What Everyone Should Know About Tonsillectomy

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Tonsils are one of the most misunderstood structures in the throat, not only by patients, but by many doctors as well. Traditional teaching states that tonsils are glands in the throat that help to fight infection. Because they are blamed for most cases of repeated throat infections, tonsillectomy is one of the most commonly performed operations in the United States. As I’ll reveal in the remainder of this article, many tonsillectomies today are being performed unnecessarily. Simultaneously, there are too many tonsils still left in place when in fact they should be removed. Here’s the reason why.

 

What Are Tonsils?

Before I can clear up the contradictory statement above, I must first explain what tonsils are and what they do to merit removal, if at all.

Tonsils are lymphoid tissue, like glands in your neck, armpits or groins. They are part of the immune system and are involved in learning what’s foreign and helping to make antibodies to help fight off infections. In young children, lymphoid tissues are very sensitive and can become greatly enlarged even after a simple cold or infection. If you have young children, I’m sure you’re familiar with their complaints of sore throats whenever they have colds.

It’s also important to note, however, that tonsils can swell up not only after viral or bacterial infections, but also from allergies and acid reflux. Any degree of irritation or inflammation can cause the tissues to swell up. This is normal, and will happen to various degrees in people after any type of infection, irritation or inflammation. As such, not all complaints of a sore throat are viral or bacterial in origin. There are many factors for an enflamed tonsil—this is the reason why antibiotics are not as effective in curing sore throats.

What Do Tonsils Do?

Tonsils are part of Waldeyer’s ring, which is a complete circle of lymphoid tissue that is made up of both tonsils in the side walls of your throat, the adenoids, which are in the midline back of your nose, and your lingual tonsil, which is located at the base of your tongue in the midline. In some cases, you’ll see small connections between all four glands, forming a complete circle. Anything that you breathe in or swallow has to go through this “ring”, so that the body can learn what’s coming into the body. This process is most active around ages 3 to 6.

It’s common knowledge what happens when your tonsils become infected: your throat hurts, you have a fever, your neck glands hurt (lymphoid glands that drain your tonsils), and you don’t sleep well. Anything from simple cold viruses to bacteria, and even allergies can cause your tonsils to swell. Streptococcal bacteria are very common, but there’s one particular strain called Group A beta-Hemolytic Streptococcus (GABHS) that tested for and treated, since toxins produced by this strain can potentially damage the heart or the kidneys. In theory, non-GABHS bacteria can also give you similar miserable symptoms, but if severe, doctors will typically give you oral antibiotics, which will make you feel better in most cases.

When Tonsils Mean More Than Sore Throats

But there’s one more variable that occurs during a tonsil infection that’s usually not appreciated—the fact that the tonsil can swell significantly. As I’ve mentioned in my book, Sleep, Interrupted, and in other related articles, humans have relatively narrowed upper airway breathing passageways to begin with, and even mild inflammation and swelling in the throat can narrow this airway even further, almost always leading to various degrees of obstruction and arousal from sleep.

What this means is that, your enlarged tonsils not only affect how sore your throat feels, they can also cause you to sleep poorly. Here’s the reason why.

If the inflammation and swelling caused by an infected tonsil causes your airway to narrow or obstruct entirely and this in turn, causes you to stop breathing, you’ll either wake up to light sleep immediately, or stop breathing for 10 seconds or longer and then wake up. In this latter situation, you would have experienced what’s called an “apnea” or “loss of breath." Most people will have lots of short obstructions and arousals—this is why if you have a simple cold, you won’t sleep as well, since you’ll toss and turn more often than normal. Luckily, in most situations, once the infection goes away, you’ll return to normal.

However, there’s one more piece to the puzzle that can prevent you from feeling better: This is the piece that many patients and even many doctors overlook as well. If you stop breathing, even temporarily, you’ll create a vacuum effect in your throat, where your stomach juices literally get suctioned up into your throat. Small amounts of acid, bile, digestive enzymes, and bacteria can cause your tonsils to stay swollen, aggravating this vicious process. Even worse, your stomach juices can then travel up into your nose or down into your lungs, wreaking more havoc. Add to this a stuffy nose, then another vacuum effect is created downstream, and the tongue can fall back even further.

