regulate pressure in the sinuses.
• Help the nose and sinus cavities to drain.
• The turbinates play an important mechanical function when we sleep.  When you sleep on the right side, with the right turbinate down, over time the right turbinate fills up with fluid and expands so that it pushes against the septum; this makes you turn on the left side until that side fills up and turns you again. If the turbinates are not functioning correctly then you may wake up feeling cramped and sore with achey muscles.

What causes turbinates to swell?

One of the most common causes of swollen turbinates (turbinate hypertrophy) are airborne allergies (allergic rhinitis) such as grass or weed pollen, birch tree pollen, or dust mites.

Other causes can include repeat upper respiratory infections, hormones, drugs, medication (i.e. as a complication from long-term nasal spray use).

What are the possible side effects of swollen turbinates?

• Stuffy nose
• Headache
• Facial Pain
• Pressure (often in forehead). In young children this may result in behavioural issues, trouble concentrating, or head banging.
• Nasal drip
• Loss of Sense of Taste and/or Smell
• Mouth breathing, noisy breathing, and/or snoring. This is especially problematic if adenoids and/or tonsils are also swollen and obstructive sleep apnea develops.
• Fatigue. Children might seem like they’re getting enough hours of sleep but in reality the quality of sleep is poor because their body is struggling to get enough oxygen through the night. It’s a bit like starting each day on a half tank of gas.
• Sore, cramped, achey muscles in the morning. Healthy turbinates play an important mechanical function when we sleep; they are key to helping us unconsciously change which side we are sleeping on through the night.
• Developmental delays. Sleep is critical for young children. During those early years, they are rapidly growing and learning. They need sleep to focus during the day; to have time for their brain to make connections between all the things they have learned or experienced; and their brain releases a growth hormone while they sleep. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can make it harder for them to stay on track.
• Behavioural difficulties. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can result in daily misery that children don’t know how to express.

Why do turbinates need surgery?

An Ears Nose Throat (ENT) specialist will be able to examine the interior of the nose quickly and painlessly during outpatient appointments; they may also opt for imaging scans such as x-ray or CT.

It is likely that they will suggest trying non-invasive means initially to see if this reduces the swelling, This is likely to involve a steroidal nasal spray and anti-histamine medication (in the case of allergic rhinitis). They may also recommend additional saline spray / drops to help keep the nose irrigated, or using a humidifier.

If these options do not work an symptoms have not been alleviated then they are likely to recommend surgery. Note: it is important that turbinates are reduced (not removed) and they will slowly regrow; in order for them not to become swollen again, any other underlying issues must still be addressed.

What does turbinate reduction surgery (turbinoplasty) involve?

Turbinates perform highly important functions and removing them entirely can cause a raft of new issues; surgeons will normally opt to reduce the turbinates. There are different methods that can be used; some remove tissue and others aim to shrink them through other means.

A procedure called submucosal resection is a common technique used to treat enlarged turbinates. With this procedure, the lining of the turbinate is left intact, but the “stuffing” from the inside of the turbinate is removed. As the turbinate heals, it will be much smaller than before surgery. Sometimes, this resection can be performed with a device called a microdebrider. This device allows the surgeon to remove the “stuffing” through a small opening in the turbinate. In some instances, more of the turbinate is removed.

Some of these methods shrink the turbinates without removing the turbinate bone or tissue. These methods include cauterization, coblation, and radiofrequency reduction. In each of these methods, a portion of the turbinate is heated up with a special device. Over time, scar tissue forms in the heated portion of turbinate, causing the turbinate to shrink in size.

Turbinoplasty is generally an outpatient procedure performed under general anaesthetic and patients can go home the same day.

Want to find out more about surgery or risks? The American Rhinologic Society has useful information.

What happens after surgery?

You can expect to have pain, fatigue, nasal stuffiness, and a clear fluid nasal discharge for several days after surgery. If this was the only surgery being performed then pain is generally mild  and typically well controlled with pain medications. A saline spray and/or steroidal nasal spray are likely to be recommended to use for several weeks after the surgery.

Swelling as a result of the procedure means that there may still be snoring for a week or two after the surgery, as well as a general feeling of stuffiness. The fluid discharge will generally begin to improve and crust after the first week.

