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 throughout the gastrointestinal 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 noticeable 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...although 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 gimmick 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.
What is the after-care like?
After removal of the tonsils and adenoids, your child may lack energy and tire easily for several days, and be restless at night and not sleep well. These problems gradually get better in three to 14 days. Your child may be constipated for several days because of the codeine in the pain medication and because he or she will not feel like eating much.
The most important thing for your child to have in the first three days after surgery is liquids. This will help lessen problems with fever and constipation and promote healing. Make an effort to give your child a drink (2 or 3 ounces) every hour during waking hours for the first two days after surgery. Soft drinks, fruit juice nectars, jello, custard, popsicles or Gatorade® are good choices. Frequent small feedings of soft foods and cool liquids are usually the most comfortable. As your child’s appetite gets better, encourage him or her to eat solid foods. There are no limits to the foods you may give your child. Let your child have his or her favorite foods; it can’t hurt the throat. Your child should not drink through a straw after surgery until the throat is completely healed because it may increase the risk of bleeding.
Your child may feel sick to the stomach, throw up or feel tired and cranky after surgery. This should get better within a few hours. Occasionally, nausea and vomiting can be caused by the codeine in pain medication. A very sore throat or ear pain is normal after the tonsils are removed. Expect pain in the ears between the third and seventh days because the same nerve that goes to the tonsils also goes to the ears. Give recommended doses of pain medicine (any acetaminophen medicines, such as Tylenol®) four to five times a day for one week. If your child has severe pain, use the prescription pain medicine as labeled. DO NOT USE ASPIRIN OR IBUPROFEN because these medicines increase the chance of bleeding. You can use cool compresses or ice packs on your child’s neck to help your child feel more comfortable. You can also have your child suck on ice chips or chew gum. Prescriptions and instructions for taking the pain medication will be given to you in the recovery room prior to discharge as applicable.
It is normal for children to run a fever between 99°F (37°C) and 101°F (38°C) for the first few days after surgery. The fever will be worse if your child doesn’t drink enough liquids and becomes dehydrated. Give acetaminophen for the fever.
Bad breath is normal and is caused by a white to yellowish scab that forms over the tonsil surgery site. The scab breaks off during healing within five to 10 days and the bad breath will go away.
There should be no bleeding from the nose or mouth after your child returns home. Get up to check on your child once or twice during the first night after surgery. If there is any bleeding, take the child to the Emergency Center immediately. The ear, nose and throat (ENT) doctor on call will check your child. Between the fifth and 10th days after surgery, the scab breaks off the surgery site and your child may spit up some bloody mucus. If the bleeding does not stop in 20 to 30 minutes, bring your child to the Emergency Center.
It is best for your child to rest at home for the first 48 hours after surgery. Activity may be slowly increased as your child’s strength increases. There is no rule for the right time to go back to school, but a guideline is seven to 10 days after the tonsils are taken out. Rough play and contact sports should not be allowed until 14 days after tonsil or adenoid surgery. A school note will be provided after surgery.
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.