The third tonsil is a natural part of the child’s immune system. It is the first protective barrier against pathogenic microorganisms and may be enlarged in children of a few years old, which is not always a cause for concern. Sometimes, however, the third tonsil reaches such dimensions that it begins to hinder breathing through the nose, negatively affecting the health of the child. Then it is necessary to consult a doctor. In this article you will learn how the hypertrophy of the third tonsil manifests itself and what the diagnosis and treatment looks like.

The third tonsil is one of several tonsils in the human body. Its professional name is the pharyngeal tonsil (tonsilla pharyngea). The term “tonsils” is most often used to refer to the palatine tonsils, located on the left and right sides of the throat. The third tonsil is located at the back of the nose – in the back of the nasopharyngeal cavity. It is not visible when examining a child through the open mouth.

Image source: https://commons.wikimedia.org/wiki/File:Blausen_0859_Tonsils%26Adenoids.png

The tonsils are natural structures found in the body of every human being. They are part of the immune system and consist of lymphatic tissue. We can distinguish between the palatine, tubal, lingual and pharyngeal tonsils. Together they form the so-called lymphatic ring (Waldeyer’s pharyngeal ring), which is a protective shield of the body against bacteria, viruses and fungi.

The tonsil appears in a child around 6-8 weeks of age and grows until the age of 8. Later it gradually shrinks and in time disappears completely. In adults, the third tonsil should not appear at all.

It is not entirely clear why some children tend to have enlarged tonsils, and others do not. Most often the abnormal growth of the third tonsil occurs at the age of 3-6 years, when children begin to have contact with an increasing number of germs (they go to nursery, kindergarten). The immune system, which is just developing, must at this time intensively defend itself against pathogenic microorganisms, which is not always successful. When there is a proliferation of bacteria in the third tonsil, it enlarges, makes it difficult to breathe through the nose and contributes to the deterioration of the child’s health.

At the time when the child begins to have contact with peers and is exposed to frequent infections, it is necessary to observe it carefully in order to react in time and take appropriate treatment. Symptoms of oversized tonsils are not always typical. They may resemble colds, allergies, concentration disorders.

Symptoms that may indicate an overgrowth of the third tonsil:

• breathing mainly through the mouth,
• recurrent rhinitis,
• frequent ear infections and sinusitis
• headaches,
• snoring,
• pauses in breathing during sleep,
• obstructive sleep apnea,
• sleeping with your mouth open,
• restless sleep (frequent waking, sweating, bedwetting),
• swallowing problems,
• hearing deterioration,
• nasal speech,
• constant fatigue,
• poor development of the child, caused by insufficient oxygenation of the body and sleep disorders.

In most children, the third tonsil produces no symptoms. About 10% of children snore regularly and 2% have nocturnal pauses in breathing and develop obstructive sleep apnea. These ailments adversely affect the child’s sleep, which translates into its functioning during the day. Such children are usually restless or even hyperactive. On the other hand, they may suddenly become extremely tired, for example during a car journey or even during lessons. Overgrowth of the third tonsil affects not only behavior, but also appearance. The child has his/her mouth open almost all the time because he cannot breathe through his/her nose. This is often accompanied by a runny nose, coughing and grunting. The chronic condition leads to malocclusion, which can change the way you speak and even your facial expression.

If the above symptoms occur, you should go with your child to a family doctor or pediatrician, who can then refer us to a consultation with an otolaryngologist.

Endoscopic examination of the nose and nasopharynx is used in the evaluation of the third tonsil. This involves inserting a thin “tube” into the nose that ends in a camera. This examination shows to what extent the tonsil is overgrown. The doctor also uses a speculum to examine the ears and assess the condition of the eardrum.

If your child is experiencing sleep problems, the ENT specialist may additionally recommend a sleep study, or what is known as polysomnography, which is done in a hospital setting. It is performed in order to diagnose whether the third tonsil has led to obstructive sleep apnea. However, you usually have to wait a long time for the examination, and in addition, it is not very comfortable for small patients. Although a parent may accompany the child during the examination, the very stay in the hospital ward is stressful and distracting for a child. In such conditions it is often difficult for the child to fall asleep, so the test results may be unreliable.

Image source: https://en.wikipedia.org/wiki/Polysomnography#/media/File:Pediatric_polysomnogram.jpg

An optimal solution is the Clebre sensor – a device for home sleep diagnostics. Its advantage is the convenience of use and comfortable for the child examination conditions. The small device is placed on the child’s neck overnight, thus avoiding the stress associated with being in the hospital. Moreover, the Clebre sensor will make it possible to carry out the test for several nights in a row and compare the results. This makes it possible to obtain detailed data on the quality of sleep and to choose the appropriate therapy.

If the third tonsil is slightly enlarged and the symptoms are mild (e.g., quiet snoring) and no sleep apnea is found, the doctor may recommend observation alone to begin with. Parents should then pay attention to whether the snoring intensifies and whether the child has pauses of a few seconds in breathing during sleep.

If the symptoms are severe, accompanied by a runny nose, cough, ear or sinusitis, anti-inflammatory treatment is undertaken. The doctor may prescribe antibiotics and drugs to strengthen immunity. In order to shrink the third tonsil, steroid nasal sprays are used, which reduce local inflammation and can gradually lead to a reduction in the size of the pharyngeal tonsil.

Only when pharmacotherapy does not work, a decision is made to remove the third tonsil (adenoidectomy/ adenotomy). The procedure takes place under general anaesthesia.

Early treatment of third tonsil hypertrophy can avoid health consequences such as:

• frequent upper respiratory tract infections due to continuous mouth breathing;
• chronic ear infections that pose a risk of hearing and speech disorders (an oversized tonsil obstructs airflow to the middle ear);
• malocclusion, e.g. mandibular misalignment, open bite, altered tongue position;
• abnormal physical development of the child and increased risk of cardiovascular diseases in adulthood (in case of coexistence of severe, long-lasting sleep apnea)
• sleep syndrome with apnea in adult life.