The tonsils (or more correctly, the palatine tonsils) are collections of lymphoid tissue at the back of the throat. This tissue is part of the immune system to help your body fight infections. There are other collections of lymphoid tissue in the mouth and throat, for example the adenoids at the back of the nose and the lingual tonsils at the back of the tongue, as well as scattered lymphoid tissue beneath the surface mucosa.
In some cases, the tonsils cause more problems than they solve, and in these situations treatment needs to be considered.
Indications for treatment:
Acute tonsillitis results in symptoms of pain, difficulty swallowing, fever, feeling unwell and often time off work or school. The tonsils look red and swollen and may have white spots on the surface. The neck glands may be enlarged and tender. These attacks need to be distinguished from less severe sore throats and pharyngitis.
Tonsillitis is common in children, and is almost part of the normal growing up process, with the body experiencing new bacteria and viruses and building up its immune response to prevent further attacks. The natural history of recurrent acute tonsillitis is for the attacks to tail off over time, so waiting long enough will in most cases allow the attacks to settle spontaneously. However, if the attacks are frequent, severe or cause a lot of time to be missed from school or work tonsillectomy can be considered.
Children starting school or nursery are particularly prone to getting recurrent tonsillitis, and it may be better to wait a little longer than normal for these children before considering surgery.
Indication for surgery: Five or more attacks of acute tonsillitis per year.
The tonsils often appear enlarged in children, but if they are not causing any symptoms this is nothing to worry about. Sometimes the tonsils are so enlarged that they cause obstructive symptoms. The adenoids are also usually enlarged in such cases. The child snores, mouth breathes and walks around with an open mouth, and has periods at night where the snoring stops, the child seems to stop breathing for 10-15 seconds and then gasps or chokes for breath. These are episodes of obstructive sleep apnoea, and reflect obstruction of the airway by the enlarged tonsils and adenoids, lack of oxygen entering the body and the brain encouraging the child to breathe. The child has disturbed restless sleep, the parents are very worried, and over a period of some years the OSA (obstructive sleep apnoea) can result in heart and lung problems (right heart strain, pulmonary hypertension) which are difficult to reverse.
A sleep study can be performed to confirm the diagnosis, but in children a good history of OSA and the presence of significantly enlarged tonsils and adenoids is sufficient. Occasionally the apnoea may be due to a central cause and if the problem persists following removal of the tonsils and adenoids further investigation may be required.
The treatment of choice is adenotonsillectomy. Removing the tonsils or adenoids alone is often insufficient.
Some patients get only a few well defined attacks of acute tonsillitis but get frequent milder sore throats, persistently enlarged and sore tonsils, and mild discomfort on eating. Although this is a “soft” diagnosis, many children with these symptoms do not eat well and fail to put on weight, and removal of the tonsils results in a remarkable improvement in their symptoms.
Peritonsillar abscess or Quinsy:
During an attack of tonsillitis, sometimes pus forms between the tonsil and its bed, leading to an abscess. The symptoms of pain , trismus (difficulty opening the mouth) and difficulty swallowing are much worse than with straightforward tonsillitis. Examination shows the affected tonsil to be pushed down and towards the midline by the collection of pus. These patients usually require admission to hospital for intravenous antibiotics and ideally incision and drainage of the pus. This can be carried out under local anaesthetic by spraying the back of the throat in adults, but is more difficult in children. If there is no improvement with antibiotics the tonsils may need to be removed during the acute phase (“hot” tonsillectomy). If the acute problem settles, definitive treatment can be considered.
After one attack of quinsy, the chances of a further attack are about 20%, so if there is no previous history of tonsil problems it is reasonable to wait as the patient may never have further problems. After the second attack of quinsy, or if there is a preceding history of recurrent infections, the chance of further attacks is about 50%, so in this case it is reasonable to remove the tonsils.
The tonsils like any tissue can be affected by neoplasia. Many of these cancers such as squamous carcinoma are rare in children. Some however such as lymphomas and leukaemias can present in the tonsils. The tonsils may look normal on the surface but one may appear larger than the other. In the vast majority of cases of unilateral tonsillar hypertrophy (one tonsil larger than the other) there is no malignancy, and one tonsil just happens to be bigger or looks bigger because of its position in the throat. However, the only way to be sure there is nothing serious going on is to remove the tonsils and examine them under the microscope, so if one tonsil remains persistently enlarged or appears to be growing it should be removed.
