Adenoid and Tonsil Hypertrophy: Airway Impact

What Are Adenoids and Tonsils?

Key Takeaway: Adenoids are small lymphoid tissue (immune system tissue) located in the back of your nose, above your soft palate. Tonsils are similar tissue located on the sides of your throat. Both are part of your body's immune system, helping protect you from...

Adenoids are small lymphoid tissue (immune system tissue) located in the back of your nose, above your soft palate. Tonsils are similar tissue located on the sides of your throat. Both are part of your body's immune system, helping protect you from infections.

During childhood, adenoids and tonsils normally enlarge as your immune system develops. This is completely normal. However, in some children, they grow much larger than necessary and start blocking the airway. When this happens, it causes breathing problems, sleep disruption, and can even affect how a child's face and teeth develop.

Assessing Size: The Brodsky Scale

Doctors use a standard scale (called the Brodsky Scale) to classify adenoid and tonsil size:

Grade 1: Very small, taking up less than 25 percent of the throat space. No breathing problem. Grade 2: Moderate size, taking up 25 to 50 percent of the space. Might cause some mild symptoms. Grade 3: Quite large, taking up 50 to 75 percent of the space. Usually causes noticeable problems. Grade 4: Very large, taking up more than 75 percent of the space and nearly blocking the airway. Causes obvious breathing difficulties.

Children with Grade 3 or 4 adenoids or tonsils often have breathing problems, especially during sleep.

Mouth Breathing Consequences

When adenoids or tonsils block the nose, children start breathing through their mouths instead. This seems like a minor adaptation, but it actually has major effects on how the face, jaws, and teeth develop:

The face becomes longer. Instead of growing forward naturally, the face grows downward excessively. Children develop what's called "adenoid facies"—a longer, narrower face with an open mouth posture. The palate becomes high and narrow. The roof of the mouth (palate) forms a narrow, high arch instead of a normal gently-curved shape. This narrower palate means less room for teeth. Teeth become crowded. Because the upper jaw is narrower, teeth don't fit properly. Crowding and crooked teeth develop. The bite becomes incorrect. The teeth don't close together properly. An "open bite" develops where the front teeth don't touch even when the back teeth are closed together. The lower jaw moves backward. Breathing through the mouth changes how the lower jaw develops and positions itself relative to the upper jaw.

These changes don't reverse automatically when adenoids shrink. The face, jaw, and bone have already grown in the wrong pattern. This is why early treatment is important—it prevents these permanent changes.

Sleep Apnea in Children

When very large adenoids or tonsils block the airway, they can collapse during sleep, stopping breathing for brief periods. This is called obstructive sleep apnea (OSA). A child might stop breathing 10 to 30 times per hour during sleep.

Each time breathing stops:

Oxygen levels in the blood drop
The child partially wakes to start breathing again
The child never reaches deep, restorative sleep

Children with moderate-to-severe sleep apnea wake 100 to 300 times during a night, even though they don't remember waking.

Effects of Sleep Apnea in Children

Sleep deprivation from sleep apnea causes:

Behavioral problems: The child seems hyperactive, has trouble focusing, and acts out in school. Parents and teachers might not realize the cause is sleep deprivation rather than ADHD. Learning problems: Sleep is when the brain consolidates learning. Sleep-deprived children don't learn effectively and might fall behind academically. Daytime sleepiness: The child might nap unexpectedly, fall asleep in class, or seem tired even after "sleeping all night." Growth problems: Sleep deprivation and breathing interruptions reduce growth hormone secretion. Children might grow more slowly than expected. Behavioral/mood issues: Sleep-deprived children are irritable, anxious, and moody. Heart problems: Severe sleep apnea reduces blood oxygen, putting strain on the heart.

Screening for Sleep Apnea

Your dentist or pediatrician might notice signs suggesting sleep apnea:

History of snoring (audible breathing noise during sleep)
Witnessed breathing pauses during sleep
Restless sleep, frequent nighttime wakings
Daytime behavior problems or difficulty focusing
Mouth breathing during the day
Speech sounds like the child is holding their nose ("nasal" speech)
Large, red tonsils on exam

If these signs are present, your child's doctor might recommend a sleep study (polysomnography)—an overnight test that measures breathing, oxygen levels, and sleep quality.

