How Often is Tonsillectomy Performed After Prior Adenoidectomy for Sleep Apnea in Kids?

Kids often see an ENT doctor for sleep apnea or other sleep disordered breathing concerns. Typically such kids have symptoms of severe snoring, nasal congestion/obstruction, restless sleep, daytime sleepiness/irritability, and/or witnessed difficulty breathing that periodically stops while sleeping (apneas).

In such situations, it is common for tonsil and adenoid surgical removal to be considered (tonsillectomy and adenoidectomy). However, it is not unusual for parents to often question the need to have both tonsils and adenoids to be removed, especially when considering the significant sore throat often associated with tonsillectomy.

The thinking is that if only the adenoids are removed, this would alleviate the nasal obstruction/congestion which in turn should hopefully resolve the other sleep disordered symptoms. By NOT removing the tonsils, it would save the child from a sore throat after the surgery as well.

But... is that actually true?

Can adenoid removal help with sleep apnea symptoms in a child?

The answer is unfortunately not a simple yes or no...

According to one research in 2016, the answer is yes... adenoid removal alone can help with sleep apnea in kids, but only in those kids with mild symptoms and small tonsils. Otherwise, there was a 20% failure rate of adenoid removal alone in resolving sleep apnea.

This supports earlier studies showing that there was up to as high as 30% chance that a child who only had an adenoid removal will later require another surgery to remove the tonsils. The larger the tonsils, the larger this risk.

BUT... even in kids with small tonsils, removing both the tonsils and adenoids was shown to be of benefit as found in this 2015 study conducted by Johns Hopkins.

When broken down by age when adenoidectomy performed in this study, the risk of future tonsillectomy increased the younger the child... 29% if adenoid removal perform <2 years of age, 15% if adenoid removal performed between 2-4 years old, 6% if 5-7 years old, and 2% if >7 years old.

If tonsillectomy performed, it usually occurred within 2 years of the adenoidectomy. The odds of undergoing a future tonsillectomy also significantly increased with increasing tonsil size at the time of adenoidectomy. A logistic regression analysis shows that each increase in tonsil size by 1 (eg, from 2+ to 3+) raised the risk of subsequent tonsillectomy by 1.6 times (95% CI, 1.2-2.1 times; p<.001); no other variables changed the risk significantly.

When taking all the information into account, it is typically recommended for both tonsil and adenoid removal in kids when treating for sleep apnea regardless of tonsil size, but especially so if they are large. But... if the parents want only the adenoids to be removed, counseling should be provided that there is risk for needing tonsillectomy in the future due to unresolved symptoms.

References:

Rates and risk factors for subsequent tonsillectomy after prior adenoidectomy: a regression analysis. Arch Otolaryngol Head Neck Surg. 2005 Mar;131(3):252-5.

Pediatric adenoidectomy: what is the effect of obstructive symptoms on the likelihood of future surgery? Int J Pediatr Otorhinolaryngol. 2006 Aug;70(8):1467-72.

Adenoidectomy for Obstructive Sleep Apnea in Children. J Clin Sleep Med. 2016 Sep 15;12(9):1285-91.

Influence of tonsillar size on OSA improvement in children undergoing adenotonsillectomy. Otolaryngol Head Neck Surg. 2015; 153:281-285.