Tonsillectomy: The “Why?” (Indications) and What to Expect Afterwards

Removal of tonsil (or tonsillectomy, where “-ectomy” is the suffix for “removal”) is one of the most common surgeries performed by ENT physicians.  We’ve discussed function and location on prior articles (see Sore Throat 101) so I won’t go into great detail on anatomy, only to say that whenever a tonsillectomy is mentioned, it generally refers to the palatine tonsils.

The palatine tonsils are those globs of tissue visible way back in the throat on each side.  However, when removing the tonsils, often the adenoid is also removed as well, since they too can create the same problems as the palatine tonsils.  The lingual tonsils however are not removed, since they typically do not cause symptoms or problems as the palatine tonsils and adenoids.  Thus, the surgery is often referred to as a “T  & A” (meaning “Tonsillectomy and Adenoidectomy” and not the cruder terminology harboring in the dirty minds of some of you folk out there).  As from prior articles, all three  of these nifty globs of tissue—the adenoids, palatine and lingual tonsils—make up Waldeyer’s Ring.

The function of Waldeyer’s Ring functions is the defensive, including the creation of immunoglobulins (antibodies), important more so in the first few years of life.  As one ages, these organs become rather useless and typically atrophy (shrink) as one gets older.  However, in some patients, they become more of a nuisance rather than inert, functionless tissue.  When this occurs, well, we then consider removing the critters as they pose a threat to health and quality of life.

Following are the indications or reasons for proceeding with a tonsillectomy (or T & A):
1.  Recurrent infections from either strep or non-strep bacteria, especially when antibiotics are used frequently.  However, patients who have recurrent sore throats that don’t regularly require antibiotics but greatly impairs their quality of life (i.e., missing school and/or work or impairing the ability to perform certain activities) also benefit from this surgery.    In regards to quantity of tonsillitis or significant sore throats, the general guidelines are:

  a.  6 or more episodes in one year or
  b.  4 episodes per year for two years or
  c.  3 episodes per year for three or more years

However, these are not hard and fast rules (except in some cases where insurance companies unreasonably insist upon this or worse, deny surgery unless the patient must have even greater numbers than those above, even after they’ve been to the Emergency Room once or more for severe episodes).  The doctor must judge other factors such as the severity of the episodes and whether they’re causing severe symptoms such as difficulty breathing or dehydration due to inability to swallow, or if they’re becoming more difficult to treat medically.  Sometimes patients present to the emergency room due to the severity of the problem or develop complications (such as peritonsillar abscesses or deep neck space infections) requiring hospital admission.  The risks of repeated antibiotic treatment also is considered, since antibiotic resistance or secondary infections due to antibiotic use can occur (for instance, C Difficile colon infections or yeast and fungal infections) from killing off the normal bacterial flora naturally found in the body. 

2.  Sleep Apnea, Sleep Disordered Breathing, Upper Airway Obstruction
These fall into the same spectrum where there’s an increased effort to breath while sleeping.  The tonsils and adenoids can become large enough to obstruct or block the upper airway above the larynx and trachea.  This typically occurs during sleep, since the muscles in the body—including those around the throat—relax completely, losing muscle tone which then allows the tissues in the throat to become more pliant or floppier.  The tonsils can flop down and also meet in the middle to touch one another, causing blockage of air flow.  Large adenoids increase resistance to nasal breathing, forcing one to breathe with the mouth open, which only worsens the effort to breath.  This causes a host of problems including poor sleep quality, daytime sleepiness or even the reverse—daytime hyperactivity  in children.  Children also can have enuresis (bedwetting) since the urge to urinate is not properly awakening them.  Some children will have slow growth, being small for their age.  This is due to lack of the secretion of  Growth Hormone, which is released during certain stages of sleep.

3.  Unusual tonsil appearance, suspicion for tumor
Sometimes only one tonsil is abnormally enlarged and can look…not right.  Unilateral enlargement can occur after an infection, where the lymphoid tissue fails to shrink back down after the infection resolves.  However, especially in adults, a tonsil that is enlarged only on one side increases the suspicion for a tumor or neoplasm.  Sometimes an adenoid or tissue in the nasopharynx (the site where the adenoid is located) also looks “not right” (which, by the way, is usually viewed with a nasopharyngoscope).  In such cases, removal of the tonsil and adenoid or a biopsy (removing a smaller piece of tissue) is required to make a diagnosis.

4.  Other reasons:
Sometimes patients have chronic dysphagia or difficulty swallowing due to enlarged tonsils.  They may frequently gag on certain types of food.  Often they chew with their mouth open since they cannot breathe nasally due to tonsil and/or adenoid enlargement.   

