What are turbinates and why do they need surgery to reduce them? (Are you sleeping badly? This may be why!)

What do swollen turbinates look like

What do swollen turbinates look like

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).

Lateral nasal airway

Lateral Nasal Airway: Turbinates, Adenoids, Eustachian Tube Opening

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.
Turbinates and sinus cavities

Feeling the pressure? Healthy turbinates help regulate pressure and drainage of the sinus cavities.

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).

Healthy inferior turbinate

Healthy inferior turbinate – you can see quite clearly that there is a tunnel for air to flow freely past the turbinates.

Swollen turbinates

Swollen turbinates – you can see how they have swollen and are bulging out across the airway to the nasal septum.

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 and why do they need removing? (What is a tonsillectomy or adenotonsillectomy?)

How inflamed tonsils compare with normal tonsils

How inflamed tonsils compare with normal tonsils

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).

What are the 4 grades of swollen tonsils

What are the 4 grades of swollen tonsils?

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.

adenotonsillectomy

Adenoids and tonsils

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.

In Splendid Isolation

Autumn wonderland

Autumn wonderland

“He who is certain he knows the ending of things when he is only beginning them is either extremely wise or extremely foolish; no matter which is true, he is certainly an unhappy man, for he has put a knife in the heart of wonder.” Memory, Sorrow, and Thorn

I drafted this a week ago…little did I know that life would throw up complications and we’d be looking at a minimum of fours weeks in isolation.

Today marks the end of two weeks of isolation leading up to Miss 2’s surgery. She spends the night in my bed (she’s refused to sleep in hers since we were rushed to hospital by ambulance for Mother’s Day) and is awake all day with it just the two of us. There is a distinct lack of personal space and it’s challenging for both of us. The only time that I have to myself is an hour or so in the evening, after finishing up cleaning the house, before collapsing into bed beside her.

Week 1 was a particularly vicious head cold with rivers of snot that covered her face no matter how often I wiped it away. Her facial dermatitis was miserable, her already swollen airways blocked up, and she’d give up on sleep entirely somewhere between 2am and 4am when the fluid build-up got too much (and she needed to be upright to have it drain away). Being awake around the clock was beyond exhausting, I got sick too, I dragged myself through each day, I was grateful whenever she was willing to listen to audio stories that might give me a break for twenty minutes.

She hit rock bottom after about 7 days and then slowly started to improve. Her doctor advised that with her surgery so close we were best to spend another week away from playgroups, Sunday School, gatherings of kids, and, well, anywhere germy, to try and prevent her from catching a secondary infection. Historically. her compromised immune system has meant a rolling series of viral infections for weeks at a time.

She missed her friends. She missed her rountines. She stomped around the house (literally) telling me, “I’m a grumpy old troll! I’m ANGRY! I want (insert names of friends)”. I’m proud of her emotional recognition and expression; I’m glad that teaching her to stomp (as opposed to kick, hit, bite, or throw) as a healthy way of venting her feelings seems to be helping. It’s exhausting and it sucks for both of us.

It’s been a mental challenge each day trying to work out where we can for the morning that ideally doesn’t cost money, will interest her, doesn’t involve kids, and can’t be an indoor playground / attraction (because let’s face it those things hardly ever get disinfected!). Oh, and it’s winter, cold, and rain keeps threatening on the weather forecast.

Each day I have to try and be cheerful, positive, and zen. Some days I do better than others. Some days I’ve burst into tears in public toilets while she just keeps tantruming and I can’t even have 30 seconds to pee in quiet (not alone, just peacefully). Some days it feels overwhelming that not only do we have to get to the surgery but then we’re still going to need to be careful about post-op infection. Some days the logistics of our upcoming hospital stay, needing to take all our food with us, needing to look after her alone (and just physically carrying everything!) seems overwhelming.

So I’ve tried to find the beauty in each day for us. She delights in the small details – the differing colours and shapes of leaves, throwing seed cones into the ocean and watching them bob like boats, stopping to listen to birds sing.