Certain viruses such as the Epstein-Barr virus (that causes mononucleosis) attack lymphoid tissues specifically, and as a result, keeps the tonsils abnormally large.

This is one reason why patients with this condition have prolonged bouts of chronic fatigue.

Misleading Throat Pain

Most people (and doctors) naturally assume that if your throat hurts, it means that you have a throat infection. If the antibiotics that you’re given works, then it means that it was an infection after all, right? Not necessarily. One of the most commonly prescribed oral antibiotics is called azithromycin (brand name is Z-Pak), which is a convenient 5 day course. One of the lesser known beneficial side effects from this medications is that it empties your stomach faster. So by keeping your stomach juices from coming up, your throat will feel better relatively quickly, sometimes working faster than what you’d expect from typical antibiotics. The problem with this medication is that it only works sometimes in some people, and the effect begins to wear off after a few doses.

Notice how for many people, cold and sinus “infections” always start in the throat, with a tickling, sore throat, mucous accumulation, hoarseness, cough and post-nasal drip, all of which are symptoms of throat acid reflux. Then as swelling in the throat worsens, more and more juices are brought up into the throat, causing more swelling. If you have larger than normal tonsils, then the narrowing in your throat will be more severe and you’ll stop breathing more and more often. If this process continues, the end result will be the classic bronchitis or sinusitis.

Normally, tonsils shrink down to very small glands by the time you’re an adult, but for some people, they stay enlarged. One possible explanation is that they are subjected to repeated bouts of inflammation from stomach juices, and the large tonsils can bring up more stomach juices.

A Rite of Passage?

In the 50s to 70s, it was a given that if you had tonsils, they were removed. The number of tonsillectomies has dropped significantly since then, but more recently, it’s climbing back up. The main reason for tonsillectomy back then was for recurrent infections, but now obstructed breathing is the most common indication.

We now know that even mild degrees of sleep-breathing problems in children can cause a wide range of problems, from bed-wetting and ADHD to behavioral issues and asthma.

A recent study published in the journal Pediatrics showed that about 50% of children with ADHD could be cured with adenotonsillectomy (this is when you remove both the adenoids and tonsils). Countless studies report significant improvement in children’s cognitive, behavioral, memory and sustained attention scores, after tonsillectomy. Even my son Jonas had dramatic improvements after his tonsillectomy.

Not all children with ADHD have a sleep-breathing disorder, but since it’s such a common condition that can be treated, it’s worthwhile to at least consider it if your child has ADHD. People are always asking why a stimulant medication such as Ritalin helps children focus and remain calmer. The answer is that they’re sleepy.

Poor quality of sleep can also heighten a child’s senses and cause abnormalities in their involuntary nervous system, making him or her have balance problems or become hypersensitive to certain sensory forms of input, such as touch, sounds or odors.

The Truth About Tonsillectomy

Unfortunately, not all children who undergo tonsillectomy improve. A recent meta-analysis combining multiple tonsillectomy studies showed that overall, about 2/3 had significant benefit. Some children do somewhat well, but not as well as some others. The explanation here is that the tonsils are not the only part of the equation. By definition, if your tonsils are large, then your jaws will be smaller. I’ve mentioned in my book, Sleep, Interrupted that modern humans have smaller jaws than our ancestors even a few hundred years back, mainly due to a change in our diets (from organic foods off the land or oceans to processed foods with refined sugars). Bottle-feeding is another modern Western phenomenon that has been shown to aggravate this process. If you have smaller jaws to begin with, you’ll have more inflammation in your throat via the mechanism that I described earlier, which will predispose your tonsils to become enlarged. Having large tonsils will cause more obstructions, causing a vacuum effect, which can also narrow your jaws, especially since a young child’s jaws are relatively soft and malleable.