Speech problems are another relative indication for surgery.  Enlarged tonsils can create a muffled, lower pitch quality to speech, such that the patient sounds as if they have marbles in the mouth or a “hot potato voice” (a term widely used in the medical field, no my creation).  Enlarged adenoids give tha hyponasal quality to the voice, a plugged-nose vocal quality.  Enlarged adenoids and tonsils reduce the natural airspace that allows for a more normal resonance of sound.

Tonsilliths (tonsil stones) create a host of problems including annoying throat irritation and bad breath (halitosis).  Surgery is indicated if other measures do not reduce their formation and if it significantly impairs quality of life.

Once in a rare occasion there’s a child with fevers of unknown origin.  They’ve had a thorough workup but the source for the fever is still undetermined.  The tonsils often to not appear abnormal and the child often does not complain of a sore throat or have any of the symptoms above to indicate a T and A surgery.  As a last effort to resolve this problem, a T & A can be done.  I had two cases of this in kids having recurrent fevers for a year or longer, needing prescription medications to keep the fevers down.  After surgery both recovered nicely with resolution of the recurrent fevers.

The Surgery

I won’t go in to great deal on surgical technique only to say that both tonsils and adenoids are removed through the mouth under general anesthesia.  I’ve already described the technique used for an adenoidectomy.  The tonsils are excised after incisions are made around them, and the tonsil beds (tonsillar fossae) are cauterized for any bleeding.

I’ll describe the tonsillectomy technique in more detail in a future post. 

Risks and Complications

As with any surgery excessive bleeding can occur but is unusual.  Others are infection, voice change (higher pitch due to resonance), and anesthesia risks such as heart arrest, stroke or death (this is true with ANY surgery.  In general, your risk of driving, getting into a motor vehicle accident and dying from the accident is more likely to occur than something catastrophic with anesthesia or surgery).  Particularly with a tonsillectomy, there is a risk of delayed bleeding from several days to two weeks after surgery.  This occurs in a few percentage of people and for this reason, I advise patients to avoid long-distance travel for three weeks.  You wouldn’t want to have a severe bleeding episode while you’re on a commercial flight or out in the middle of nowhere, far from a hospital with ENT coverage.

Postoperative Course and Instructions

In general, I tell patients that they will experience one of the worse sore throats of their life for at least a week.  Young children however tend to tolerate this much better than teenagers and adults and often can use over-the-counter (OTC) pain medications such as Tylenol or ibuprofen liquid (however, avoid ibuprofen, naproxen, aspirin and other medications in this NSAID (nonsteroidal anti-inflammatory drug) category 2 weeks BEFORE surgery since these can cause one to bleed more easily during surgery.  However, studies have shown they do not tend to increase the risk of bleeding after surgery.  We do advise avoiding aspirin however, since bleeding can be more significant with this drug).  Often, narcotic pain medication is needed (hydrocodone, oxycodone, codeine, often combined with Tylenol), especially in teenagers and adults, and this is often used as a back-up in the event the OTC meds do not help.

CAUTION: be very cautious with narcotic pain medications since they can lead to sedation, a decrease in respirations (decreased rate of breathing) and in rare cases respiratory arrest (stopping breathing altogether).  The dosing of narcotics for children is typically calculated by the patient’s weight, and often there is a range of dosing on the instructions.  Try using the lower dose first, as the goal is to minimize the amount of narcotics given.  Some parents find alternating the narcotic medication with Tylenol (acetaminophen) or ibuprofen works well, which reduces the daily intake of narcotic.  For instance, if the child takes a narcotic, this is followed by Tylenol or ibuprofen 4 hours later, and then the narcotic four ours after that, such that each medication is used only every 8 hours.  Keep in mind though not to “double-up” with Tylenol and the narcotic at the same time, since the narcotic usually has Tylenol mixed with it.

The patient must also keep to a soft diet for about two weeks to avoid irritation to the tonsillar fossae during healing.  One will notice the fossae will develop yellowish to whitish exudate that looks pretty gnarly especially after a few days, and the patient’s breath will stink rather mightily.  Don’t be concerned about these postop features—they’re expected as part of the normal healing process.  Also, one must avoid heavy lifting or vigorous exercise for at least two weeks.  Walking around the house or outdoors is actually good for recovery and light playing for kids also is O.K., as long as they aren’t overdoing it (i.e., avoid “rough-housing,” play-structures, trampolines or sports).

A week from school or work is often needed, sometimes a little more.  Children often return to school after a week, with instructions to avoid sports or P.E. for at least two weeks after surgery.

What are long term problems?  None really, since the health of individuals who’ve had a tonsillectomy compared to those who haven’t is really no different.  Being tissue that is part of the immune system, people often wonder whether removal poses additional health problems.   As I’ve said before, they are not important in the immune system after young childhood and their absence is not a detriment.   

As with any surgery, a T and A is recommended if the benefits far outweigh the potential risks and complications.

©Randall S. Fong, M.D.