Autumn dreaming

Autumn dreaming

Autumn explorer

Autumn explorer

We’ve walked through parks of imported oak trees with their beautiful autumn leaves still covering the ground like snow.

We’ve spent hours exploring Botanic Gardens admiring the hidden mazes and the surprise of colourful roses even though it’s winter.

New Zealand beaches in winter

New Zealand beaches in winter

What is New Zealand like in winter?

What is New Zealand like in winter?

We had one morning that saw me teaching her chess in the library while the wind and rain swirled outside, only for it to suddenly be replaced by a little beachside microcosm of warm blue skies and sunshine. We walked on the sand, splashed in the waves, and drew pictures in the sand creating beach art.

Being isolated was anything but splendid (although it makes for a catchier title) but looking for the beauty in each day and seeking a positive focus made it more bearable. We can’t always change our circumstances, we can only change how we choose to view our circumstances and how we react within them.

What a nightmare! Getting hospitalised for Mother’s Day at the same time as my toddler!

Hospitalised for gastroenteritis

Hospitalised for gastro

Being a solo mother for a medically fragile child with chronic health issues (including multiple food and airborne allergies) poses a heap of challenges at the best of times. Having us both hospitalised at the same time was incredibly difficult and it frightens me to think what would have happened if my family hadn’t been willing to spend an hour driving in to us and forgoing sleep for about 40 hours.

We actually had quite a pleasant Mother’s Day to begin with. We went to a playgroup for a short time and then went on to a wonderful Solo Mother’s event that was being held.

I’d spent Saturday cleaning like mad (which takes hours because of her dust mite allergies) and then feeling unwell with a nose running like a faucet. I still wasn’t feeling well on Sunday and figured I might have a mild cold.

Things all went downhill at 1am (so, I try to tell myself in an upbeat way that really Mother’s Day had finished) when a loud barking noise coming from my daughter’s room woke me and I found her struggling to breathe. Her story is here.

When the ambulance crew arrived at 1.30am, I was deperately trying to keep my daughter upright (who was determined that she wanted to be alone, prone, and asleep), trying to wake her up to full consciousness, and trying not to throw up.  There’s no time to be sick when your a solo parent with a sick child – I also had a sufficiently high embarassment reflex not to want to hurl in front of the three lovely (male) paramedics; there’s something that’s just easier about vomiting in private.

I spent the ambulance ride sucking on a home-made coconut milk ice-block trying to convince myself not to vomit and looking after Miss 2.

I’m so grateful for all of the lovely staff that helped us at the hospital. A nurse read Miss 2 picture books while I was busy vomiting in the hospital bathroom.  My embarrassment reflex declined as I got sicker; I ended up just drawing the curtain for her room and being grateful for the many vomit buckets the hospital stocks.

My parents spent an hour driving in to us and while Nana stayed with Miss 2, Poppa drove me (in the opposite direction) to collect the car seat and various things from home. This took a long time as the vomiting and diarrhoea kept me in the bathroom a lot and the pain often felt like a thousand glass daggers writhing through my intestines. At times I was crawling through my home on my hands and knees on gritted teeth determined to pack. Poor Poppa! he so wanted to help but couldn’t do more than watch quietly as I assembled everything we needed; it can’t have been easy either having me dry wretch all the way back to the hospital.

We finally got back to the Children’s Hospital and the nurses transferred me to the adult hospital’s Emergency Department. Nana and Poppa stayed with Miss 2 while I got admitted. I was so wracked with constant vomiting that I couldn’t even speak to the doctor unless it was in-between the waves of pain (and more importantly once the anti-emetic had kicked in). They did various tests for infection, a chest x-ray, and were monitoring me in case my appendix burst or my gallbladder (squeezed dry by that point) did anything gnarly. Apparently I was horribly pale, shivering uncontrollably (bless the nurses that brought heated blankets!), and looking pretty crap (aside from the vomiting and hobbling to the adjacent toilet), I went through two IV bags of fluids and a bunch of drugs before I was stabilised enough to sip water. As really awkward timing, Miss 2 got discharged almost 6 hours before me! Thank god Nana + Poppa were with her as I’m not sure what would have happened otherwise – it certainly would have been a far more traumatic experience for both of us!

