My child needs their adenoids and tonsils removed and palate expansion – what should we do first?

Many snoring children will have immediate sleep and symptomatic improvements with surgical removal of enlarged adenoids and tonsils.

However, research tells us surgery is not a complete cure. Often children will have residual breathing disturbances during sleep, or a recurrence of symptoms with time.

This is because snoring and other disturbed breathing is a multifactorial problem and there are usually a combination of risk factors that contribute to the issue, and need to be addressed.

In fact, there is growing support for the hypothesis that enlarged adenoids and tonsils may be a symptom of a greater underlying airway problem, including poor palate development, nasal disuse and dysfunctional breathing during sleep.…/

Palate expansion

  • Is well proven as an adjunct to removal of adenoids and tonsils to address snoring and obstructive sleep apnoea
  • Has been well demonstrated to help improve nasal airflow and nasal breathing
  • Improves tongue space. This can promote or facilitate better tongue to palate seal and less encroachment of the base of tongue in the throat.
  • Has been demonstrated to reduce the volume of the adenoids and tonsils, and improve symptoms of disturbed sleep in one study published this year

When a child has a constricted palate, a common question is what should we address first?

If a child is too young to engage directly with us and sit in the chair for a full series of orthodontic photos, then palate expansion is not an option. Surgery first to remove enlarged adenoids and tonsils can be a good option to help open the airway. This is because young children are most vulnerable to unrestorative sleep, and increased risks of behavioural and learning problems down the track.

From around 3 years, some children will be ready to engage directly with us, and co-operate for a complete series of orthodontic photos. These children may be good candidates to start palate expansion.

Often it can take time to get an ENT consult or a date for surgery, so it’s common for me to suggest we start expansion prior.

In fact sometimes children are recommended surgery based on symptoms, and without a proper assessment using a video endoscope of the nose and throat. Apart from certain x-rays, this is the only way to visualize for certain that the adenoids are in fact obstructing the airway. I would rather address narrow palate, or what we know for certain is there and contributing to limitation of airflow, and reassess response to expansion over the first 4-6 weeks.

One of the benefits with this approach is that if breathing, sleep and day function is improving quickly within that time frame, then it could be an indication that a child may be able to avoid surgery.

This is something I see often, but individual results will vary depending on each child’s combination of risk factors.

To make the most fully informed decision on what is right for your child, it is best to have an individualised assessment, and a second opinion from your ENT surgeon.

Yesterday I saw eight expansion patients between the ages of 3-4 years. It made me reflect on how much younger my patient base is becoming, how impactful I’m finding it, and my journey starting treatment younger and younger.

The traditional age for expansion is age 7-8 years when the first permanent teeth start to come through.

But five years ago, I made a brave decision that I was going to expand my youngest daughter’s palate at age 6.
This was especially because that was before the days of digital scanning at Sparkle and I had to subject her to bulky and messy impression materials that was never a fun experience for any child!

She had persistent symptoms of disturbed breathing during sleep after earlier surgical removal of adenoids, tonsils and turbinate reduction. Symptoms included teeth grinding, very wet pull ups at night, and she was the type of child you wouldn’t want to go to bed with, doing 360 turns all night long in bed. Her teeth were wearing away, and she was starting to feel self conscious when we bought pull ups at the shops. I was running out of options to address the underlying airway problem and if palate expansion was helping 7 year olds, why wouldn’t it help her?

Her symptoms resolved within a month of treatment, her sleep was sounder, and the bonus was it made more space for her first permanent teeth to come through in good alignment. Age 6 became my new ideal age to start treatment and I thought I was doing a great service.

Two years ago, influential colleagues in the US challenged me further to start even earlier.

There’s always the professional concern that treatment can be more efficient and less costly for patients if we can delay the start of treatment.

However my colleagues gave the analogy that delaying treatment is like telling parents not to get glasses for their child until age 8 when a vision problem is detected much earlier. Yes, it rules out them needing a new pair as they grow bigger. But what experience will they miss waiting and watching for those extra years?

You see the palate is the floor of the nose and the housing for the tongue. The narrow palate is a known risk factor for obstructive breathing during sleep. But when growth is off track to any degree, there is some degree of airflow limitation and breathing and sleep will not be the best it could be.

Two important studies that followed 11,000 children found mouth breathing, snoring and gasping during sleep in the earliest years of life increase a child’s risk of behavioural and socio-emotional problems, and special education needs at age 4 and 7, even when the breathing problems have peaked and subsided at age 30 months. We can’t predict exactly which children will be most affected. But I’ve seen enough of the 7-8 year olds who are on wait list to see a paediatrician for an ADHD diagnosis or who are already being medicated, to question the watch, wait and roll a dice approach.

That’s why I think it’s important our profession offers parents the info and choice to start treatment earlier than we have in the past.

Honestly, we used to be a practice where none of the dentists were eager and comfortable working with young children, and our front office team used to cringe when parents had a great experience and wanted to bring their children too.

But now, thanks to the support of our talented with children team, I really enjoy our little patients, and am rewarded knowing we are helping them achieve a better trajectory of development.

I’m not promising we can manage ADHD.

But I do think we need to focus on health and not letting symptoms compound, and that includes optimising jaw and airway development, breathing and sleep. This photo is a throwback to my first 3.5 year old patient that I had the privilege of treating! How could I not love this work with patients as adorable as her!

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