Does your child snore at night and sleep with their mouth open?

Why are adenoids and tonsils in children considered together?

The adenoids are lymphoid tissue located at the back of the nose, just above the soft palate. The tonsils sit on both sides of the throat, above the base of the tongue. These two tissues belong to the same family of lymphoid tissue and, especially in the preschool years, often enlarge together. That is why enlarged adenoids in children are rarely assessed on their own; the condition of the tonsils is always examined as well.

Enlarged adenoids narrow the airway at the back of the nose, and enlarged tonsils narrow the airway in the throat. When both are present, the upper airway running from the nose to the mouth is narrowed at two points at once. This is also the most common reason for removing the tonsils in children: not infection on its own, but blocking the upper airway together with the adenoids.

On this page, in language families can easily follow, you will find the breathing problems caused by enlarged adenoids and tonsils in children, frequent tonsillitis with fever as a separate reason, and the diagnostic and treatment options. For tonsil problems in adults, see our page on tonsillectomy in adults.

Upper airway obstruction: the most common reason for surgery

When the adenoids and tonsils enlarge together in children, they cause upper airway obstruction during sleep. Because the muscles in the throat relax during sleep, the narrowing becomes more pronounced at night. This can range from mild snoring to sleep apnea, where breathing stops for short periods. Because symptoms often develop slowly, families may think this is simply the way their child sleeps.

Snoring, mouth-open sleep and pauses in breathing

A child who cannot get enough air through the nose breathes through the mouth. The mouth stays open during sleep, there is snoring almost every night and, in some children, breathing stops for a few seconds and then restarts with a deep gasp. These children may wake often at night, sweat, and sleep with their head tilted back or in an almost sitting position. In some, bedwetting may start again.

Pauses in breathing interrupt the deep stages of sleep. Even if the child stays in bed long enough, they do not get restful sleep. You can find more information about the causes of snoring and sleep apnea in children in our article on snoring and sleep apnea in children.

Daytime symptoms: tiredness, attention and behavior

The effects of broken sleep show up during the day. Difficulty waking up in the morning, tiredness, irritability, poor concentration and difficulty focusing at school may be seen. Unlike adults, children often show lack of sleep not by dozing off but through restlessness and impatience; this picture is sometimes confused with attention deficit. Poor appetite, eating slowly and poor growth may also be present.

Ears, speech and facial development

The adenoids sit very close to the openings of the Eustachian tubes, which connect the ears to the back of the nose. When they enlarge, ventilation of the middle ear is disrupted, fluid builds up in the ear and the child may have frequent middle ear infections. This should always be investigated in children who respond late when called or whose speech lags behind their peers. If needed, ear tube insertion can be done under the same anesthesia.

Years of mouth breathing can also affect the development of the face and jaw. A mouth that constantly stays open, a long-face appearance, a narrow palate and problems with tooth alignment are more common in these children. A nasal-sounding voice, a constant runny nose and night-time cough are also symptoms that often accompany enlarged adenoids in children.

The second reason: frequent tonsillitis with fever

The second important reason for removing the tonsils in children is frequently recurring tonsillitis with fever. This is a separate indication from airway obstruction; it can be a reason for surgery on its own even in a child whose tonsils are not very large. Some children have both obstruction and frequent infections.

Not every sore throat is tonsillitis. A large share of sore throats in children are caused by viruses and clear up on their own. Tonsillitis, on the other hand, usually comes with high fever, marked pain when swallowing, redness and white spots of pus on the tonsils, and tender lymph nodes in the neck. During episodes the child misses school, and frequent antibiotic use may be needed.

What frequency brings surgery into consideration?

When considering surgery, the number of episodes and whether they have been recorded regularly are important. Tonsillectomy is considered in children who have had seven or more episodes of tonsillitis with fever in the past year, at least five a year for the past two years, or at least three a year for the past three years. Children who do not meet these criteria but whose episodes come with conditions such as febrile seizures or an abscess around the tonsil are also considered separately.

For this reason, it greatly helps the decision process if families note each episode with its date, the fever and the medicines used. For children with few episodes, monitoring is usually recommended, because in most children tonsillitis becomes less frequent with age on its own.