Overall, they thought I had a severe case of viral gastroenteritis with severe pain from the inflammation + a cold/flu virus, and possibly Miss 2’s croup as well. I was unwell enough that they were considering admitting me into of the other wards but Miss 2 needed me so I got discharged to family care and monitoring instead (as there’s still a risk the appendix could progressively worsen). I’m so grateful that this has happened at a time when my family can help care for us as I can’t walk much without the pain starting and am pretty much living on mum’s Fail-safe Porridge and Rehydration Therapeutic Tonic.

What is croup and how does it effect toddlers?

What does croup look like in toddlers?

What does croup look like in toddlers?

Croup is a viral illness in young children which causes narrowing of the upper airways. Croup is often a mild illness but can quickly become serious, so do not hesitate to get medical help.

The funny thing about croup is that it’s like the vampire of toddler illnesses. During the day it may not have a visible impact beyond your toddler eating little (and lets face it sometimes they do want to live on air and crayons) and sounding hoarse. For Miss 2, it was that she woke up on Mother’s Day having largely lost her voice, was eating little, and had a mild temperature in the afternoon.

Toddlers have softer windpipes than older children so it’s often when they lie down to sleep that the narrowed airways will become more apparent. Their breathing may start to wheeze and become progressively more of a struggle; it can also cause a strange cough (stridor). What does a croup cough sound like in a two year old? It sounds a bit like a lion purring or a seal bark; personally I think stridor sounds most like a lion coughing up a fur ball.  The animal metaphors might sound cute but the cough can be so loud that it’s enough to travel between rooms and wake you up at night; it can also be frightening if it’s the first time you’ve heard it and you have no idea what it means!

For many children, croup will be a mild illness (which can recur) and which can be treated at home. For others, they need to see a doctor or require urgent medical care. In New Zealand there is a registered nurse available 24/7 to provide free health advice on Healthline (0800 611 116); they can help assess your child and advise whether to ring for an ambulance or wait to see a doctor the next morning.

Personally, I think that croup is worse for children that have allergies. In fact, as well as viral croup, there is also a form of spasmodic croup which may be caused by Gastric Reflux Disease (GERDs) or by allergies. I’ve also read blog posts from other allergy families where croup has become a recurrent problem for their toddllers.

For Miss 2, I was woken at 1am by her strange noises (the croup cough) and found her struggling to breathe; she’d also started a mild fever while she was sleeping. She already has enflamed adenoids, turbinates, and tonsils as a result of her airborne allergies (and any undiagnosed food intolerances) so having her airways swell further was frightening.  My gut instinct said she needed immediate help and I rang Heathline to check if I should was right, if I should drive her to the children’s hospital (which would delay things) or ring an ambulance. After listening to her breathe, I was told to ring an ambulance.

She was so sick that she slept most of the night in the Emergency Ward bed; she needed to be kept semi-upright (to help her airways). Her fever worsened, even with parecetamol, and didn’t break until morning. The recommended treatment for croup is oral steroids. This made me nervous as:

  • she’s allergic to topical steroids
  • even temporary steroids can cause massive behavioural changes and tantrums in toddlers.

Her allergy to topical steroids results in awful periorficial dermatitis rather than anaphylaxis and having her airways potentially constrict in life threatening ways – so I opted for the oral steroid.

It definitely helped with her breathing. She still had virtually no voice on Day 2 or 3 (it might take a week to return) and I still had to sit up with her on Night 2 but her breathing was manageable at home and no where near as bad as the night she was hospitalised. Thankfully she also hasn’t had any major tantrums so far; mind you, she’s probably too tired to tantrum yet. She’s eating very little as her throat is so sore and is mainly sticking to formula, sips of water, and the occasional mouthful of soft foods.

NOTE – Thank you to all the readers that have shared their stories with me!

