Pediatric Ear, Nose & Throat
Tonsils and Tonsillectomy
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).
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.
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.
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.
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.
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.
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.
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 Hospital6411 FanninHouston, Texas 77030
Phone: (713) 222-2273
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