Variation in Tonsil Size in 4- to 17-Year

The Journal of Otolaryngology, Volume 35, Number 4, 2006
Variation in Tonsil Size
in 4- to 17-Year-old Schoolchildren
Ahmet Akcay, MD, Ciineyt Orhan Kara, MD,
Erol Dagdeviren, MD, and Mehmet Zencir, MD
Abstract
Objective: The purpose of this study was to evaluate the variation in tonsil size and prevalence of asymmetric tonsils in 4- to
17-year-old schoolchildren and the relationships between tonsillar hypertrophy and frequent tonsillitis, frequent fever, and
sleep-related symptoms observed by parents.
Design: Cross-sectional study.
Setting: Six daycare centres, four primary schools, and four high schools.
Methods: Questionnaire and physical examination.
Main Outcome Measures: The size of the tonsils was evaluated and scored on a 4-point scale. The interrelationships
between tonsillar hypertrophy and other studied symptoms were examined.
Results: In the study, the parents of 1784 children, consisting of 803 (45%) boys and 981 (55%) girls, completed the questionnaires. The prevalence rates of snoring, habitual snoring, observed apnea, and habitual observed apnea were 24.6%,
4.1%, 3.8%, and 0.9%, respectively. The results of tonsil scoring were grade 1, 62.7%; grade 2, 28.4%; grade 3, 3.3%; and
grade 4, 0.1%. The prevalence rate of grade 1 tonsils was increasing, whereas the prevalence rates of grade 2 and 3 tonsils
were decreasing with increasing age. Tonsil size peaked in 4- to 8-year-old children. The prevalence rates of tonsillar hypertrophy and asymmetric tonsils were 3.4% and 1.7%, respectively. Tonsillar hypertrophy was found to be significantly associated with male gender, a history of frequent tonsillitis, a history of frequent fever, often or always snoring, and often or
always observed apnea.
Conclusions: A tonsil size curve was developed in 4- to 17-year-old schoolchildren. Children aged 4- to 8 years with oropharyngeal symptoms and particularly male gender should undergo consultation with otorhinolaryngology and pediatric pulmonology pliysicians for the evalution of adenotonsillar tissue.
Sommaire
Objectif: Le but de cette etude etait d'evaluer les variations dans le volume des amygdales et la prevalence d'une asymetrie
amygdalienne chez les enfants de 4 a 17 ans et d'evaluer la relation entre l'hypertrophie amygdalienne et l'amygdalite recidivante, la fievre recidivante et les symptomes relies au sommeil notes par les parents.
Devis: Etude de cohorte
Localisation: Six garderies, 4 ecoles primaires et 4 ecoles secondaires.
Metbodes: Questionnaire et examen physique.
Variables evaluees: Le volume des amygdales a ete evalue sur une echelle en 4 points. Nous avons aussi evalue la relation entre
l'hypertrophie amygdalienne et les autres symptomes.
Resultats: Les parents de 1784 enfants (803 gar9ons (45%) et 981 filles (55%)) ont complete le questionnaire. La prevalence de
ronflement, de ronflement regulier, d'apnee documentee et d'apnee reguliere documentee etait de 24.6%, 4.1%, 3.8%, 0.9%
respectivement. Le volume des amygdales se presentait comme suit: grade 1, 62.7%; grade 2, 28.4%; grade 3, 3.3% et grade 4,
0.1%. La prevalence des grade 1 augmentait avec l'age a I'inverse de la prevalence de grade 2 et 3. Le volume des amygdales
atteint un sommet entre l'age de 4 et 8 ans. La prevalence d'hypertrophie amygdalienne et d'asymetrie etait de 3.4% et del.7%
respectivement. L'hypertrophie etait statistiquement associee aux garjons, a une histoire amygdalite a repetition, a une histoire
de fievre frequente, a un ronflement occasionnel ou continuel et a des apnees occasionnelles ou regulieres.
Conclusion: Nous avons developpe une courbe normative pour le volume amygdalien chez les enfants de 4 a 17 ans. Les
jeunes de 4 a 8 ans avec des symptomes orophrynges, en particulier les gar^ons, devraient etre evalues en ORL et en pneumopediatrie.
Key words: apnea, asymmetric tonsil, snoring, tonsil size, tonsillar hypertrophy
270
Akcay et al. Variation in Tonsil Size in Childhood
T
he tonsils and adenoids are part of Waldeyer's
ring, the basic function of which is antibody formation; they react later against a great variety of antigens.' The tonsils and adenoids are very small at birth.
