Can Your Tonsils or Adenoids Grow Back After Surgery?

May 5, 2016

Amy felt great a few weeks after undergoing tonsillectomy for mild obstructive sleep apnea. She was sleeping better and was able to focus again in school. This lasted about 2 years, but her symptoms of fatigue, brain fog, and sleepiness slowly started to come back. It wasn’t to the same degree as before her surgery, but she felt a difference from just after surgery.
When I looked at her mouth, her tonsils did seem slightly enlarged. Before surgery, they were touching in the midline (called kissing tonsils). Now they were about 10-20% enlarged, especially in the highest part of the tonsil bed, near the soft palate. 
One of the most common questions I get from patients when I propose tonsillectomy is if tonsils can grow back after surgery. My general answer is that yes, in theory, but the overall chances are very small. It really depends on two main variables: how completely the tonsils were originally removed, and whether or not you have persistent inflammation that can cause additional swelling. 
In the old days, surgeons used to take out the entire tonsil, including the capsule that surrounds the tonsil on the sidewall of the throat. This was done for recurrent tonsillitis or for sleep apnea. With advances in technology, we can now shave down about 95% of the tonsils (sub-capsular or partial tonsillectomy), leaving a very thin cuff of tonsil tissue next to the capsule. This has been found to be relatively equivalent to total (extra capsular) tonsillectomy for obstructive sleep apnea, as well as being slightly less painful with with faster recovery. 
However, if you have persistent sources of inflammation, then any remaining tonsil tissues can slowly get bigger. This can aggravate more obstructed breathing, leading to more stomach juices being suctioned up into the throat, causing more tonsil swelling. Your tonsil tissues are made of lymphoid tissues, which helps educate your immune system and fight infections. In addition to your two tonsils, you also have adenoids (behind the nose) and lingual tonsils in the back of your tongue, just on top of your voicebox. Additionally, you have countless lymph nodes spread throughout your entire body.
Here’s what the research says:
Of 636 children (age < 11) who underwent partial tonsillectomy using Coblation technology, 33 patients (5%) had regrowth. Of these 33 patients, 5 needed repeat surgery due to recurrent symptoms. Of note, these 5 children’s age ranged from 1 to 3 years (1). Other studies found tonsil regrowth after partial tonsillectomy ranging from 6 to 17% (2,3). In most cases, patients did not feel any worsening of symptoms. As far as I can tell, there are no studies on rates of regrowth after total tonsillectomy. 
Adenoid tissues are more likely to come back, since it’s impossible to remove 100% of adenoid tissues (there’s no capsule). Investigators from Temple University found that 2 to 5 years after adenoidectomy, 46 out of 175 patients (26%) had symptoms of nasal congestion. Of the children who agreed to nasal endoscopy, not one patient had more than 40% regrowth, and about 70% had only trace or minimal degrees of regrowth (4). Another study from the Mayo clinic looked at 163 revision adenodectomies out of 8245 original cases. Initial younger age at surgery, presence of ear infections, and signs of acid reflux were significant risk factors for patients needing repeat adenoid surgery. Surgical technique, surgical experience, or the presence of allergies were not significant risk factors for needing repeat surgery (5). A third study found that about 13% of children had adenoid regrowth, but most were asymptomatic (6).
Lingual tonsils are not commonly taken out, and sometime can be a major source of obstructed breathing, Not surprisingly, the presence of acid reflux was strongly correlated to lingual tonsil size (7).
If you’re considering tonsil or adenoid surgery for yourself or your child, the good news is that for the vast majority of patients, tonsils and adenoids don’t grow back, but even if it does, it won’t cause any problems. Rarely do you have to go back to repeat the surgery.
What are your experiences with tonsil or adenoid regrowth? Did you have to go back to the operating room again?
1. Doshi, H. K., Rosow, D. E., Ward, R. F., & April, M. M. (2011). Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy. International journal of pediatric otorhinolaryngology75(11), 1395-1398.
2. Zhang, Q., Li, D., & Wang, H. (2014). Long term outcome of tonsillar regrowth after partial tonsillectomy in children with obstructive sleep apnea. Auris Nasus Larynx41(3), 299-302.
3. Çelenk, F., Bayazıt, Y. A., Yılmaz, M., Kemaloglu, Y. K., Uygur, K., Ceylan, A., & Korkuyu, E. (2008). Tonsillar regrowth following partial tonsillectomy with radiofrequency. International journal of pediatric otorhinolaryngology72(1), 19-22.
4. Buchinsky, F. J., Lowry, M. A., & Isaacson, G. (2000). Do adenoids regrow after excision?. Otolaryngology–Head and Neck Surgery123(5), 576-581.
5. Dearking, A. C., Lahr, B. D., Kuchena, A., & Orvidas, L. J. (2012). Factors associated with revision adenoidectomy. Otolaryngology–Head and Neck Surgery, 0194599811435971.
6. Kim, S. Y., Lee, W. H., Rhee, C. S., Lee, C. H., & Kim, J. W. (2013). Regrowth of the adenoids after coblation adenoidectomy: cephalometric analysis. The Laryngoscope123(10), 2567-2572.
7. DelGaudio, J. M., Iman, N., & Wise, J. C. (2008). Proximal pharyngeal reflux correlates with increasing severity of lingual tonsil hypertrophy. Otolaryngology–Head and Neck Surgery138(4), 473-478.

