The third tonsil (adenoids): when does a blocked nose call for treatment?

When we say tonsils, most people picture the two pink lumps in the throat. There is a third one, though, that cannot be seen in the mirror: the adenoid, also called the pharyngeal tonsil. It sits high behind the nose, in the nasopharynx, and together with the palatine and lingual tonsils it forms the so-called Waldeyer's ring. This is lymphoid tissue placed exactly at the entrance of the upper airways, where viruses and bacteria from the air are intercepted first.

In babies and small children this tissue is in its prime and keeps growing until about age 6 to 7, after which it gradually shrinks, and by the teenage years it is barely noticeable. Enlarged adenoids are observed in nearly a third of children (about 34%, according to the StatPearls reference), so this is a common picture, not a rare diagnosis.

The adenoid cannot be seen directly in the throat, so a parent can recognize it by its manifestations. The best known of these is mouth breathing even during the day: the child sounds nasal (as if the nose is blocked from the inside) and always has a mild cold. Other signs are night snoring and sleeping with the mouth open, dry lips and bad breath, a persistent dry cough (worst at night and in the morning), as well as frequent ear infections with fluid collecting in the middle ear and temporarily reduced hearing.

In the pharmacy this often looks like this: last week a mother asked me for a nasal decongestant (nose-unblocking drops) for her four-year-old, because for months the child's nose had been blocked. The child stood next to her with an open mouth and cracked lips. A stuffy nose that does not clear in a week or two can be a sign of an enlarged third tonsil, and the check is performed by an ENT specialist. Pauses in breathing during sleep, or if the child wakes up suddenly as if suffocating, are an unmistakable reason for an urgent visit.

Every cold leads to swelling of the lining in the nasopharynx, and the adenoid swells along with it. In autumn, when colds follow one after another, a child can spend weeks with a partially blocked nose without actually being seriously ill. The condition becomes chronic when the swelling does not get a chance to subside between the individual infections, or when the causes behind it are factors such as allergy, exposure to cigarette smoke, or the dry, hot air from indoor heaters at home.

The practical advice to parents is to watch the overall pattern, not just each individual cold: how many nights in a row the child snores, how it breathes during the day and whether its voice has changed. And to reduce how often the infections themselves occur, the basics remain the same ones I describe in the article on immunity in kindergarten: enough sleep, regular hand washing, clean air and patience.

The specialist examines the adenoid with a thin endoscopic camera passed through the nose; the procedure is painless and takes only a minute or two. The size is rated on a scale from 0 to 4, depending on how much of the space behind the nose is blocked. If sleep apnea is suspected, a sleep study is ordered (polysomnography), and with frequent ear problems, a hearing test (audiometry). This visit is not a verdict: it simply shows how much the obstruction interferes with the child's breathing, sleep and hearing.

If the tonsil is enlarged but the child has no complaints, the recommendation is usually observation, since the tissue often shrinks naturally with growth. Surgical removal (adenoidectomy) is discussed when obstructive sleep apnea is confirmed, when ear infections with fluid collecting in the ear keep coming back, or when the tissue itself stays chronically infected. The decision is made by the specialist after an individual examination. Modern pediatric guidelines are far more conservative than the old practice where tonsils were removed en masse: today surgery is undertaken only for clear medical indications.

While you wait for the appointment, or during yet another cold, the useful steps are simple: saline as a spray or rinses for the nose, keeping the air in the room humid (especially with the heating on), drinking enough fluids and a smoke-free environment. Decongestant nose drops for unblocking the nose in children are used as a short course and only when needed, not for weeks on end, because prolonged use causes the opposite effect (medication-induced rhinitis). And doses of syrups for colds and fever are calculated according to the child's kilograms, not by spoons, as I have described in detail in the separate article on dosing.

And now the bad news for advertisers: no spray, ointment or herbal blend can melt adenoids away. There are medical treatment schemes with nasal corticosteroid sprays that reduce the swelling in some children, but they are prescribed and monitored entirely by a doctor, and their effect requires daily, long-term use. Every promise to dissolve the third tonsil without surgery, with drops bought online, is aimed at your wallet, not at your child's health. And if you are unsure whether what you are noticing is just another cold or something more, write to me in the Ask Didi chat: I answer personally and free of charge for information purposes only, without placing diagnoses and without changing prescribed therapy.

This article was written by Donka Arabadjova, Master of Pharmacy, and confirmed against the following sources: StatPearls: enlarged adenoids, causes, signs and reasons for adenoidectomy; American Academy of Pediatrics: signs of an enlarged adenoid and when surgery is recommended; NHS: what an adenoidectomy is, risks and recovery; Medical University of Varna: obstructive sleep apnea in children and the role of the tonsils and adenoids.