A recent study showed that compared with tonsillectomy alone, orthodontic palatal expansion was equally effective. When both procedures were performed, the results were additive. This study goes to show that dental and orthodontic issues may be important considerations long before parents consider braces for their teens.

Outgrowing Your Tonsils

Some of you may be asking, if the tonsils are an important part of the immune system, why take them out? Most of the early education of your immune system occurs before age 6. Either during this time, or even long afterwards, if your tonsils are so large that they literally obstruct your breathing at night, then wouldn’t you think that this is a more important issue that needs to be dealt with? Doctors will also say that children will “grow out of it.” Yes, in most cases, they will, but based on all the recent studies, there’s plenty of evidence that before they “grow out of it,” there can be potential long-term consequences, including your risk for developing obstructive sleep apnea, heart disease, heart attack and stroke later in life.

I once heard a presentation at a national sleep meeting, where they showed children who underwent tonsillectomies all improved dramatically. The disturbing finding from this study was the fact that compared with children who did not have sleep-breathing issues, the children who underwent tonsillectomies never fully caught up to the control children in terms of cognitive and behavioral measures. What this implies is that there’s some degree of permanent brain damage. Fortunately, children’s brains are highly adaptable, and can compensate very well.

By no means am I advocating routine tonsillectomies for all children. But if your child has any of the issues that I talked about in this article, or if you’re on the fence about whether or not your child should undergo some type of treatment, these issues are definitely worth thinking about.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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162 thoughts on “What Everyone Should Know About Tonsillectomy

  1. Thank you for your reply, I’m glad the gag reflex is gone then, and I’m looking forward to see if I’m one of the lucky ones with good results. I’ll definitely keep you posted!

  2. Thank you very much for this information and for your helpful responses.

    1. I am 23 years old and I would like to ask the risks for my immune system once the tonsils are removed?

    2. Also, I am having a difficulty in breathing right now. I thought I do not need to have my tonsils removed as long I can still breathe. A doctor advised my parents to have these removed when I was in Elementary. Now I am strongly considering having these taken out because of the difficulty in breathing. I had a fever last week and at the middle of the week, I had tonsilitis which made my large tonsils grow bigger. Now there is no pain but the size of the tonsils still remain the same so the airway became smaller. After taking some antibiotics, do you think it will become smaller, which can improve breathing?

    Thank you.

  3. So I had absolutely no gag reflex before my tonsillectomy,but acquired one afterwards. Ive tried researching why this could happen but have always come up blank. Any explanation would be appreciated.

  4. Thank you sir for your wonderful article. But i have one major problem. The problem is that i had tonsillectomy in the age of 19. The reason for tonsillectomy was that i always had sore tonsils that cannot be corrected even i take strong medicines, therefore i had tonsillectomy. Now the condition is that i always have allergy in my tonsils and runny nose, mostly 4 a.m in the morning, . i have ignored all the food which makes allergy. But still i have this problem. Kindly please guide me how to remove allergy for ever.

  5. Hi,

    I had sinus surgery, deviated septum surgery and tonsil surgery two months ago. My ENT doctor decided to cut my tonsils and uvula down to help with snoring and because I had large tonsils. Now my right tonsil is swollen larger than it was before I had the surgery and he wants to go ahead and remove both tonsils. Why wouldn’t he have just removed them to begin with? He thinks there might be some type of infection deep down inside of the tonsil, it sucks that I am going to have to go through this again.

  6. Hello Dr.Park!! I’m 34 and I had my tonsils removed March 5, 2015. I constantly struggle with having the feeling of something in my throat. My Doctor ran a scope down my nose to check everything about a week out from surgery, and said it all looked good. I still to this day have that feeling. It’s a little sharp, but very annoying and distracting. I notice I still have a TON of post nasal dripping happening. Could that be it? Do you think he should have taken the adenoids out too? I constantly feel like I have oneof those early morning sore throats. If you have any suggestions please let me know.

  7. Hi Dr. Park, I am 21 yrs old from Philippines. My right palatine tonsil has been swollen for 7 months now, thing is it interferes with my throat. It makes me gag to the point I wanna vomit. It does it on a daily basis. My question is, should I consider my swollen palatine tonsil removed? Coz its really annoying, I can’t eat and I feel gaggy and pukey all the time. Please help. Thank you.