Podcast #21: How Mouth Breathing Can Ruin Your Sleep

April 25, 2016

In this episode, Kathy and I will reveal 7 ways that mouth breathing can cause sleep and health problems. 

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Show notes:

Unstuff Your Stuffy Nose ebook

Interview with Dr. Michael Mew on Breathing and the Modern Melting Face

Interview with Patrick McKeown on Buteyko Breathing

Shut Your Mouth to Save Your Life, by George Catlin

Good review of Catlin’s book

Podcast #14: Your Sleep Apnea Questions Answered

November 17, 2015

In this episode, I answer 13 of your questions that I get through my blog, email, and contact me page. This is completely live and unscripted. I have no ideal what Kathy will ask me. See below for a list of the questions.
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1. How much do you charge for a office visit or procedure? 
2. How can I make an appointment to see you?
3. Various questions about specific medical issues.
4. What’s the difference between upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA)?
5. Will sleeping pills work for upper airway resistance syndrome?
6. Does sleep apnea cause brain damage? 
7. Are apneas more damaging on the brain than hypopneas?
8. What’s the relationship between depression and sleep apnea?
9. How do dental extractions affect sleep apnea?
10. Can nasal surgery cause sleep apnea later in life?
11. What’s the link between reflux and sleep apnea?
12. Can sleep apnea cause dizziness?
13. What questions should I be asking my doctor?
Show Notes:
Podcast 13: Which surgeon do  you recommend?
Sleep, Interrupted
How to Unstuffy Your Stuffy Nose e-book
Contact Dr. Park
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The Link Between Asthma, Reflux, and Mood Disorders

January 6, 2014

About one in 12 people in the US (about 25 million, or 8% of the population) had asthma in 2009. More than 1/2 of all adults and children with asthma had an attack in 2008. 185 children and 3,262 adults died from an asthma attack in 2007. These numbers are likely to be higher in 2014 (source: CDC).

Asthma is thought to be a chronic inflammatory disorder of the lungs. Symptoms include chronic cough, wheezing, chest tightness and shortness of breath. 

A recent study out of Taiwan reported that teenagers with asthma had a significantly higher chance of developing depression or bipolar disease 10 years later. After adjusting for other conditions such as allergic rhinitis, atopic dermatitis, and other confounders, patients with asthma were 1.81 times more likely to develop major depression, 1.74 times more likely to develop any depressive disorder, and 2.27 times more likely to develop bipolar disorder than patients without asthma. This was the first prospective study linking asthma with mood disorders.

Not too coincidentally, another study came out that showed that pepsin, a stomach enzyme, was found in 71% of  bronchial washings in children with chronic lung diseases. In contrast, healthy children had no cases of pepsin in bronchial washings. 

