Tubes and Tonsillitis Q&A

Child with ear pain

As part of Kids ENT (Ear, Nose, and Throat) Health Month in February, ENT specialist Jocelyn Kohn, MD, answers questions she receives frequently from parents at Stanford Medicine Children’s Health in Walnut Creek and Brentwood.


Q: What are tonsils and adenoids?

A: The tonsils are located on each side in the back of the throat. If they are very small, they can be hard to see, but if they are large, they can be obvious rounded structures when you look in the mouth. Adenoids are not visible from the outside because they are located at the back of the nose. It requires a scope to see them directly or an x-ray to demonstrate an outline of their size. Tonsils and adenoids are both comprised of lymphatic tissue. This means they house cells that are part of our immune system. Thankfully our immune system is redundant, so we are able to remove the tonsils and adenoids without increasing our risk of infections.

Q: What are the symptoms of tonsillitis?

A: Tonsillitis can produce a variety of symptoms, most notably sore throat, and sometimes it is accompanied by fever, white spots in the throat, pain with swallowing, and swollen lymph nodes. At other times, children experience less acute but still bothersome sore throat and tonsil swelling.

Q: Is tonsillitis contagious? How contagious? How does it spread?

A: While tonsillar inflammation is not itself contagious, the underlying illnesses can be. For example, an active cough that sends aerosol droplets into the air can spread an underlying virus or bacteria. Sharing drinks, food, and utensils, and practicing poor handwashing techniques, can also spread tonsillitis.

Q: What is the difference between strep throat and tonsillitis?

A: Strep throat is a specific variety of tonsillitis. In fact, strep throat is also called streptococcus tonsillitis. When we suspect strep throat, we perform a rapid strep test and/or a throat culture to check for the strep bacteria. While some people can carry strep in their throats without symptoms, we consider it strep throat when symptoms are present. Symptoms of strep throat include sore throat, fever, a whitish appearance to the tonsils, and swollen lymph nodes.

Q: How do you know when it’s necessary to take out a child’s tonsils?

A: There are specific criteria for removing tonsils for treatment of tonsillitis, called the Paradise Criteria. If there have been seven episodes of acute tonsillitis in one year, five a year for two years, or three a year for three years, then we consider removal. However, there are other clinical scenarios, such as a history of complicated infections or failure of medical therapy, which might make us move to perform the surgery sooner. Other children have their tonsils and adenoids removed if there are concerns for snoring and abnormal breathing during sleep, something called sleep apnea.

Q: How long does the ear tubes surgery take?

A: It is very fast! Often the procedure can be done in about 15 minutes.

Q: What is the connection between tonsillitis and snoring/sleep apnea?

A: Sleep concerns (snoring and sleep apnea) are often caused by large tonsils and adenoids in children. Certainly, some people with frequent tonsillitis do have large tonsils and may also have sleep issues secondary to this. However, you can have sleep apnea without a history of tonsillitis and vice versa.

Q: How do I know if it’s truly necessary to have adenoids removed in a 1-year-old child?

A: Most of the time, the decision to remove the adenoids is based on both the adenoid size and the degree of symptoms your child is having. When the adenoids are enlarged and causing nearly constant congestion, runny nose, postnasal drip, and/or snoring to the point that it really is disrupting your child’s quality of life, it can be worth considering removal. If symptoms are mild, medical management and observation can be appropriate.

Q: Is there any long-term harm from removing tonsils in children who need it?

A: While there are the immediate risks associated with surgery and recovery, we do not find significant long-term problems from removing the tonsils and adenoids. They are part of our lymphatic system, which defends against infection. However, this system is very redundant, so even without tonsils and adenoids, we have plenty of ways of defending against infection.

Q: Can tonsils grow back?

A: Small tonsil tissue remnants after surgery can increase in size with time. The chance of this happening is low, but not zero. Typically, any regrowth will not be clinically significant.

Q: What are some of the ways to prevent tonsil stones in children who get them frequently?

A: Tonsil stones are difficult to prevent. Frequent gargling with salt water is one way to try to minimize buildup within the tonsils, but this isn’t always enough. A water flosser such as a Waterpik can be used when there are stones present to help irrigate them out of the tonsils. Ultimately, when the stones are frequent and bothersome, removing the tonsils is an option to truly keep the problem from coming back.

Ear Tubes

Q: What leads to a decision for ear tubes for kids with a history of ear infections?

A: We decide to do ear tubes when kids have had recurrent ear infections or persistent fluid behind the eardrums. Current guidelines say that if kids have had at least three separate infections requiring antibiotics in a period of six months, or at least four in the past year, the ENT specialist may suggest ear tubes. Likewise, if fluid is present for three months without resolution, that would be another indication for tubes. Factors such as how the ears look at the time of the ENT’s exam, how the child is doing with speech development, if any of the infections have been complicated or difficult to treat, or other patient factors may also impact when ear tubes are recommended. However, there are exceptions to these “rules.”

Q: How long does the surgery take?

A: It is very fast! Often the procedure can be done in about 15 minutes.

Q: How long do ear tubes last?

A: The duration of ear tubes varies depending on the type of tube used and the healing of the child. Most ear tubes last six to 18 months. They typically will fall out on their own as the eardrum heals. If they have not fallen out after about three years, they typically will be removed at that time.

Q: Can kids still get ear infections with tubes?

A: Yes, children can still be exposed to viral or bacterial infections even after tubes are in place. When this happens, the tubes allow fluid from the ear to be able to drain out, rather than building up behind the eardrum. This helps prevent some of the pain and the decreased hearing that can come along with ear infections. Drainage from the ears can often be treated with ear drops alone rather than requiring oral antibiotics.

Q: Do ear tubes impact hearing?

A: Yes, they can impact hearing, but in a good way. When kids have fluid or infection in the ear, it can muffle their hearing. The ear tubes allow that fluid to escape and drain into the ear canal so that they can hear normally again. A hearing test will be done after ear tubes are placed to ensure that hearing is normal following the surgery.

Q: Can kids swim with ear tubes?

A: Yes! They can bathe and swim in the pool without any ear protection in most cases. It is recommended to protect the ears with earplugs when swimming in untreated (lake or ocean) water.

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