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.
Indications
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.
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.
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