Obstructive sleep apnea is found in up to 10% of chidden and about 25% of adults. During an apnea, tremendous vacuum forces are created in the chest cavity, leading to a suctioning effect of normal stomach juices into the throat. These juices can then go into the lungs or the nose and ears. Stomach juices not only contain acid, but also bile, digestive enzymes, and bacteria. Even microscopic amounts of these materials can wreak havoc inside your lungs or nose.

Here’s a review of the link between asthma and obstructive sleep apnea. Not too surprisingly, the peak time for the highest levels of restricted breathing in asthmatics is during 3 to 5 AM. This is also the same time that REM sleep peaks, when apneas are most common. There are countless studies showing strong associations between obstructive sleep apnea and mood disorders. 

This is another great example of  how everything comes together when you start to connect the dots.


Reflux, Sleep Apnea and Increased Survival in Lung Disease

May 29, 2013

This blog post’s topic may sound completely unrelated to obstructive sleep apnea, but here’s a study showing that in people with idiopathic pulmonary fibrosis (IPF), being placed on an acid reflux medication (proton pump blocker) boosted survival significantly by about 2 years (3.4 vs. 1.4 years). The author’s explanation is somewhat complicated:

“DDAH and inducible nitric oxide synthetase are increased in lung epithelium and fibroblastic foci in IPF, and we found that proton pump inhibitors inhibit DDAH.”

In other words, Proton pump inhibitors, such as Prilosec, Nexium, or Aciphex have properties that prevent a complex pathway that leads to inflammation in the lungs. This phenomenon was also seen in subjects that had no reflux symptoms, leading the authors to postulate that a non-reflux mechanism could explain the survival benefit.

Here’s a simpler possible explanation: Many people with obstructive sleep apnea have silent reflux, due to vacuum forces that are created in the chest and throat during an apnea. Stomach juices (which include acid, bile, digestive enzymes, and bacteria) travel up into the throat, and then down into the lungs, causing chronic long-term inflammation. Treating with acid reducers may lower the acidity of the juices going into the lungs, thus possibly increasing survival.

The problem with using reflux medications is that they don’t really do anything for reflux. They only lower acid levels in the stomach, but what comes up into the throat is just less acidic. However, you still have bile, enzymes and bacteria, which can be very caustic to the lungs (or ears or sinuses).

It would be interesting to do a similar study, but instead, screen for and treat obstructive sleep apnea in patients with IPF, and see what the results show.

Why Your Heartburn Medications Don’t Work

November 14, 2012

Here’s an article from the Wall Street Journal that explains why many people who have heartburn don’t respond to acid reflux medications. In addition to what’s explained in the article (non-erosive reflux disease, or NERD), another explanation is that acid reflux medications don’t do anything to treat reflux. What they are designed to do is to lower acid production in the stomach. However, they don’t do anything to prevent reflux of normal stomach contents into the esophagus or throat. This is a common condition in obstructive sleep apnea, where acid, bile, stomach enzymes, and even bacteria can irritate the throat, lungs, and nose.

The Missing Link Between Gum Disease and Heart Disease

April 19, 2012

It’s medical dogma that having gum disease can cause heart disease. The most common explanation is that bacteria from your mouth can spread through the bloodstream and infect your heart valves (called endocarditis). The problem with this explanation is that endocarditis is a tiny fraction of people who have heart disease. Just because there’s an association, it doesn’t mean that one causes the other.

The American Heart Association recently reviewed 537 articles on this subject and published a review, stating that there’s no scientific evidence that gum disease causes heart disease, heart attacks, or stroke. Past studies were mainly observational, and not based on prospective studies. They also state that there’s no evidence that treating periodontal disease can prevent heart disease.

What’s the missing link? You guessed it: Obstructive sleep apnea. We know that obstructive sleep apnea can cause reflux and inflammation in the mouth. Mouth breathing due to craniofacial narrowing and inflammation also dries out saliva, which helps to protect your mouth from pathogens. If you’re missing teeth, then your mouth gets smaller, narrowing your airway even further. We also know that obstructive sleep apnea significant increases your risk of heart disease, heart attack, stroke, and death.