Rarely, children are born with unusually large adenoid
and tonsil tissues. The adenoid and tonsil tissues usually increase in size throughout childhood and tend to
regress in adolescence.^
Several authors have reported that grossly enlarged
tonsils have serious symptoms and complications.^"^
Although it is well known that adenotonsillar hypertrophy is a childhood disease, epidemiologic studies on the
prevalence of adenotonsillar hypertrophy in childhood
are rarely seen in the literature.
Tonsillar asymmetry is usually secondary to benign
hyperplasia. However, asymmetric tonsils may indicate
a serious underlying disorder, such as lymphoma, lipid
storage disease, or Langerhans' cell histiocytosis.^"^
Asymmetry of tonsils that arouses a suspicion of malignancy is one of the indications of tonsillectomy.'" As
with the variation in tonsil size, there is a lack of
knowledge about the prevalence of tonsil asymmetry in
the literature.
This study was performed to evaluate the variation
in tonsil size and the prevalence of asymmetric tonsils
in 4- to 17-year-old schoolchildren and the relationships between tonsillar hypertrophy and frequent tonsillitis, frequent fever, and sleep-related symptoms
observed by parents.
Methods
Between March and May 2003, 2000 children aged 4 to
17 years in six daycare centres, four primary schools,
and four high schools in DenizH, Turkey, were surveyed.
From these children, 1784 questionnaires were completed appropriately, with an overall response of 89.2%.
The questionnaire included questions concerning
histories of tonsillectomy and/or adenoidectomy, frequent tonsillitis, frequent fever, and symptoms of sleepdisordered breathing, such as regularity in snoring,
observed apneas, sleeping disturbances, and constant
mouth breathing during sleep. The Obstructive Sleep
Apnea Syndrome Expanded Childhood Questionnaire
Received 08/08/05. Received revised 10/03/05. Accepted for publication 10/04/05.
Ahmet Akcay and Erol Dagdeviren: Department of Pediatrics,
Ciineyt Orhan Kara: Department of Otorhinolaryngology, and
Mehmet Zencir: Department of Public Health, Faculty of Medicine, Pamukkale University, Denizli, Turkey.
Address reprint requests to: Dr. Ahmet Akcay, Department of
Pediatrics, Faculty of Medicine, Pamukkale University, 20100,
Denizli, Turkey. e-mail:[email protected].
DOI: 10.2310/7070.2005.0118
271
formulated by Carroll and colleagues" was used. Parents reported snoring and apnea on a 4-point scale: 0 =
never, 1 = seldom, 2 = often, and 3 = always. Habitual
snoring and apnea were considered present if parents
reported snoring and apnea as either often or always. A
detailed form was completed for each child by the parents. Thereafter, the size of the tonsils was evaluated by
the first author in all children and scored on a 4-point
scale as follows: grade 1, tonsils were in the tonsillary
fossa and were barely seen behind the anterior pillars;
grade 2, tonsils were visible behind the anterior pillars;
grade 3, tonsils extended three-quarters of the way to
the midline; grade 4, tonsils were completely obstructing the airway.^''^"'^ Tonsillar asymmetry was determined to be present when there was at least a +1 difference in the two tonsils.''*
The interrelationships between tonsillar hypertrophy and other studied items were examined by chisquare tests, and those with tonsillectomy and/or adenoidectomy were excluded from statistical analysis. A
significant difference was indicated by a p value < .05.
Results
Two hundred sixteen children were excluded from the
study owing to incomplete or improperly completed
questionnaires. A total of 1784 questionnaires, from
803 (45%) boys and 981 {55%) girls, were completed
by parents.
The prevalence rates of frequent tonsillitis and fever
were 19.9% and 24.7%, respectively. The prevalence
rates of snoring, habitual snoring, observed apnea, and
habitual observed apnea were 24.6%, 4.1%, 3.8%, and
0.9%, respectively (Table 1). The prevalence rates of
often or always snoring and observed apnea, frequent
Table 1 Summary of the Results of the Questionnaire
Questions
n (%)
Sex
Male
Female
History of frequent tonsillitis
< 2 episodes in year
> 2 episodes in year
History of frequent fever
< 2 episodes in year
> 2 episodes in year
Snoring
Never
Seldom
Often
Always
Observed apnea
Never
Seldom
Often
Always
803 (45)
981 (55)
1406 (80.1)
349 (19.9)
1326 (75.3)
436 (24.7)
1325 (75.4)
361 (20.5)
44 (2.5)
28 (1.6)
1676 (96.2)
51 (2.9)
4 (0.2)
12 (0.7)
272
The Journal of Otolaryngology, Volume 35, Number 4, 2006
fever, and tonsillitis decreased with increasing age (Figure 1).