How are enlarged adenoids and tonsils in children assessed?

The assessment begins with the complaints the family describes. Before the visit, it is very valuable to check on your child several times during one night and note snoring, mouth-open sleep and pauses in breathing. A short sleep video taken on your phone is the easiest way to show the severity of snoring and breathing pauses at the examination.

The tonsils can be seen by looking into the mouth, and their size is graded during the examination. The adenoids, however, cannot be seen through the mouth, so the back of the nose is examined with a thin, flexible endoscope. This takes a few minutes and is done gently, in a way suited to the child's age. The eardrum is also examined; if needed, a tympanometry test is done to show fluid in the middle ear.

In children with marked breathing pauses, or whose complaints do not seem to match the examination findings, a sleep study may be added to the assessment. All of this information is considered together to determine how much the adenoids and tonsils are narrowing the child's airway and how this is affecting the child's health.

Treatment options

Not every child with enlarged adenoids or tonsils has surgery. The decision depends on how severe and long-lasting the symptoms are and how they affect the child's sleep, development and ear health. In children with mild symptoms, medication and monitoring are tried first. If symptoms are marked or continue despite treatment, the surgical option is discussed.

Medication and monitoring

Especially in children who also have allergies, nasal sprays can help shrink the adenoids and reduce nasal blockage. Rinsing the nose with salt water makes it easier to clear secretions. The effect of treatment is assessed within a few weeks; during this time the child's snoring, sleep pattern and ear condition are closely monitored. If there is clear improvement, monitoring continues.

Adenotonsillectomy: removing the adenoids and tonsils together

In most children with upper airway obstruction, the adenoids and tonsils need to be removed in the same session for the airway to open fully. This procedure is called adenotonsillectomy. Removing only one may not fully relieve the complaints, because the other narrowing point remains. That is why the level of obstruction is carefully determined at the examination.

The operation is performed through the mouth under general anesthesia; there is no external incision. The child is asleep and feels no pain during the procedure. If there is long-standing fluid in the ear, ear tube insertion can be done under the same anesthesia. You can also find information about the general features of the procedure on the MedlinePlus adenoid removal page.

Adenoids only, or both together?

In children whose tonsils are small, who do not get frequent tonsillitis and whose complaints are nasal blockage and fluid in the ear, adenoidectomy alone may be enough. If the tonsils are also large and narrow the airway, or the child has frequent tonsillitis with fever, removing both together is recommended. The decision is made individually based on the examination findings. You can find at what ages this procedure is more commonly considered in our article at what age adenoid surgery is done.

Preparing for surgery

Once the decision for surgery has been made, your child's general health is assessed, basic tests such as a blood count and clotting tests are done, and a meeting with the anesthesia team takes place. A family history of bleeding problems, any medicines your child takes regularly, or a previous problem with anesthesia must always be shared. If the child has an illness with fever a few days before surgery, the operation is usually postponed.

On the night before surgery, eating and drinking stop after a set time. Explaining simply to your child that they will go to the hospital, that they will sleep and that you will be with them when they wake up makes the day of surgery easier for them. Bringing a favorite toy or blanket helps them feel safe in an unfamiliar setting.

What happens on the day of surgery?

On the morning of surgery, your child comes to the hospital with an empty stomach. The anesthesiologist examines your child and answers your questions. Many children fall asleep with a mask while their parent is beside them, which reduces separation anxiety. The operation is usually short, and you wait in the waiting area during this time.

The child is monitored for a while in the recovery room. Restlessness, crying and drowsiness in the first hours are expected. Once it is clear that the child can drink, has no bleeding and is generally well, most children go home the same day or after one night of observation. For young children with marked sleep apnea, an overnight hospital stay may be preferred.

Recovery after surgery

In children who have only their adenoids removed, recovery is usually complete within a few days. If the tonsils are also removed, recovery takes longer, usually ten to fourteen days in most children. During this period there may be a sore throat, bad breath and pain radiating to the ear. Painkillers are given regularly as the doctor recommends.