Patients may be off school or work for a week and are recommended to avoid strenuous activity for two to three weeks afterwards.

 

What are tonsils?

Tonsils are soft tissue located at the back of your throat; they are part of the body’s lymphatic system (so are adenoids). When they are working properly, they help to recognise bacteria and viruses entering through the mouth and produce white blood cells to fight off infection.

Tonsils are particularly useful during childhood while the body is still encountering new bacteria and viruses for the first time and building up the immune system. Doctors seem to be of differing opinion as to how useful they are as adults; I’ve some that have called them redundant and unnecessary, I’ve also met other doctors who view removing them as an absolute last resort.

Why do tonsils need removing?

Tonsils may temporarily swell while fighting infection, sometimes they become so swollen that they result in a very sore throat and fever (tonsilitis), they may also partially obstruct the airways and not respond to non-invasive treatmeants.

Surgery may be recommended to help treat:

• Multiple case of tonsillitis (seven cases of tonsillitis or strep in the last year, or five cases or more over each of the last two years).
• Breathing problems related to swollen tonsils
• Frequent and loud snoring
• Periods in which you stop breathing during sleep (sleep apnea)
• Bleeding of the tonsils
• Trouble swallowing chewy foods, especially meats
• Cancer of the tonsils

Back in the 1980s, having your tonsils out was kind of a childhood rite of passage. It was a very common procedure and often parents had already experienced a tonsillectomy in their own childhood. Medical opinion has now swung in a different direction and there is a more stringent list of criteria that often needs to be met (as well as requiring parent consent / advocacy). For a balanced medical opinion, try this post by Christopher Johnson (a pediatric intensive care physician) .

What is tonsil grading?

Surgery is most likely to be recommended if tonsils are consistently swollen at Grade 3 or Grade 4 coupled with other complications (such as snoring and/or sleep apnea).

Basically tonsils are graded based on how much of the airway they block.

• Grade 0 = tonsils are within the the tonsillar fossa
• Grade 1 = tonsils obstruct 0-25% of oropharyngeal airway
• Grade 2 = tonsils obstruct 26-50%
• Grade 3 = tonsils obstruct 51-75%
• Grade 4 = tonsils obstruct 75%

What are the possible side effects of swollen tonsils?

• Fever / temperature. Keep in mind that children can react in their own individual ways – they may keep getting low grade temperatures instead of a fever.
• Runny nose and congestion (as well as the sore throat).
• Difficult or painful swallowing.
• Swollen and tender glands (lymph nodes) on the sides of the neck.
• Bad breath.
• Fever and chills.
• Tiredness and headache.
• Stomach upset or pain.
• Mouth breathing, noisy breathing, and/or snoring (due to enlarged tonsils blocking the airways). Obstructive sleep apnea. The swollen tonsils and/or adenoids can intermittently block airflow. It sounds like your child is silent and then there’s a big noisy sucking in of air.

  • In Miss 2 it can be so loud that I can hear it through her closed bedroom door and can sound like something’s fallen off a shelf and hit the floor! It’s a crappy and frightening thing as a parent that can result in just sitting with them in the dark either to check that they are breathing or to give them a gentle nudge to help them breathe again. If you’ve spent time with them hooked up to an oxygen saturation monitor then you’ll be familiar with what a stark difference there is between their oxygen levels when alert and upright versus lying prone to sleep.

• Fatigue. They might seem like they’re getting enough hours of sleep but in reality the quality of sleep is poor because their body is struggling to get enough oxygen through the night. It’s a bit like starting each day on a half tank of gas.
• Developmental delays. Sleep is critical for young children. During those early years, they are rapidly growing and learning. They need sleep to focus during the day; to have time for their brain to make connections between all the things they have learned or experienced; and their brain releases a growth hormone while they sleep. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can make it harder for them to stay on track.
• Behavioural difficulties. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can result in daily misery that they don’t know how to express.

Keep in mind that young children (i.e. toddlers) may not be able to describe their symptoms to you and it may not even occur to them to do so (especially if they chronic health issues). They may also be confused by referred pain; the ears and throat share nerves (as well as being linked by eustachian tubes) so they may say their ear is sore when the infection is actually in their throat. Another possibility is if they keep exhibiting teething type behaviour well after all their teeth are in (i.e. chewing on fingers or a dummy constantly, lots of drool) combined with a temperature and bad breath – the cause may actually be their tonsils!

