Are Your Child’s Large Tonsils a Problem? A Frisco ENT’s Guide for Parents

“Why Are My Child’s Tonsils So Big?”

As a pediatric Ear, Nose, and Throat (ENT) specialist serving families here in Frisco, Texas, this is one of the most common questions I hear from concerned parents. You peek into your child’s mouth to check on a sore throat, and you see two large, reddish lumps in the back that seem to be nearly touching. It’s a sight that can be genuinely alarming, and it often leads to a flood of questions: Is this normal? Is it painful? Does my child need surgery?

In my practice, I see many children for evaluation of large tonsils, and I’ve found that both parents and pediatricians are often looking for clear, straightforward information. The internet is filled with conflicting advice, and it can be difficult to know when to worry and when to be reassured.  

The goal of this guide is to cut through that confusion. We will explore the role of tonsils and adenoids, explain why they get large in children, and review the two main, evidence-based reasons that might lead a family to consider surgery. My aim is to empower you with the knowledge you need to be a confident partner in your child’s health.

The Tonsil and Adenoid Story: A Child’s First Line of Defense

Before we discuss problems, it’s important to understand what tonsils and adenoids are and what they do. Think of them as the “security guards” at the main entrances to your child’s body—the nose and mouth.  

Tonsils and adenoids are clumps of lymphoid tissue, which is a key part of the immune system. Their job is to sample bacteria and viruses entering the body and then help the immune system develop antibodies to fight those germs. The palatine tonsils are the two you can see in the back of the throat, while the adenoid (or pharyngeal tonsil) sits higher up, behind the nose, and isn’t visible without special instruments.  

So, why do they seem so large in young children? This is a normal part of development. A child’s immune system is still learning and maturing. The tonsils and adenoids are most immunologically active between the ages of 3 and 7. During this time, as they are constantly exposed to new germs at daycare and school, they grow larger to do their job effectively. This enlargement is often a sign that the immune system is working exactly as it should.  

After about age 8, as the body develops other, more sophisticated ways to fight infection, the tonsils and adenoids naturally begin to shrink, a process called involution. By the teenage years, they are often quite small. This is why seeing large tonsils in a four-year-old is common and often normal, while the same finding in an adult would be more unusual.  

When “Big” Becomes a Problem: Two Key Reasons for an ENT Visit

While large tonsils can be a normal part of childhood, there are times when their size or frequent infections can cause significant problems that affect a child’s health and quality of life. Over the past few decades, the medical community has developed very clear, evidence-based guidelines to determine when surgery is truly necessary. The primary indication for tonsillectomy has shifted from recurrent infections to issues related to airway obstruction during sleep.  

There are two main reasons a child should be evaluated by an ENT for their tonsils and adenoids:

1. Obstructive Sleep-Disordered Breathing (OSDB)
2. Severe Recurrent Throat Infections

Let’s break down what each of these means for your child.

Indication #1: Obstructive Sleep-Disordered Breathing (OSDB) – Is Your Child’s Snoring More Than Just Noise?

Many parents tell me, “He snores just like his dad!” While occasional, soft snoring (especially during a cold) is harmless, loud, habitual snoring every night is not normal for a child. It can be a sign of Obstructive Sleep-Disordered Breathing (OSDB). OSDB is a spectrum of breathing problems during sleep, ranging from simple snoring to the more serious Obstructive Sleep Apnea (OSA), where a child repeatedly stops breathing for short periods.  

This happens when overly large tonsils and adenoids physically block the airway in the back of the throat when the child’s muscles relax during sleep.

What should you look for at night?

• Loud, habitual snoring: Snoring that occurs most nights.
• Witnessed apneas: You may notice your child pauses in their breathing, followed by a gasp, snort, or sudden awakening.  
• Restless sleep: Tossing and turning, frequent waking, or sleeping in unusual positions (like with their head tilted way back) to open the airway.  
• Mouth breathing: The child cannot get enough air through their nose, so they sleep with their mouth open.  

The reason we take OSDB so seriously is that poor sleep quality can have a cascade of negative effects on a child’s waking hours. A child who isn’t getting restful sleep isn’t getting the chance to restore their brain and body.

What might you see during the day?

