What Everyone Should Know About Tonsillectomy
September 16, 2009
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.
20 Responses to “What Everyone Should Know About Tonsillectomy”
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Dr. Park,
Thanks for a wonderful article about adenotosillectomy. I agree that more children today need their tonsila and adenoids removed due to sleep distrubed breathing issues. Other big concerns of mine are mouth breathing, lip apart oral posture, and allergies. If any of these are present as well , the problem is more complex.
I have referred many patients to my local ENT’s for T/A. As you are aware, mouthbreathing will lead to a vertical facial growth pattern. This leads to an increased anterior face height. Many of the kids I see on a daily basis have a habitual open mouth posture, and other related problems, that seem to go unnoticed by the Pediatricians.
But, how do we get the kids to breath through their nose again after the posterior airway space is clear? This has been a tough issue to deal with. Some kids will spontaneously breath thru their nose, which other persist in mouthbreathing? What can we do to help them breath normally, so their face can grow normally?
Sincerely Michael K. Willkerson DDS., MS.
Dr. Wilkerson,
You’re right. Mouth breathing is a common problem even after tonsils and adenoids are removed. If you haven’t listened to my interview with Dr. Bill Hang last month, I strongly urge you to do so. We talk about pediatric orthodontic issues and sleep apnea and he goes into some detail about what to do, as well as some good resources regarding myofacial exercises. Email me at doctorpark@doctorstevenpark.com and I’ll send you the link to the recording. You may also want to contact Dr. Hang yourself at facefocused.com. Let him know that I referred you. As you’ll hear from his talk, taking out tonsils and expanding the palate is a good “start.”
Sir
Having been through a tonsillectomy at age 22 years, the process was extremely painful, and yet the medical doctor concerned simply decided that rather than determining why I had repeated tonsillitis, removing my tonsils was the only option. However, post surgery, I developed a throat infection, or to be precise an upper respiratory infection suspected as being caused by a Streptococcal bacteria and, nearly 25 years later, I remain ill. Tests show that I have a chronic Streptococcal bacterial infection, suspected as being protected from my immune system and antibiotics through the formation of a bio film. In other words, my tonsillectomy hit my immune system, exposed nerves in my throat, and presented a serious risk of developing post surgical infection, which is what happened.
The diagnosis is M.E., often called C.F.S, but as very recent tests show that 97% of those with M.E. have a chronic Retoviral infection, albeit not HIV, means that quite clearly, as in my case, removing my tonsils did not deal with the reason why I kept getting infections in my throat area, removed a defence barrier, and made my health considerably worse, not better.
The golden rule must be to fully understand the problem before pursuing a solution, as simply tackling the problem based upon assumptions can cause considerable damage rather than dealing with the underlying problem.
our nearly 7 yo has snored since birth — after switching to an all natural, no processed food diet her health has been fantastic…no ear infections, minimal colds and generally ridiculously healthy in comparison to her peer…but she still snores only less so. our dentist recommends tonsil and adenoids removed as her adenioids are quite large…also starting to have the elongated face…it is not visible to me but to them.
basically he did a scan and it is limiting her breathing capacity..the operation seems like an obvious choice but can you recommend palate expansion options? she has a t4k myobrace and her teeth are coming in quite crowded.
thanks! Maryanne
Sounds like you have a reasonable plan. I do agree that your daughter will probably need both adenotonsillectomy as well as palatal expansion. A recent Stanford study showed that undergoing both procedures had a additive effect. I can’t recommend any one palatal expansion system, as that’s’ a personal choice made by dentists that perform these procedures. Did you get a chance to listen to my interview with Dr. Bill Hang?
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Thanks. To subscribe to my RSS feeds, go to the orange RSS feed button/link in the upper right corner or my site. I have other options on the right side as you scroll down mid-way.
my girlfriend has this similar Tonsillectomy.
she is 47 years of age.
her fear is, the danger of having her tonsils removed because of her age
how dangerous could it be for her.
we need more opinions
cheers and hope some of you could give out some information
Louis,
The more important question is the reason why her tonsils need to be taken out. You have to weight the benefits versus the risks. Age really has nothing to do with risks.
I am over 50+ years old and I have a problem with my tonsils swelling and snoring. I have notice that when I eat nuts my tonsils tend to swell more. Do you think this could be an allergic reactions to nuts at times?