The most important rule is for the child to drink plenty of fluids. Cold and lukewarm, soft foods are preferred; hot, hard and spicy foods are avoided. Towards the end of the first week after surgery, pain may increase briefly as the white scabs in the tonsil beds come away; this is expected. If there is blood from the mouth or nose, a high fever, or the child cannot drink fluids, a doctor should be contacted without delay.

Eating and drinking advice

In the first days, drinks such as water, ayran (a yogurt drink), compote, cold milk and fruit juice, and soft foods such as yogurt, milk pudding, purées, soup and ice cream are preferred. Acidic fruit juices and hard foods such as fried foods, crisps and crackers can irritate the throat, so they are not given for a while. Encouraging your child to drink small sips at frequent intervals is the easiest way to prevent dehydration.

Snoring that continues in the first days is due to temporary swelling in the surgical area and decreases over the following days. In most children, snoring and mouth-open sleep improve markedly within the first weeks. For details on the recovery process, see our article on recovery after adenoid surgery.

Possible risks

Adenoid and tonsil surgery are common procedures considered safe; even so, like any surgical procedure, they carry some risks. The most important is bleeding. Bleeding is mostly seen in the first hours or at the end of the first week, when the tonsil scabs come off. That is why fresh blood from the mouth or nose is always treated as an emergency.

Mild fever for a few days after surgery, pain radiating to the ear and a change in voice are usually temporary. Before surgery, the risks are discussed in detail according to your child's condition, and your questions are answered.

What happens if it is not treated?

In most children, the adenoids and tonsils shrink with age. For this reason, some families feel that waiting will be enough. However, in a child with significant obstruction, this waiting period can last for years, and these years are very valuable for the child's development. Long-lasting sleep disturbance can lead to attention and learning difficulties, poor growth, recurrent ear infections and changes in facial development.

On the other hand, surgery is not necessary for every child with mild symptoms. What matters is that the child's condition is assessed correctly, avoiding both unnecessary intervention and unnecessary waiting.

Allergies and related conditions

Allergic rhinitis often occurs together with enlarged adenoids and can make symptoms worse. In children with allergies, the tissues inside the nose and the adenoids swell, and nasal blockage and mouth breathing increase. Sneezing, an itchy nose, watery eyes and complaints that get worse when the seasons change are clues to allergy. In these children, treating the allergy reduces the complaints and in some children may remove the need for surgery.

Not smoking at home, reducing dust mites, washing bedding often and airing the room regularly are simple but effective steps that support nasal health.

Conditions such as excess weight, asthma and reflux can also make breathing problems during sleep worse. For this reason, your child's general health is considered as a whole during the assessment, and planning is done together with the pediatrician when needed.

Common mistakes and misconceptions

One of the most common misconceptions is that snoring in children is normal. Mild snoring during a cold can be normal; however, loud snoring almost every night is a sign of an underlying obstruction and should be assessed.

Another misconception is that the tonsils are removed only when they are frequently inflamed. In fact, the most common reason for surgery in children is not infection but the tonsils narrowing the airway together with the adenoids. Finally, the worry that removing the adenoids or tonsils will weaken immunity is also often heard. Because the immune system has many different parts, removing these tissues does not reduce the child's resistance to illness.

Advice for families

Observing your child's sleep gives the most valuable clues. Go into their room several times during one night and note whether their mouth is open, whether they snore and whether there are pauses in their breathing. Also record episodes of tonsillitis with fever, along with the date, the fever and the medicines used. Feedback from teachers about poor concentration or not hearing is also important.

You can find more information about the symptoms in our article on symptoms of enlarged adenoids, and general information about snoring and sleep problems in the NHS guide to snoring.

When should you see a specialist?

If your child snores almost every night, sleeps with their mouth open, seems to stop breathing during sleep, has frequent ear infections or has tonsillitis with fever several times a year, it is recommended that you see an ear, nose and throat specialist. Daytime tiredness, poor concentration and restlessness may also accompany these symptoms.

Prof. Dr. Mustafa Deniz Yılmaz assesses adenoid and tonsil problems in children with a gentle examination suited to the child's age and creates a personalized treatment plan for each child. Whether surgery is needed, and which tissues will be removed, is decided together with the family based on this assessment.

By completing the parent test at the top of this page, you can see which group your child's symptoms fall into and contact us through the pre-assessment form.