I continue to feel that croup can be a much more serious illness for families with medically fragile children – including food allergies, airborne/environmental allergies, asthma, and reflux. Doctors will most commonly look for croup in babies and very young toddlers but plenty of allergy families have shared that their children have continued to have viral croup up to age 10!

If you’re familiar with what a croup cough sounds like then do advocate on behalf of your child for medical care if it’s needed – you’re the one awake in the wee hours of the night hearing it (and they may not have the cough during the day)!  Don’t hesitate to ring for an ambulance at night if your child is struggling to breathe!

It’s worth investigating what charges there are for your local ambulance service and if they have a subscription service. If you live in New Zealand, it’s around NZD$90 for each medical emergency (non-ACC) call-out of a St John’s ambulance but you can get an annual ambulance subscription for the whole household for NZD$65 per year. I’m so glad that I signed us up for membership after her ambulance trip just before Christmas!

 

What are adenoids and why do they need removing? (What is an adenoidectomy?)

What are adenoids?

What do swollen adenoids look like?

Miss 2 is now on the waiting list for surgery. She needs her adenoids removed, her turbinates (inside her sinuses) reduced, and her tonsils will continue to be monitored.

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.
    • 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.

  • 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.

Allergy update & how we’re coping

I’m having to put a list together of all of Miss 2’s medical appointments for the last 12 months. It’s part of a bureaucratic process and it feels kind of bleak, we’re at something like 33 now out of 52 weeks. If you factor in her being sick most of the time in between those appointments and the fact that I’m a single mother with very little support, it’s pretty fracking overwhelming. Good thing I’m sitting down with a coffee to write this while she plays gleefully in a ball pit. 

She’s doing better this week – She laughed the other day and it was such a beautiful spontaneous sound that it brought tears to my eyes because it had been so many weeks since I’d heard it.

We both had airborne allergy tests recently and in her typical atypical fashion she came up in hives in several places – except for where she’d been pricked. Later that day her breathing started to labour and an awful snotty nose started that is still with us 10 days later. It makes it hard for her to breathe at times even with her mattress on a 45′ angle and three allergy medications each day (2 oral + 1 nasal spray). 

The good thing is that I reacted typically. Dust mites, dogs, and lots of grasses/weeds. With the help of a gardening association I identified that our little lawn has very little lawn grass and lots of highly aero-allergenic grasses/weeds. I’ve got Bermuda running grass, plantain, and Bahia grass (paspallum) that has an extended pollen season of about 5 months. Oh, there’s also the clover I love but the bees have adored it also this summer and it turns out we’re both allergic to being stung 😦

The grass allergy explains why I haven’t been able to breathe for months with an ongoing cough, worsening wheezing, feeling like there’s an elephant on my chest, and so many headaches / sinus pressure. It explains why walking my daughter to home care I get a headache and have trouble breathing but can easily run around an air conditioned mall. I’m on allergy medications now as well but it’s not like I can just avoid grass for the summer!

Hopefully the grass allergy also explains why Miss 2 has been deteriorating so rapidly since the start of the year. It would fit in timing wise and an aero-allergen would help to explain the summer colds, swollen terminates, swollen tonsils, and bruised swelling under her eyes.

There’s still the possibility of another food allergy or intolerance as well so I’m keeping a daily food diary for both of us (down to each ingredient). There are also several foods (like dairy, soy, gluten, eggs) that can cause excess mucous production even if you’re not allergic. There’s a wider range of allergenic-friendly foods available these days that may still appeal to a toddler but price-wise they’re not too friendly. I’d already reduced the amount of gluten and eggs in our diet; the aim will be to reduce them further (and dairy) to see if it helps and potentially work towards eliminating them all together.

More medical appointments next month with at least three different hospital departments. She may need to go back on her reflux medication as well since that has improved but not gone away and could be another factor in her misery this summer.

On the bright side, she is loved and knows that she is loved. She loves books, her vocab continues to increase (with hilarious and/or imperious sentences being uttered), she is kind, and she is growing.