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Open wide and say "ahh": Seattle Children's Hospital shines a light on the role of tonsils in sleep apnea

Tonsillectomies are back in vogue — not so much to soothe throat infections, but rather to cure sleep apnea as well as sinus problems.

Kids of the ’70s will remember the oft-revisited TV plotline where a kid’s scorching sore throat quickly turns into a tonsillectomy and gorging on ice cream. For most of us, however, this rite of passage never materialized. But like that era’s bohemian fashions, tonsillectomies are back in vogue — not so much to soothe throat infections, but rather to cure sleep apnea as well as sinus problems.

Seattle Children’s Hospital specializes in sleep-study tests for kids, screening 2,000 children annually at its Bellevue clinic. Monitors are placed on a child’s head, face and body to check for sleep apnea. We spoke to Dr. Maida Chen, director of the hospital’s Sleep Disorders program, to learn more.


SC: What is sleep apnea?

MC: Obstructive Sleep Apnea is where you have a pause in your breathing due to an airway blockage during sleep. In kids aged 3 to 6 years, the primary causes of obstruction are large tonsils and large adenoids.

Sleep apnea matters to overall health because several things happen when you have these blockages. Your oxygen levels go down, your carbon dioxide levels go up, your heart rate and blood pressure go up and your body doesn’t like it. You have a stress response and you get unrefreshing sleep. The kids are experiencing physical stress during sleep, and they’re sleep-deprived the next day.


What are tonsils and adenoids?

They’re lymph tissue. There’s a concentration at the back of your throat and up to the back of your nose. They help fight off infections, but the reality is you have lymph tissue everywhere. So if you take [those] out, it doesn’t mean it will reduce your ability to fight off infections.


How does the blockage happen?

When you lay down to sleep, your airway naturally becomes smaller because of positioning, sleep-related floppiness of the neck muscles that hold the airway open, and gravity. Large tonsils block available space in the airway. Even kids with smaller tonsils may have blockage due to varying degrees of decreased muscle tone during sleep.


Are tonsillectomies now more commonly prescribed for sleep apnea than strep throat?

I don’t know the hard data on that. It’s more commonly done to treat sleep apnea than it has been in the past because of heightened awareness. We used to think a snoring kid was just annoying. Now we’re linking sleep apnea to difficulties with learning, behavior, academic performance, heart strain, blood pressure and emotional regulation. The stakes for not treating sleep apnea are higher than previously believed.

Strep throat is still common, but testing for strep is easier and we don’t let kids go for a long time with an untreated infection. We’re more aggressive with testing and antibiotics, so complications from strep — when kids get huge tonsils — are less common.


How do you test for sleep apnea?

It’s diagnosed with an overnight sleep study, when we can count how many times you’re having these obstructive events and what your body is doing in response.

But not every place can do sleep studies on young children, and there can be a long wait. For that reason, if you come to me and say “My kid snores, stops breathing and tosses and turns all night” and I look in their mouth and they have huge tonsils, I’d recommend tonsillectomy. Most children who have their tonsils removed because of sleep apnea never have a sleep-study test.


Why do tonsillectomies help?

The main thing is they remove an obstruction. You are taking out blockages and creating more space in their throat.


Does a tonsillectomy help every child?

Tonsillectomies, at least for sleep apnea, don’t help everybody. If you are somebody who has baseline floppiness in the neck muscles, taking out your tonsils isn’t going to address that. It doesn’t help kids who are obese as much. That’s because they have fat deposits inside and outside of their throat, and that creates more floppiness and blockage, and narrows the circumference of the air space.


What are the alternatives?

The primary, non-surgical treatment is CPAP or continuous positive airway pressure. It’s a little machine connected to the child with a mask that goes around their nose, sometimes their nose and mouth, that blows air hard enough to blow the throat open, and it keeps the airway open. If the cause of the sleep apnea is due to floppy muscles, that can help. But if you have huge tonsils, you can’t blow through a closed gate.

For some kids, if you wait long enough, their throats will grow larger to accommodate their tonsils and their tonsils might shrink a little. Age 3 to 6 is the peak for tonsillectomies to address sleep apnea.


What should parents consider before a tonsillectomy?

It is a common surgery, but still a surgery, so talking in detail with a qualified surgeon is important.  If the sleep study is borderline, you consider whether the tonsils are big enough to take out. And if the child is doing well at school and behaving, maybe you would opt to continue to observe. But if they’re tired in school, have ADHD symptoms and doing poorly academically, we might be more willing to take that kid to surgery even if their tonsils are on the smaller size.

There has been research looking at the effects of removing the tonsils versus leaving them in. The kids with sleep apnea who had the tonsillectomy had better behavior, better sleep and better quality of life. But the study only looked at kids seven months after the surgeries.


Children’s sleep program:

This interview has been edited for length and clarity.