Treatment Options

Adenotonsillectomy (surgical removal): This is the primary treatment when sleep apnea is confirmed. Removing the obstructive tissue usually resolves breathing problems. Studies show that 50 to 60 percent of children with sleep apnea are cured by adenotonsillectomy. The remaining children show significant improvement even if not completely cured.

Recovery involves one to two weeks of soreness and dietary restrictions (soft foods), but activity can usually resume within a week.

Rapid Maxillary Expansion (RME): This orthodontic treatment widens the upper jaw, creating more space in the throat. It can be used alone for mild cases or combined with adenotonsillectomy. RME involves wearing a special palatal screw appliance that gradually widens the roof of the mouth. Combination approach: For children with moderate adenoid enlargement and significant upper jaw narrowness, combining adenotonsillectomy with RME provides the best results.

Timing Is Crucial

Ideally, adenotonsillar obstruction should be addressed before age 8. This is when the face, jaws, and teeth are still actively growing. Early treatment allows the jaws and face to develop more normally.

If a child waits until age 12 or older, the face and jaw patterns have already become fixed. Surgery or RME might not prevent the established crooked bite. The child might then need comprehensive orthodontics to correct the damage that already occurred.

After Surgery: What Happens to Teeth

In young children (under age 8): After adenotonsillectomy, the child returns to nasal breathing. This change in breathing pattern can actually help normalize facial growth. Some children's anterior open bite (front teeth not touching) resolves spontaneously as tongue posture normalizes. This spontaneous correction is why early surgery is valuable. In older children: Established malocclusion patterns usually don't resolve completely with surgery alone. An older child might need orthodontic treatment afterward to correct the bite problems that developed during years of mouth breathing.

Working with Multiple Specialists

Optimal management requires coordination between pediatrician, otolaryngologist (ENT), orthodontist, and dentist:

Pediatrician identifies the child for assessment and manages overall health. Dentist notices adenoid facies, anterior open bite, and other signs suggesting sleep apnea or airway problems. Orthodontist documents malocclusion and discusses timing of RME or other interventions. ENT specialist confirms adenotonsillar enlargement via nasopharyngoscopy (camera in the nose) and determines whether sleep apnea is present via sleep study.

Together, they decide on timing and approach. A child might get adenotonsillectomy, then RME if needed, then orthodontics if the bite needs further correction.

Long-Term Outlook

Children treated early (before age 8) with adenotonsillectomy and RME if needed often develop relatively normal bite patterns. Their faces grow more normally, and they avoid extensive orthodontic treatment.

Children diagnosed later might still benefit from surgery for health reasons, but they'll likely need orthodontic treatment afterward to correct established malocclusion.

What Parents Should Watch For

Contact your pediatrician if your child:

Snores loudly or has witnessed breathing pauses during sleep
Breathes through the mouth constantly (not just when congested)
Has very enlarged tonsils visible in the back of the throat
Seems excessively tired despite adequate sleep time
Has attention or behavior problems in school
Has noticed crooked teeth or open bite developing

Early detection and treatment offer the best chance of preventing permanent changes to facial growth.

Summary

Enlarged adenoids and tonsils block the airway, causing mouth breathing and sleep apnea in children. Chronic mouth breathing triggers permanent changes to facial growth: longer face, narrow upper jaw, crooked teeth, and incorrect bite patterns. These changes don't reverse automatically. Treatment by removing the adenoids and tonsils (adenotonsillectomy) resolves breathing problems and, in young children, allows more normal facial development.

For children with narrow upper jaws, rapid maxillary expansion (RME) widens the palate and helps breathing. Early treatment (before age 8) prevents malocclusion development; later treatment might require orthodontics to correct established bite problems. Coordination between pediatrician, ENT surgeon, orthodontist, and dentist provides optimal care. If you notice signs of enlarged adenoids or sleep apnea in your child, discuss evaluation with your pediatrician.

Conclusion

> Key Takeaway: Adenoids are small lymphoid tissue (immune system tissue) located in the back of your nose, above your soft palate. Talk to your dentist about what options work best for your situation.