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.
3 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.