The results of tonsil scoring were as follows: grade
1, 62.7%; grade 2, 28.4%; grade 3, 3.3%; and grade 4,
0.1%. Ninety-eight children had tonsillectomy and/or
adenoidectomy operation before the study. The prevalence rate of tonsillar hypertrophy in schoolchildren
was 3.4%. Forty-seven children (1.7%) were determined to have asymmetric tonsils (Table 2). The prevalence rate of grade 1 tonsils was increasing, whereas the
prevalence rates of grade 2 and 3 tonsils were decreasing with increasing age. Grade 4 tonsils were determined in only 6- and 7-year-old schoolchildren. Tonsil
size peaked in 4- to 8-year-old children (Figure 2).
For statistical comparisons, grade 3 and 4 tonsils
were grouped as obstructive tonsil size and grade 1 and
2 tonsils were grouped as nonohstructive tonsil size.
Ninety-eight children with tonsillectomy and/or adenoidectomy were excluded from the statistical analysis.
The interrelationships between obstructing tonsil size
and all other studied items were examined hy chi-square
tests (Table 3). Tonsillar hypertrophy was found to be
significantly associated with male gender (p = .007, odds
ratio [OR] 1.99), a history of frequent tonsillitis (p <
.001, OR 3.4), a history of frequent fever (p < .001, OR
2.7), often or always snoring (p < .001, OR 15.1), and
often or always observed apnea {p = .017, OR 6.62)
(see Table 3).
Discussion
Lymphoid tissue in Waldeyer's ring is sparse at birth.
This is followed by a period of proliferation and eventual involution.'^ Tonsillar hypertrophy begins in early
childhood and continues until puberty, after which
atrophic changes may occur.'^ In the literature, there is
a lack of knowledge about variation in tonsil size in
children. This is the first report that evaluated tonsil
size by physical examination in 4- to 17-year-old
schoolchildren. Previously, Fujioka and colleagues
found that the adenoids peak in size between 3 and 6
60
LU
n (%)
Size of tonsils
Grade 1
Grade 2
Grade 3
Grade 4
Tonsillectomy
Tonsillar hypertrophy
Asymmetric tonsils
— 0 bserved apnea
'\
* *
^
20
/— "
z_
10
—
^
5
6
7
8
9
1119 (62.7)
507 (28.4)
58 (3.3)
2 (0.1)
98 (5.5)
60 (3.4)
31 (1.7)
years of age and then begin to atrophy according to
radiographic evaluation of adenoid size.'^ We similarly
found tonsil size to be the greatest in 4- to 8-year-old
children and to gradually decrease in the following
years. Grade 2 tonsils were most frequently encountered in the 4-year-old age group, whereas grade 3 tonsils constituted only 14% of this group.
In our study, tonsillar hypertrophy was found to
be significantly associated with male gender. Greenfeld
and colleagues reported male dominance among children with obstructive sleep apnea syndrome, which is
compatible with our results.'^ Male gender may be a
risk factor for tonsillar hypertrophy. This may be due
to anatomic structure and hormonal profile.
Hypertrophic tonsils may cause obstruction or
accompany chronic or recurrent tonsillitis in some children. They are also accused of repeated attacks of local
or systemic infections.'^''^ In our study, there was a
statistically significant association between tonsillar
hypertrophy and a history of frequent tonsillitis and
fever (see Table 3). On the other hand, in the studied
population, 55% of children with tonsillar hypertrophy had no history of recurrent tonsillitis. It is well
known that tonsillar hypertrophy can be present even
in the absence of a history of infection.^
Snoring, restless sleep, observed apnea, and constant oral breathing during sleep are nocturnal signs of
pharyngeal obstruction owing to tonsillar or adenoid
q noring
^40
O
\k 30
LU
Q.
Tonsillar Tissue
— 0ften tonsillitis
- 0 ften fever
50
Q
LU
Table 2 Tonsillar Tissue in 4- to 17-Year-Old Children {n ••
1784)
10 11 12 13 14 15 16 17
AGE
Figure 1 The variation in snoring, observed apnea, frequent tonsillitis, and
frequent fever among 4- to 17-year-old schoolchildren.
