Tonsils and Tonsillectomy
What are tonsils and adenoids?
The tonsils are two clumps of tissue, on either side of the throat, embedded in a pocket at the side of the palate (roof of the mouth). The lower edge of each tonsil is beside the tongue...way in the back of the throat. The adenoids are a single clump of tissue in the back of the nose (nasopharynx). They are located (in the adult) on the back wall of the throat (pharynx)...about one inch above the uvula (the little teardrop shaped piece of tissue that hangs down in the middle of the soft palate).
What function do they serve? Aren't they important?
The tonsils and the adenoids are mostly composed of lymphoid tissue, which is found thoughout the gastointestinal tract and on the base of the tongue. Lymphoid tissue is composed of lymphocytes...which are mostly involved in antibody production. Since we generally consider antibody production to be a good thing, many studies have been performed to try to clarify the importance of the tonsils. There seems to be no adverse effect on the immune status or health of patients who have had them removed. Any noticable effect has generally been positive. It appears that the tonsils and adenoids were not "designed" to effectively handle the multitude of viral infections that occur in children in an urban population. Rather, the immune system, including the tonsils and adenoids, developed during a era where the child was rarely exposed to a large number of other people and the germs they carried. It may also be that these organs are relatively more important in dealing with certain types of infections, such as worms or other parasites, that are relatively uncommon in today's society. It is clear that in many cases, the tonsils and/or the adenoids become "dysfunctional" and are more of a liability than an asset.
Why are the tonsils removed?
There are a number of well-established valid reasons for removal. Some patients will have more the one reason. The most common are listed below.
|Blockage of the throat...they are too big.
||This is now the most common reason for removal. The tonsils can be large enough to impede breathing, swallowing, or clear speech production. The blockage of breathing can range from simple "mouth breathing" to severe snoring, or sleep apnea (blockage of breathing at night). The health risks of this can be slight to life-threatening. Not all tonsils that appear to be large are actually causing obstruction. A history and an examination by a skilled practitioner is usually sufficient for the diagnosis.
|Chronic and recurrent tonsillitis...sore throats.
||This used to be the most common reason for removal...and remains so in some parts of the world. Some patients will have frequent severe bouts of tonsillitis. A study by Bluestone, et al., looked at this reason. Other patients have a pattern of low-grade constant or very frequent sore throats. Unrelenting strep (Group A streptococcus) infection or colonization is still encountered...despite antibiotics.
|White debris in the tonsils..."chronic cryptic tonsillitis".
||The tonsils contain many pits and pockets...called crypts. These, in some patients tend to become impacted with white foul-smelling (especially to the owner) debris that is composed of bacteria and dead cells. It may cause a low grade intermittent sore throat. Antibiotics are only transiently helpful. Some patients will use various mechanical picks and swabs to attempt removal. The only consistent cure is a tonsillectomy...althought the problem often is minor enough that no therapy is necessary.
|Unusual enlargement or appearance.
||Like any other tissue, the tonsils can be the site of benign or malignant tumors. An unusual or markedly enlarged tonsil is sometimes seen in this situation. Lymphoma is the most common tumor of the tonsil in children. In adults, lymphoma or carcinoma can be seen.
Will he/she outgrow the problem?
In general, yes. We rarely see patients over 40 years old with significant enlargement or infections of the tonsils. However, we have also seen 35 year old patients in severe heart failure due to sleep apnea and severely enlarged tonsils...about to undergo a heart transplant...and their doctor had said they did not need the tonsils out because they would outgrow the problem. (A tonsillectomy would have prevented the heart failure and years of sleep deprivation.) In short, the potential gain of a tonsillectomy (or any other procedure) has to be weighed against the likelihood of resolution, the risks of the procedure, the discomfort, and the expense. For many patients, tonsillectomy is still an appropriate decision.
Should the adenoids be removed also?
At least in young children, enlargement or infection frequently affects the adenoids as well as the tonsils...so they are often removed together. Compared to a tonsillectomy, an adenoidectomy is less traumatic and painful.
How are tonsils removed?
There are many techniques used for tonsillectomy. General anesthesia is usually employed; but it is possible to perform tonsillectomy with sedation and local anesthesia. In the United States, some degree of electrocautery assisted dissection is most commonly employed, because of the ability to rapidly stop bleeding. Some surgeons use very little cautery...with more bleeding, but with less burned tissue. Use of lasers has been studied and considered by most surgeons. We feel that laser use is primarily a marketing gimmack at this point, since it offers no apparent advantage over certain cautery techniques, and has some very real hazards and extra costs.
What are the complications of tonsillectomy?
Most surgical procedures share the general risks of anesthesia, bleeding, and infection. The anesthetic risk is, in general, proportional to the health of the patient; and serious problems should be very rare. Bleeding is most commonly encountered in a delayed fashion...five to ten days after surgery...when an eschar (scab) comes off. Post-operative bleeding is more likely in teenagers and adults, as opposed to younger children (who have smaller vessels). The area where the tonsils were removed (the tonsillar fossae) always become colonized with high numbers of bacteria, and often cause a low-grade fever. Serious infections are very rare. If tonsils are very large, speech may be different post-operatively (often temporarily high-pitched and "whiney"). Most often the post-op speech is actually more normal. Remember...very rarely, someone can die from complications of tonsillectomy (or any other surgery); so no surgical procedure should be undertaken lightly.
Is hospitalization necessary?
Not usually. Nine out of ten patients do well enough to go home. We will admit anyone who doesn't meet standard discharge criteria...significant breathing problems, no oral intake, severe nausea/vomiting, or serious co-existing illnesses. An occasional patient goes home, but comes back to the hospital, because of poor liquid consumption or bleeding.
Children' s Memorial Hermann Hospital
Houston, Texas 77030
Phone: (713) 222-2273
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This information, although based on a thorough knowledge and careful review of current medical literature, is the opinion of doctors at The University of Texas Medical School and is presented to inform you about surgical conditions. It is not meant to contradict any information you may receive from your personal physician and should not be used to make decisions about surgical treatment. If you have any questions about the information above or your child's care, please contact our doctors.