Time to Take Out Tonsils?

When should tonsils be removed? My daughter has had a number of infections, and her pediatrician has recommended a tonsillectomy, but I’m very nervous about it. How dangerous is the operation today?

– August 22, 2014

Tonsils are small masses of tissue on either side of the back of the throat – you can sometimes see them by looking down your throat in front of a mirror. Adenoids are located high in the throat behind the nose, and even doctors can’t see them without special instruments. Both are parts of the immune system, serving to protect us from dangerous germs that enter our bodies through the mouth and nose.

Years ago, tonsils were removed routinely after kids (and some adults) had repeated bouts of infection (tonsillitis). Today, the procedure is most often recommended for sleep-disordered breathing in kids, but pediatricians may suggest it for youngsters who are having repeated infections, such as more than:

  • seven episodes per year
  • five per year in each of the preceding two years
  • three per year in three consecutive years

Whether or not you have confidence in your daughter’s pediatrician, you should always get a second opinion whenever surgery is suggested.

Because of their location, tonsils and adenoids can easily become infected by inhaled bacteria and viruses, which can cause sore throats, fever, and bad breath. Although this happens most often in children, adults are not immune. Infected tonsils and adenoids may also become enlarged, which can result in breathing and swallowing difficulties. Bacterial infections can often be treated with antibiotics, but surgery may be needed when other treatments fail to work. Because tonsils and adenoids are working immune organs, they should be removed only when they cause significant problems that cannot be managed in other ways.

In January 2014, a study published in the medical journal Pediatrics found a wide variation in how often children develop complications (usually bleeding) after tonsillectomy. Rates ranged from three percent to close to 13 percent from one hospital to another, so it’s worth trying to get information on the rate of complications at the hospital where your daughter’s tonsils will be removed. The risk of bleeding during or after the surgery is about one in 100 cases, the study found. Adverse reactions to anesthesia occur in only one out of 10,000 procedures. The risk of death is very small, one out of 35,000 cases.

The researchers examined the records of almost 140,000 children who had uncomplicated tonsillectomies at 36 children’s hospitals between 2004 and 2010. All the kids had outpatient surgery and went home the day of the procedure. The study found that between 2004 and 2010, about eight percent of the youngsters had to return to the hospital within a month, usually because of bleeding.

The researchers also looked at the use of dexamethasone, a drug that can help reduce postoperative nausea, vomiting, and pain. They also reviewed the use of antibiotics, which earlier studies had shown do not reduce postoperative bleeding. Guidelines issued in 2011 by the American Academy of Otolaryngology–Head and Neck Surgery recommend giving dexamethasone to children before the surgery and recommend against the use of antibiotics.

It’s natural to be nervous about surgery, but odds are that your daughter’s procedure will go smoothly, and tonsillectomies today are safer than in years past. Some things don’t change much though, so be sure to stock up on ice cream and sorbet – treats that your daughter will be able to swallow easily and will ease her sore throat when she comes home.

Andrew Weil, M.D.

Sanjay Mahant et al, "Variation in quality of tonsillectomy perioperative care and revisit rates in children’s hospitals" Pediatrics. 2014 Feb; 133(2):280-8. doi: 10.1542/peds.2013-1884. Epub Jan 20, 2014

American Academy of Otolaryngology—Head and Neck Surgery, "Clinical Practice Guideline: Tonsillectomy in Children," http://www.entnet.org/sites/default/files/CPG-TonsillectomyInChildren_0.pdf, accessed June 16, 2014

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