Halitosis (bad breath) and tonsilloliths:
The tonsils have dips on the surface called crypts. These can fill up with dead skin and food debris leading to formation of small yellow or white cheesy balls called tonsilloliths. These can in some cases lead to halitosis (bad breath). Most of the time halitosis is due to gum or dental disease, but in a few cases may be due to the tonsils. The tonsilloliths can be squeezed out with a finger or toothbrush, but if this is not possible or acceptable the tonsils can be removed.
Some children have a high fever with tonsillitis leading to febrile convulsions. Others may get flare ups of skin conditions such as psoriasis every time they have tonsillitis. Although they may only get two or three attacks per year, due to the associated severe symptoms it is reasonable to consider tonsillectomy.
Access to deeper structures:
The tonsils may sometimes be removed to get access to structures underneath the tonsils, for example an elongated styloid process, the glossopharyngeal nerve and so on, but fortunately this is rarely required.
The patient should not have anything solid to eat for 6 hours before surgery. Sips of clear water(not juice) are allowed up to 2 hours before surgery. Medications and tablets should be taken as usual at the normal times with sips of water.
The operation is carried out under a general anaesthetic. “Magic cream” (Emla cream, a local anaesthetic cream) may be put on the back of the hand to numb it. The anaesthetic may be started with a small injection or by breathing in gas, and this can be discussed with the anaesthetist beforehand. The tonsils are removed by dissection and ties or diathermy used to make sure all the bleeding has been stopped. The operation takes 20 to 30 minutes, the child is kept in recovery for a short while and then returned to the ward.
The operation may be carried out as a day case. If surgery is carried out in the morning, the patient can be monitored for 6 hours afterwards and then allowed home. If the operation occurs later in the day, or there are any problems, overnight stay is required and the patient goes home the next day.:
It is painful after surgery for up to 7-10 days, so take painkillers (Paracetamol and Ibuprofen) regularly for the first few days, 30 minutes before meals. You can eat and drink whatever you like. Chewy things encourage healing and reduce the risk of infection or bleeding, so bread, toast, crisps, solid food are all fine. Jelly and ice cream do not encourage chewing and so are not as good.
The patient should stay away from school or work for 2 weeks afterwards.
There is always a small risk from a general anaesthetic, for example a bad reaction, equipment failure and so on, but this is rare with modern techniques.
Loose teeth may fall out during surgery when the gag is inserted to open the the mouth.
There is a small risk of bleeding which occurs in 2-3% of cases. This may happen in the first few hours so the child is carefully monitored for 6 hours after surgery. The bleeding may also occur about 5 days later, when the child has gone home. This is more likely if the child does not eat properly or chew after the operation, so it is recommended that the child is given painkillers 30 minutes before meals and then given normal food (not jelly and ice cream)and encouraged to chew. If there is bleeding after going home, you should contact the hospital on the number given to you before you leave. If there is heavy bleeding, get to accident and emergency as soon as possible.
Due to removal of bulky tonsils, there may be a small change in the resonance of the voice afterwards. Most people will not notice any change; professional singers may notice a slight change.
Various techniques including dissection, bipolar and monopolar diathermy, laser and coblation have been tried. A large national audit of tonsillectomy in the UK in 2006 suggested standard dissection tonsillectomy was the best as it produced least pain and least complications.
Will I get more infections if I have my tonsils removed?
No, there is plenty of other lymphoid tissue around the throat to fight infection, so removal of the tonsils does not lead to more throat, chest or stomach infections.
Will I never have any more sore throats?
No, tonsillectomy prevents further attacks of tonsillitis, but it is still possible to get sore throats and pharyngitis, particularly if you smoke or are exposed to irritant fumes or dust. Maintaining good general health by eating a healthy diet including plenty of fresh fruit and ensuring adequate sleep and rest will reduce the risk of sore throats.
Will my tonsils grow back?
The tonsils run into the lingual tonsils at the back of the tongue, and occasionally small remnants of lymphoid tissue are left behind. These can continue to get infected and may enlarge over time, so the tonsils may seem to grow back and revision surgery may be required. The lingual tonsils may also get infected or enlarged and may require removal.