To kick off my blog, I want to discuss a topic that is near and dear to me: tonsillectomy. It is the first procedure I learned how to perform in residency and it’s by far one of the most popular surgeries – approximately 500,000 pediatric and 300,000 adult tonsillectomies are performed in America every year. With those kinds of numbers, it often surprises me that my patients have major misconceptions and mismanaged expectations about their tonsils, so before you say goodbye to those dear friends, read this article thoroughly so you can make a smart and informed decision before undergoing the knife.
The first question you should always ask yourself before you decide to remove something from your body is: “why was it there in the first place?” About 50 years ago, when millions of tonsillectomies were being performed every year, many thought the tonsils performed no practical function other than to serve as a nidus for throat infections. As medical knowledge advanced, it came to light that tonsils had an important role in our immune system. Researchers found that tonsils contained lymphoid tissue, filled with multiple types of immune cells that trap foreign viral and bacterial particles to help the body mount an efficient defense against them. Recently, researchers at Ohio State found that tonsils actually produce T-Cells, previously thought to be exclusively produced by the thymus.[i]
So, you may ask, “if the tonsil is a part of my immune system, will I get sick if you take them out?” The short answer is “probably not,” especially if you’re older. The longer answer is a little bit more complicated. In 1994, a group of European researchers compared the health of children who had their tonsils out and didn’t.[ii] Their main finding was that the two groups of children seemed equally healthy and equally prone to infections. The researchers went a step further and drew blood samples from both groups of children as well. They found the children who had tonsillectomies had overall lower levels of IgA, an antibody that typically resides in our respiratory and GI tracts. So, how do we reconcile the two findings – in other words, why don’t children with lower levels of antibodies get sick? There isn’t a medical consensus for that question, but my personal theory is that the tonsils were much more important to our survival and well-being when we were still living in caves and foraging for food. The relatively small amounts of bacteria and foreign antigens we come in contact with today in modern society probably diminish the need for our tonsils. Given these findings, I tend to be more conservative in offering tonsillectomy to those who are younger.
So now that we’ve laid out the long-term risks of tonsillectomy, let’s discuss the short term risks. The two short term complications of tonsillectomy everyone should be aware of are hemorrhage and inability to eat/drink due to pain. Hemorrhage can occur up to two weeks after surgery and will often require a trip back to the operating room for cauterization. Depending on the age of the patient and the reason for tonsillectomy, bleeding rates can be as low as 1% or as high as 5%. Mortality from bleeding is a real risk but is exceedingly rare. Rates of dehydration and food intolerance due to pain requiring IV fluids can be as high as 15%. Both complications can be mitigated to some extent with newer techniques such as microdebrider intracapsular tonsillectomy, which I will cover in a future post.
I discussed the risks of tonsillectomy before the benefits so that the dangers of surgery do not become an afterthought. As one of my mentors famously said, “there is no such thing as a routine surgery.” With that in mind, let’s talk about who can be helped by tonsillectomy. We’ll start with 3 categories – those who will definitely benefit from tonsillectomy, those who might, and those that probably won’t.
Patients who will definitely benefit from tonsillectomy:
- Children under the age of 10 who have obstructive sleep apnea: approximately 3 out of 4 children with sleep apnea will have complete normalization of their sleep study after adenotonsillectomy, defined by an AHI score of < 1. The vast majority of children who don’t have a complete response still have improvements in their AHI scores and their symptoms. [iii]
- Children with periodic fever, aphthous ulcers, and pharyngitis (PFAPA syndrome): this is a disease entity characterized by recurrent fevers, sore throats, and oral cavity ulcers. Removing the tonsils can often times completely relieve the patient of their symptoms. [iv]
- Older children / adults with peritonsillar abscesses (PTA): typically a disease process found in patients between 20 and 35, PTAs are extremely painful and often require incision and drainage to treat. Having a PTA greatly increases your chances of having subsequent PTAs. Tonsillectomy obliterates the peritonsillar space and prevents the recurrence of PTAs.
Patients who may benefit from tonsillectomy:
- Adults with sleep apnea: Tonsillectomy, in conjunction with uvulopalatoplasty (UPPP) is a commonly performed procedure for the treatment of adult sleep apnea. However, many factors such as the patient’s oral / oropharyngeal anatomy, their weight, and the severity of their sleep apnea can affect the probability of success. The surgical treatment of sleep apnea is a complex and fast-evolving aspect of otolaryngology and I will discuss it in more detail in a future post. [v]
- Children with chronic tonsillitis: In 1984, researchers at the University of Pittsburgh published their study on tonsillectomy for chronic tonsillitis in children, which showed tonsillectomy is effective at reducing the intensity and frequency of throat infections in children who have severe chronic tonsillitis. Severe is defined as more than 5 infections in one year, 4 infections per year for 2 years, or 3 infections per year for 3 years. It’s important to note that the study also found that children who didn’t have tonsillectomy typically outgrew their tonsillitis and had no more infections than their counterparts who underwent surgery after 3 years.
- Adults with chronic tonsillitis: The evidence supporting tonsillectomy for chronic tonsillitis / recurrent acute tonsillitis is largely extrapolated from data on pediatric tonsillitis. Two smaller trials show that tonsillectomy can both reduce the severity and frequency of acute pharyngitis in adults. [vi] [vii]
Patients who probably won’t benefit from tonsillectomy:
- Halitosis / Tonsil Stones: Quality literature on this topic is sparse and opinions vary widely. My opinion is that halitosis is rarely caused by the tonsils and is more often associated with diet, dental hygiene, acid reflux, post nasal drip, and to a large extent, genetics. The caveat is very large, extremely cryptic tonsils that may trap enough old food and debris to cause halitosis. Reduction of these tonsils may be considered on a case-to-case basis.
How to make use of all this data to decide if you or your child should have a tonsillectomy?
I think the best way to illustrate this is to describe a conversation I would have with a few theoretical patients.
An otherwise healthy 4 year old boy who has speech language delay. His parents noticed he snores loudly at night and often seems to stop breathing completely. They brought him to his pediatrician who suggested a sleep study. The sleep study showed a case of severe sleep apnea. On my examination, he has very large tonsils and adenoids.
This is a patient where a tonsillectomy would be strongly indicated. The chances of the tonsillectomy improving the patient’s sleep apnea approaches 100%. The long term consequences of untreated sleep apnea in children include developmental delay, hyperactivity, bed wetting, and depression. The risk / benefit analysis in this case clearly justifies tonsillectomy.
An otherwise healthy 5 year old boy who keeps getting recurrent sore throats. He’s had about 4 episodes in the past year, several with fevers. The pediatrician swabbed his throat each time and there was no evidence of strep infection. The parents are interested in tonsillectomy.
This patient fits into the category of patients who may (or may not) benefit from tonsillectomy. If we strictly go by guidelines, then this patient should not receive a tonsillectomy (5 documented infections in 1 year is the minimum). However, I would want to know how much the throat infections are impacting the patient’s life – for example, if the patient misses 1 week of school with each infection, that gives me more impetus to perform surgery.
So as you can see, decision making about surgery is a not always crisp and clear. The first step towards making a good decision is to collect all the facts. A good surgeon will then help you weigh the risks and benefits and ultimately come up with a good treatment plan. Good luck!!!