Akcay et al. Variation in Tonsil Size in Childhood 273
100
90
2
80
LU
=^
g 70
— G rade 1
^ 60
O
u. 50
O
H 40
LU
O
^^
X
on
30
- G rade II
- G rade III
V-
— G rade IV
~\
E 20
'^ 10
——\
-
0
4
5
6
7
8
9 10 11 12 13 14 15 16 17
AGE
Figure 2 Tonsil size variation among 4- to 17-year-old schoolchildren.
hypertrophy in children. In previous studies, the prevalence of snoring every night (described as habitual
snoring in this study) was found to be between 6.2 and
12.1 in children up to 7 years old.^"'^^ In this study,
habitual snoring was found to be 4.1%, and this is
lower than the results of previous studies^""^^ but
higher than the results of Kara and colleagues' study
done in Denizli {7.A°/o)P The different age groups
could explain these varying rates. As clearly seen in our
results, the prevalence of snoring reaches its maximum
at age 4 years and gradually decreases parallel to the
prevalence of tonsillar hypertrophy. On the other hand,
the prevalence rate of habitual snoring was found to be
higher than the prevalence rate of tonsillar hypertrophy. Therefore, habitual snoring could not be
explained only with tonsillar hypertrophy.
Observed apnea is an associated symptom of
obstructive adenotonsillar hypertrophy. In this study.
the rate of observed apnea prevalence was found to be
3.8%, which was higher than the results of Kara and
colleagues' study {2.J°/o)P The different age groups
could explain these varying rates. Also in our study,
there was a statistically significant relationship between
tonsillar hypertrophy and observed apnea, which agrees
with the results in the literature.
There are not enough studies on the prevalence of
tonsil asymmetry. The prevalence of asymmetric tonsils
was uncommon among 4- to 17-year-old schoolchildren in Denizli. Although the asymmetry of tonsils
arouses a suspicion of malignancy, it may often be an
illusion secondary to a difference in the depth of the
tonsillar fossa.''' The presence of tonsil asymmetry
without factors such as significant systemic signs and
symptoms, progressive enlargement of the tonsil, ipsilateral cervical adenopathy, and a history of malignancy may not indicate malignancy.''' In our study.
Table 3 Interrelationships between Tonsillar Hypertrophy and Studied Factors [n = 1686)
Factors
Grades 3 and 4
n (%)
Grades 1 and 2
n (%)
37(2.2)
23 (1.4)
725 (43)
901 (53.4)
.007
1.99 (1.18-3.39)
1.00
26(1.5)
32(1.9)
309(18.3)
1293 (76.7)
<.OO1
3.40 (2.00-5.79)
1.00
27(1.6)
31 (1.8)
387(22.9)
1221 (72.4)
<.OO1
2.75 (1.62-4.66)
1.00
19(1.1)
39 (2.3)
50 (3.0)
1554(92.1)
<.OO1
15.14 (8.17-28.04)
1.00
3 (0.2)
55 (3.3)
13 (0.8)
1578 (93.5)
.017
6.62 (1.83-23.90)
1.00
Sex
Male
Female
History of tonsillitis
> 2 episodes in year
< 2 episodes in year
History of often fever
> 2 episodes in year
< 2 episodes in year
Snoring
Often or always
Never or seldom
Observed apnea
Often or always
Never or seldom
CI = confidence interval; OR = odds ratio.
p Value
OR (95% CI)
274
The Journal of Otolaryngology, Volume 35, Number 4, 2006
because children with asymmetric tonsils did not have
these warning sign and symptoms, the tonsils were not
considered to be malignant.
8.
9.
Conclusions
A tonsil size curve was developed in 4- to 17-year-old
schoolchildren in Denizli, Turkey. The rates of tonsillar
hypertrophy and the prevalence of asymmetric tonsils
were found to be low.
Tonsillar hypertrophy was found to be significantly associated with the signs and symptoms of upper
airway infection and upper airway obstruction. Tonsillar hypertrophy is most frequently encountered at age 4
years and gradually decreases in the following years.
Children aged 4- to 8 years with oropharyngeal
symptoms, such as a history of frequent tonsillitis and
fever, snoring, observed apnea, and particularly male
gender, should consult with otorhinolaryngology and
pediatric pulmonology physicians for the evaluation of
adenotonsillar tissue and polysomnography.