Mary,
An allergic response is certainly possible, but sometimes small nuts can get trapped in small spaces inside the tonsils. If you’re not sure, you can see an ENT doctor in your area to make sure.
Dear Docotrs
My child is just 3 years old. He is suffering from a repeated throut infection and he had to used 8 times antibiotics during the last 9 months. This includs strong ones by injection for five days when we noticed a swolen glands in his nick from outside in both sides. in the last two months he used four different types of antipiotic. He has enlarged tonsils and large adenoids which caused difficult breathing during his illness and he mostly breath from his mouth. the ENT doctors advised to remove his tonsils and adenoids and the pediatrics advise not to do so in such age and they keep prescriping antibiotics. My child ammunity seystem seems very week and he get sick easly. his hemoglobin is only 11.6 though he takes iron sublement and his overall health seems week though he takes vitamins sublimints since he was a baby. I am afraid his ammunity system is week and this is why he has an enlarged tonsils even if they are not infected.
I will be greatful if you kindly advise whether I shoule remove his tonsils or not in sutch age and if so, do I need to take any precautions to improve his health before the operation. Many thanks
There are different philosophies by different specialists on the right age for adenotonsillectomy. He has large tonsils and adenoids due to inflammation from breathing pauses and reflux, which causes his tonsils to stay big. Not breathing properly can cause physical, cognitive and developmental delays. A 3 year old is not too young for surgery.
My 7 year old has been diagnosed with PANDAS. We did not know about this, or have clearly documented strep infections, although my other 3 kids did, and 2 oldest had T&A. Our dr. wants us to have her tonsils out ( adenoids were out at age 5.5), in case she is harboring strep in tonsils. My fear is in what you stated: “the tonsils are part of the immune system and are involved in learning what’s foreign and helping to make antibodies to help fight off infections.” PANDAS is an autoimmune response to strep, where antibodies to strep are made erroneously by the immune system, and start to cause inflammation in the basal ganglia. I have heard of kids developing PANDAS AFTER T&A. Can you explain anything about this. I had thought T&A might help, but wouldn’t hurt. But now, with the autoimmune issue of it, and Tonsils being part of immune fighters, I wonder. Thanks.
I know this article is a few years old, but it all falls inline with what my son (who just turned 3) is experiencing. My ENT says he won’t do a tonsillectomy for a child under 4 because it’s too dangerous. I feel completely helpless at this point and don’t know where to turn to next. My son wakes up constantly during the night due to sleep apnea. His tonsils are huge. Even a minor irritation compounds his problems. Today my sitter had me come pick him up because she was so freaked out by it during his nap and she said his mouth was turning blue as he was trying to catch a breath. I relayed all this the ENT nurse today – we have an appointment this afternoon, but she said there’s probably nothing they can do for him and they won’t do a tonsillectomy because he’s under the age of 4. My worry is also that he already is a year to 6 months behind cognitively from where my oldest son was at this age. He barely puts 3 words together in a sentence, doesn’t completely form most of his words and is sleepy and/or irritable throughout the day. I’m at the mercy of their willingness to do something about this. We’re going to another ENT on Friday for a second opinion if nothing comes out of our appointment today. Is there any venue to find doctors here in California that don’t have this ‘not if under the age of 4′ policy?
My daughter 5 has snoring problem during the night ,she does not wake up on her sleep ,but if given alergy drugs the snoring goes away only to come back again after a while.My worry is that she cannot be on drugs on a daily basis .what should i do
Ms. Modi, it sounds like you may need to have your daughter see an ENT doctor to more definitively address her nasal congestion issue that is aggravated by allergies. Good luck.
My son has follicular tonsilitis.
Many have advised us to approach ayurvedic doctors for treatment
I have reservations about this
My child had high fever for two days inspite of the antibiotics.
I just dont want to take a risk with respect to his health.
Dear Dr Park,
i have found your write up very enlightening and informative. however i’m in a terrible turmoil over what to do. i’m 47 i’m a singer and for the last four years i have been experiencing insistent inflammation of my throat (tonsils) worsened by the frequent appearance of white smelly pellets. when i go to hot climates it worsens thus my job becomes very painful. my fear is the period of recovery with relation to my age and the effect it would have on my voice. thanks once again
i am 34 yr old suffering from chronic tonsillitis since last 9 yrs. i have repeated bouts of infection that hampers my quality of life. i am also planning my first pregnancy . iwant to know whether tonsillectomy will help me at this stage?