• Behavioral issues: Children who are sleep-deprived often don’t act tired; they can become hyperactive, aggressive, irritable, or have trouble concentrating. These symptoms can sometimes be misdiagnosed as ADHD.  
• Poor school performance: Difficulty with learning and memory can be directly related to fragmented sleep.  
• Growth problems: In severe cases, the effort of breathing all night can burn extra calories, and the lack of deep sleep can interfere with the release of growth hormone, leading to poor weight gain or growth retardation.  
• Bedwetting (Enuresis): One of the most surprising but common signs is a child who was previously dry at night starting to wet the bed again. Deep sleep is necessary for the brain to produce a hormone that reduces urine production at night. With fragmented sleep from OSDB, this process is disrupted.  

If you are noticing loud, nightly snoring combined with any of these daytime symptoms, an evaluation is strongly recommended.

Indication #2: Severe Recurrent Throat Infections – How Many Sore Throats is “Too Many”?

The other primary reason to consider tonsillectomy is for recurrent, severe throat infections. In the past, this was the number one reason for surgery, but today we follow very specific, research-backed guidelines to avoid performing unnecessary procedures. These are often called the Paradise Criteria, named after the lead researcher of the landmark studies.  

Watchful waiting is strongly recommended if your child has had fewer infections than these thresholds, as many children’s immune systems mature and the frequency of infections decreases on its own.  

To be considered a candidate for surgery due to infection, a child should meet the frequency criteria outlined in the table below. It is also critical that each episode is properly documented in a medical record by a physician and includes not just a sore throat, but at least one of the following clinical features:

• Fever higher than 100.9°F (38.3∘C)
• Swollen or tender lymph nodes in the neck (cervical adenopathy)
• White spots or coating on the tonsils (tonsillar exudate)
• A positive test for Group A Streptococcus (strep throat)  

Table 1: Quick Guide: When Are Throat Infections Frequent Enough for Surgery?

Export to Sheets

It is important to note that there are some “modifying factors” that might make surgery a reasonable option even if a child doesn’t meet these exact numbers. These can include having multiple antibiotic allergies that make infections difficult to treat, a history of a severe complication like a peritonsillar abscess (a collection of pus behind the tonsil), or a diagnosis of a specific condition like PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis).  

What to Expect at Your ENT Visit in Frisco

If your child’s symptoms fall into one of the two categories above, the next step is a formal evaluation. My goal during this visit is to listen to your story, perform a thorough examination, and work with you to create a plan that is best for your child. A consultation does not automatically mean surgery.

• The Conversation: We will start by talking in detail about your child’s symptoms. I will ask about their sleep, breathing patterns, snoring, and the frequency and severity of any sore throats. Bringing any records from your pediatrician about past infections can be very helpful.  
• The Examination: I will perform a careful examination of your child’s ears, nose, and throat. To see the tonsils, I will simply have your child open their mouth wide. To evaluate the adenoids, which are hidden behind the palate, I may use a small, flexible camera called a nasal endoscope. This procedure is quick and gives us a clear view of the size of the adenoid and how much it might be blocking the nasal passage.  
• Further Testing: In some cases, especially for children under age 2 or those with other medical conditions like obesity or Down syndrome, I may recommend a formal sleep study (polysomnography). This is an overnight test that precisely measures breathing, oxygen levels, and sleep quality to confirm a diagnosis of obstructive sleep apnea before we consider surgery.  

Your Partner in Your Child’s Health

As a parent, your instincts are your most powerful tool. If you are concerned about your child’s breathing, sleep, or frequent illnesses, you deserve clear answers from a specialist who will take your concerns seriously. The decision to proceed with a tonsillectomy and adenoidectomy is a significant one, and it should only be made after a careful evaluation and a thorough discussion of the potential benefits and risks.

The ultimate goal is not just to remove large tonsils, but to improve your child’s overall health and quality of life. For many children suffering from sleep apnea or debilitating infections, surgery can be truly life-changing, leading to better sleep, improved behavior, and healthier, happier days.

If you’re in the Frisco, Plano, or McKinney area and your child’s large tonsils are causing concerns about their sleep, breathing, or overall health, it’s time for a conversation. Schedule a consultation with me, Dr. Benjamin Cable, today, and let’s work together to help your child breathe easier, sleep better, and thrive.