10.
11.
12.
13.
14.
15.
16.
References
1.
2.
3.
4.
5.
6.
7.
Gonzalez Rivera SR, Coromina Isern J, Gay Escoda G. Respiratory orofacial and occlusion disorders associated with
adenotonsillar hypertrophy. An Otorrinolaringol Ibero Am
2004;31:265-82.
Potsic WP. Assessment and treatment of adenotonsillar
hypertrophy in children. Am J Otolaryngol 1992;13:259-64.
Menashe V, Farrehi C, Miller M. Hypoventilation and cor
pulmonale due to chronic upper airway obstruction. J Pediatr
1965;67:198-203.
Ahlqvist-Rastad J, Hultcrantz E, Svanholm H. Ghildren
with tonsillar obstruction: indications for and efficacy of
tonsillectomy. Acta Paediatr Scand 1988;77:831-5.
Brodsky L, Moore L, Stanievich JF. A comparison of tonsillar size and oropharyngeal dimensions in children with
obstructive adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 1987;13:149-56.
Brodsky L. Modern assessment of tonsils and adenoids.
Pediatr Glin North Am 1989;36:1551-69.
Berkowitz RG, Mahadevan M. Unilateral tonsillar enlargement and tonsillar lymphoma in children. Ann Otol Rhinol
Laryngol 1999;108:876-9.
17.
18.
19.
20.
21.
22.
23.
Gortez EA, Mattox DE, Holt GR, Gates GA. Unilateral tonsillar enlargement. Otolaryngol Head Neck Surg 1979;7:707-16.
Dohar JE, Bonilla JA. Processing of adenoid and tonsil specimens in children: a national survey of standard practices and
a five-year review of the experience at the Children's Hospital
of Pittsburgh. Otolaryngol Head Neck Surg 1996;115:94-7.
Ginar F. Significance of asymptomatic tonsil asymmetry.
Otolaryngol Head Neck Surg 2004;131:101-3.
Garroll JL, McGoUey SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive
sleep apnea syndrome in children. Ghest 1995;108:610-8.
Friedman M, Tanyeri H, La Rosa M, et al. Glinical predictors
of obstructive sleep apnea. Laryngoscope 1999;109:1901-7.
Walker RP. Snoring and obstructive sleep apnea. In: Bailey
JB, Galhoun KH, Deskin RW, editors. Head & neck
surgery-otolaryngology. 2nd ed. Philadelphia: LippincottRaven Press; 1988. p. 707-29.
Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg 2002;!28:767-9.
Seigel G. Theoretical and clinical aspects of the tonsillar
function. Int J Pediatr Otolaryngol 1983;6:61-71.
Kornblut AD. Non-neoplastic disease of the tonsils and adenoids. In: Paparella MM, Shumrick DA, Gluckman JL,
Meyerhoff WL, editors. Otolaryngology. 3rd ed. Philadelphia: W.B. Saunders Gompany; 1991. p. 2129-47.
Fujioka M, Young LW, Girdany BR. Radiographie evaluation of adenoidal size in children: adenoidal-nasopharyngeal
ratio. AJR Am J Roentgenol 1979;133:401.
Greenfeld M, Tauman R, DeRowe A, Sivan Y. Obstructive
sleep apnea syndrome due to adenotonsillar hypertrophy in
infants. Int J Pediatr Otorhinolaryngol 2003;67:1055-60.
Ballantyne JG, Groves J, Edwards GH, Downton D. A synopsis
of otolaryngology. Bristol (UK): John Wright and Sons; 1978.
Hultcrantz E, Lofstrand-Tidestrom B, Ahlquist-Rastad J.
The epidemiology of sleep related breathing disorder in children. Int J Pediatr Otorhinolaryngol 1995;32 Suppl:S63-6.
Smedje H, Broman JE, Hetta J. Parents' reports of disturbed
sleep in 5-7-year-old Swedish children. Acta Paediatr 1999;
88:858-65.
Teculescu DB, Gaillier I, Perrin P, et al. Snoring in French
preschool children. Pediatr Pulmonol 1992;!3:239-44.
Kara GO, Ergin H, Kocak G, et al. Prevalence of tonsillar
hypertrophy and associated oropharyngeal symptoms in primary school children in Denizli, Turkey. Int J Pediatr
Otorhinolaryngol 2002;66:175-9.