So it makes sense that if you treat sleep apnea, you’ll have less gum disease, and less heart disease. Obviously a prospective, randomized, placebo-controlled, double-blinded study is needed to prove this point.

Can Reflux Medications Help Asthma Symptoms?

January 27, 2012

Here’s a classic example of a study with negative results which is not surprising. Researchers gave acid reducing medications (lansoprazole) to children with steroid dependent asthma. About 300 children were randomized to receive either the medication or a placebo. They found no significant differences between the two groups in terms of asthma symptoms. If you look at all the studies that link asthma to obstructive sleep apnea, and reflux to obstructive sleep apnea, it makes more sense that the two (asthma and reflux) are connected by obstructive sleep apnea. 

It’s been shown that apneas create conditions in the esophagus and throat which can cause your stomach juices to reach your throat. Furthermore, pepsin and bile have been found in lung and sinus washings. What this means is that your stomach juices are still coming up into your throat, especially if you have obstructive sleep apnea. However, what’s coming up is just less acidic juices, but still includes bile, digestive enzymes, and bacteria. We know that proton pump inhibitors and H2 blockers such as cimetidine don’t really do anything to prevent reflux into the throat. 

My hypothesis is supported by studies that show that pro-motility agents such as domperidone and clarithromycin can help lower asthma symptoms. There are also numerous studies showing that treating obstructive sleep apnea can help with symptoms of asthma and reflux. 


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How Azithromycin Can Help COPD

August 28, 2011

Here’s a study showing that taking azithromycin can help to cut the rate of acute exacerbations in people with COPD. The anti-inflammatory properties of the macrolide antibiotics are well described. However, one thing that’s usually not addressed is the fact that the macrolides have anti-reflux properties. In general surgery, we used to give intravenous erythromycin to help speed gastric emptying after abdominal surgery. So by helping to empty the stomach faster, less juices are around to reflux up into the throat and then to the lungs. It’s important to realize that what comes up not only includes acid, but also stomach enzymes, bacteria and sometimes bile. Imagine even small amounts of these substances in your lungs. 

Even if you don’t have significant obstructive sleep apnea, juices from your stomach can come up with any of the smaller obstructive events that aren’t classified as apneas or hypopneas. Not only do these same juices go into your lungs, it can also reach your nose and sinuses. 

Is Nocturnal Asthma Really Sleep Apnea?

August 21, 2011

Having an asthma attack in the middle of the night can be a frightening and terrifying experience. Typically, these attacks happen in the early morning hours, just before awakening. 

Now there’s research showing that poorly controlled asthma during pregnancy can increase a woman’s chances of developing preeclampsia (50%) and premature births (25%). Furthermore, infants born to mothers with poorly controlled asthma delivered babies that were about 0.2 pounds less than those born to mothers without asthma.

We typically think of asthma being a separate, distinct condition from obstructive sleep apnea, and it’s treated in completely different ways. However, it’s not just coincidence that nocturnal awakenings from asthma and the most intense periods of apnea occur at the same time in the middle of the night—the early morning hours. The early morning hours are when REM sleep is most prominent, and this is the time when throat muscles are most relaxed. Having an apnea also is known to cause reflex, which is known to reach the throat as well as the nose and the lungs. In one small study in people with sleep apnea and asthma, treating sleep apnea with CPAP significantly improved nocturnal asthma symptoms. 

We know that any degree of stress on the mother’s body can lead to a higher rate of pregnancy-related complications and low birth rates. Even snoring by the mother alone was found to result in lower Apgar scores in newborn infants. Apneas are also known to raise blood pressure and promote insulin resistance. Stress hormones are also known to increase when you have apneas.

In light of all these findings, it’s not surprising that pregnant women with poorly controlled asthma have higher complications rates. This is another great example of “connecting the dots” between two seemingly unrelated conditions, which only adds to support my sleep-breathing paradigm.



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