  8. Thanks doc for all the useful information up there.
    i have a seven year old son who had his tonsilectomy 2years ago due to mouth breathing,snoring and even foaming. i was made to understand that his tonsils had risen and covered 2/3 of his throat and they had ti remove them. few weeks after the surgery, the breathing was getting better and his sleep got sounder but some months later, it started getting bad again. right now he mouth breathes,snores,has a long face and a small jaw. what else can we do?

  9. I am having throat infection since last two months. Doc says its tonsillitis.
    Although I don’t have much problem. I can eat and breath properly though it feels a little when swallowing. Now since it is two and it is not recovering after medications doc is suggesting tonsillectomy.
    Should I consider it, I had read lots of after tonsillectomy complication. I am worried.
    Please give me your advice

  10. I am 40, and had a bilateral tonsillectomy February 11th, 2016. Tonsillectomies had been recommended several times for me in childhood, but my caregivers could not prioritize the cost. At 17, and then again at 26, I developed quinsy infections, and had to be hospitalized while the abscesses were drained, and until I could swallow again. I was diagnosed with moderate OSA in 2014, but could not tolerate CPAP. It was for this reason, and the fact that I’ve had strep and/or tonsillitis and/or sinusitis more often than not since 2012, that the tonsils were finally removed. The crypts were so large and deep by then that I could not dislodge the stones with a waterpick. This greatly affected my social life, self esteem, a lot of things. My ENT says my tonsils (once removed) were like tangerines, even though externally they had looked actually small. The problem is that my sleep apnea is worse now. I will investigate gastric causes, since I do have chronic bloating and pain, but can tell by just looking in the mirror that the passageway is narrowed since the surgery. My uvula is offside and lower in my throat (often touching my tongue), and no longer prevents food from going up my nose when I eat: attractive. My post nasal business is exacerbated to such a degree that I sound like a world war in the morning. It is not a delicate and ladylike way to exist. I am so tired I forget what I’m going to the kitchen for before I get there, and I live in a 500 square foot apartment. Since on a good day I may have the energy to get out of bed (or not) this decrease in basic functioning is very concerning indeed. I have people to look after. I had an “appliance” for the apnea first, which was meant to bring my jaw forward, but it also succeeded in causing inflammation. My bite was thrown off, I had constant headaches, I clicked all the time, and could barely chew, you get it. I had basically ground through both the day and night appliances by month three, and I am not a wealthy woman. I doubt then that I’m a candidate for the horrible surgery I read about where they basically remodel your face so you look like a Neanderthal and drool. I am not overweight, so the last option is removal of the lingual tonsils + uvula, but people say this can sometimes narrow the airway more. I can barely fit a finger down there as it is (which I must attempt several times a day to scoop food out of my sinus), so will probably die if my throat becomes further constricted. It’s a bit depressing that after having a belt sander down my throat for a month things are actually worse for me. I had a septoplasty in 2012, and they made me wait to see if that improved my breathing first before they even ordered the sleep study. I’m not sure how many more trials and errors I can endure before I give up and just admit my quality of life will never improve.

  11. V,

    Sorry to hear about your experience. Tonsillectomy can help a lot of people feel better, but there are always some (thankfully rare) people who feel worse afterwards. I can’t recommend what you should do without examining you first, but the first priority is to find out what’s causing your symptoms. Only a good office exam using a flexible camera in your throat can tell. Sometimes I’ll place patients under general anesthesia to look at the airways in deep sleep, when muscles are more relaxed and you’re still breathing.

  12. I had my tonsils and adnoids removed at age 10. I am 76 now. For many years I have experienced food and liquids slipping down my throat while chewing causing me to have severe coughing to remove whatever is clogging my throat. I learned to eat and swallow with my chin down to avoid the uncontrolled movement of food/liquids down my throat. Could the lack of tonsils be the cause of this?