What does surgery (a tonsillectomy) involve?

Surgery will normally take place at a hospital (probably as an outpatient). The doctor will review medical history in advance and make recommendations about pausing medications. You will normally be advised not to take anti-inflammatory medications within 7 days of surgery. They will also discuss post-operative pain medication.

The day of the surgery will involve a period of fasting; food or water won’t be permitted because they can impact the anesthetic. It’s a good idea to have family support and a game plan of how to distract your child; an older child may understand why they can’t eat but a toddler is likely to just focus on the fact that they are off routine and they are HUNGRY!

During surgery, your child will be under a general anesthetic. The surgeon will enter through the mouth and the tonsils will be removed with an electrical cauterizing unit.  You can watch videos of surgery on YouTube but they can be a bit difficult to stomach; I preferred this video of a digital tonsillectomy surgery.

Often the adenoids will be removed at the same time as the tonsils (if they are also swollen); this is termed an adenotonsillectomy. Click here for information about the adenoids.

What happens after surgery?

Depending on the age of your child, they may keep them in the hospital overnight for monitoring or they may go to a recovery room and then go home the same day. You should be given a pamphlet with information about post-op care (i.e. like this tonsillectomy guide).

Your child may feel quite groggy and tired for the next few days and also have some nausea; vomiting once or twice is normal but contact your doctor if vomiting persists.

A light, cool diet for the next few days is generally recommended (avoid hot liquids or spicy food) but doctors will often recommend that children eat whatever they want – the abrasion from bread or crackers will actually help to clean the area. (That’s not to say there won’t sometimes be screaming pain because a sharp cracker edge has just struck the surgical site).

Some doctors will prescribe antibiotics. They will normally be prescribed painkillers (like Pammol and Tramadol) and anti-inflammatories (like Nurofen); if your child won’t take the fully funded options consider buying over-the-counter replacements (for kids) that have been flavoured.  It is important to keep on top of their medication (including waking them up around the clock for a few nights) as the pain is severe; it will often peak somewhere around around Days 5-9 due to the way the membranes heal and can be excruciating.

It’s important to keep them rested and hydrated – even if this means just getting small regular sips of water, lemonade ice-blocks, or melty ice=cream into them; overall, the fluids are more important than food.

Common side effects will include:

• Swollen tongue
• Bad breath (like a hyena!)
• White coating on the tongue
• White scabs over the tonsils

Your doctor will talk you through potential complications and when to seek immediate medical care – i.e. if bleeding occurs (it can be life threatening); they may be able to resolve with medication or surgery may be required.

They need lots of rest for two weeks to promote healing and will be off school during this time due to the risk of infection.  They will also generally have several weeks off sports, exercise, and swimming.

Keep in mind that removing tonsils may only be one part of a wider treatment plan. If the chronic inflammation was linked to allergies then you will still need to work with a doctor to create an ongoing allergy treatment plan.

What are adenoids?

Adenoids are soft tissue located located behind the sinuses; they are part of the body’s lymphatic system (so are tonsils). When they are working properly, they help to recognise bacteria and viruses entering through the nose and produce white blood cells to fight off infection.

Adenoids are particularly useful during early childhood while the body is still encountering new bacteria and viruses for the first time and building up the immune system. Doctors tend to consider them most useful up to age 7; in adolescence they begin to shrink and by adulthood they can practically disappear.

Why do adenoids needs removing?

Sometimes in childhood the adenoids swell and stay swollen. This can be due to frequent infections, due to a chronically over-active immune system (i.e. in an atopic child there might be ongoing aero-allergens and food allergies), or for reasons unknown.

This swelling is particularly problematic the younger the child is because their airways are so small to begin with! Also, swollen adenoids often aren’t the only problem. Look at the picture above and imagine that there is also swelling in the nasal passage (swollen turbinates) and that there are also swollen tonsils in the throat – that can result in a highly miserable toddler!

What are the possible side effects of swollen adenoids?

• Obstructive sleep apnea. The swollen adenoids can intermittently block airflow. It sounds like your child is silent and then there’s a big noisy sucking in of air.
• Snoring and heavy mouth breathing.
• Snotty / blocked nose.
• Repeated ear infections. The swollen adenoids can block the Eustachian tubes and prevent fluid draining from the ears to the throat.
• Blocked ears meaning that everything sounds a bit like it’s underwater.
• Blocked nose meaning a deadened sense of smell. This can also impact their ability to taste foods.
• Sinus headaches / pressure (in conjunction with blocked nose).
• Sore throat and/or difficulty swallowing.
• Fatigue. They might seem like they’re getting enough hours of sleep but in reality the quality of sleep is poor because their body is struggling to get enough oxygen through the night. It’s a bit like starting each day on a half tank of gas.
• Developmental delays. Sleep is critical for young children. During those early years, they are rapidly growing and learning. They need sleep to focus during the day; to have time for their brain to make connections between all the things they have learned or experienced; and their brain releases a growth hormone while they sleep. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can make it harder for them to stay on track.
• Behavioural difficulties. Poor sleep, fatigue and pain/discomfort, trouble hearing: these can result in daily misery that they don’t know how to express.

Why didn’t the doctor identify this earlier?

Your normal doctor (a GP) and even a paediatrician can’t see that the adenoids are swollen. You need to be referred to the Ears-Nose-Throat clinic at your local children’s hospital. They will be able to look in their nose and throat during the initial visit and then may request a facial x-ray and/or CT scan for confirmation. They may also monitor the adenoids over a few visits in order to confirm that they are chronically enlarged and not temporarily swollen due to infection; they may also try medications for a few months to see if these help.

It can be a bit like diagnosing the wind – you can’t see the wind but you can see the effects of the wind. You may even have the referral because of something unrelated (like repeated ear infections) and as a result of that find out that the adenoids have been swollen all along.

What does surgery (an adenoidectomy) involve?

Surgery will normally take place at a hospital (probably as an outpatient). The doctor will review medical history in advance and make recommendations about pausing medications. You will normally be advised not to take anti-inflammatory medications within 7 days of surgery. They will also discuss post-operative pain medication.

The day of the surgery will involve a period of fasting; food or water won’t be permitted because they can impact the anesthetic. It’s a good idea to have family support and a game plan of how to distract your child; an older child may understand why they can’t eat but a toddler is likely to just focus on the fact that they are off routine and they are HUNGRY!

During surgery, your child will be under a general anesthetic. The surgeon will enter through the mouth and the adenoids will be removed with an electrical cauterizing unit. You can watch videos of adenoidectomies (like this one); they aren’t pleasant to watch but it can be useful to help you understand what will happen.

What happens after surgery?

Depending on the age of your child, they may keep them in the hospital overnight for monitoring or they may go to a recovery room and then go home the same day.

They may feel quite groggy and tired for the next few days and also have some nausea; vomiting once or twice is normal but contact your doctor if vomiting persists.

A light, cool diet for the next few days is generally recommended (avoid hot liquids).

I’m sure my parents don’t have fond memories of me having my tonsils out when I was 4. I still remember staying overnight in the hospital! Mostly my memories are positive ones due to the fact that I got to spend a week lording it over my baby brother that I got to eat jelly and ice cream. No memory of the pain remains but the joy of those unexpected treats has lasted decades!

They will prescribed antibiotics and some light pain relief. They need lots of rest for 4-5 days to promote healing but the good news is that it is a much faster heal time than for having tonsils removed. They will also generally have 7-10 days off school and 3 weeks off sports, exercise, and swimming.

They will generally have post-surgery check-ups; your doctor will talk you through potential complications and when to seek immediate medical care.

They may have nasal stuffiness for a few months after surgery and may need nasal drops. Snoring may continue for several weeks after surgery (and may temporarily get louder). Their voice may temporarily change for a few weeks to a few months!

Keep in mind that removing the adenoids may only be one part of a wider treatment plan. If the chronic inflammation was linked to allergies then you will still need to work with a doctor to create an ongoing allergy treatment plan.

Looking for more information? I read through a wide number of sites  and this was the one I found most useful.