Tonsillectomy, the surgical removal of the tonsils, is one of the most frequently performed procedures in pediatric medicine. This procedure involves balancing the discomfort and risks of chronic illness against the risks associated with surgery and recovery. Tonsils are lymphoid tissues, and when they become a source of significant health problems, removal may be considered. Understanding the function of the tonsils, the medical thresholds for removal, and the treatment alternatives available is important for parents navigating this choice.
The Function of Tonsils and Reasons for Enlargement
Tonsils are paired masses of lymphatic tissue situated at the back of the throat, serving as a first line of defense against inhaled or ingested pathogens. They contain immune cells that trap bacteria and viruses, producing antibodies to fight infection. These tissues are most active during early childhood and typically start to shrink naturally as a child reaches adolescence.
Enlargement, known as hypertrophy, results from the tonsils’ role in fighting infections. Repeated exposure to pathogens causes the tissue to swell, sometimes remaining chronically enlarged after the acute infection has passed. The two primary problems leading to removal consideration are recurrent infections, such as tonsillitis or strep throat, and airway obstruction. When tonsils become too large, they can physically impede normal breathing, especially during sleep.
Medical Criteria That Justify Removal
Physicians use specific guidelines to determine if the benefits of tonsillectomy outweigh the risks, differentiating between infectious and obstructive indications. The criteria for recurrent infection often follow the established Paradise criteria. Surgery may be considered if a child experiences a high frequency of documented sore throat episodes:
- Seven or more in the preceding year.
- Five or more in each of the preceding two years.
- Three or more in each of the preceding three years.
For an episode to count, it must be documented and accompanied by clinical features like a temperature greater than 100.9°F (38.3°C), enlarged lymph nodes in the neck, or tonsillar exudate. Tonsillectomy for recurrent infection reduces the frequency and severity of future throat infections. Surgery is also a justified option in cases of chronic tonsillitis, where an infection persists despite appropriate antibiotic treatment.
The second major indication for surgery is Obstructive Sleep Apnea (OSA) caused by tonsillar hypertrophy, which is the most common reason for tonsillectomy in children today. Large tonsils can partially or fully block the upper airway during sleep, leading to snoring, gasping, or momentary pauses in breathing. This poor sleep quality can be associated with significant daytime issues, including hyperactivity, poor school performance, and growth retardation.
While a physical exam can grade tonsil size, a sleep study, known as a polysomnography, may be used to confirm a diagnosis of moderate to severe OSA. Less common indications for removal include a peritonsillar abscess (a collection of pus behind the tonsils) or a unilateral tonsil enlargement that raises suspicion of malignancy. When tonsils are removed for OSA, the adenoids are often removed at the same time in a procedure called adenotonsillectomy.
Non-Surgical Treatment Options
Before proceeding to surgery, medical management and observation are often recommended. This approach, called “watchful waiting,” involves monitoring the child’s symptoms over time. Since tonsils naturally shrink as children age, symptoms related to size may resolve without intervention.
For bacterial infections, such as strep throat, antibiotics are the standard treatment. For chronic or recurrent infections, physicians may explore underlying causes of inflammation, such as allergies or chronic acid reflux, which can be managed with targeted medications. Addressing environmental irritants, like secondhand smoke, can also help reduce tonsil inflammation.
In cases of obstructive symptoms, particularly mild sleep-disordered breathing, a trial of nasal steroids may be used to reduce upper airway inflammation. For older children or adolescents with severe OSA, Continuous Positive Airway Pressure (CPAP) therapy, delivered through a mask, is an alternative. Encouraging a healthy weight can sometimes alleviate obstructive symptoms, as can managing any contributing craniofacial or structural issues.
Surgical Procedure and Post-Operative Recovery
Tonsillectomy is performed under general anesthesia. Surgeons may use various techniques, including traditional cold steel dissection, electrocautery, or radiofrequency ablation. The procedure is typically performed on an outpatient basis, though an overnight stay may be required for young children or those with complex medical conditions.
The most significant challenge following surgery is managing post-operative pain, which can be considerable and may feel like a severe sore throat or an earache due to referred pain. Pain often peaks between the second and seventh day post-surgery, corresponding with the sloughing of the protective white scabs that form over the surgical sites. Pain management involves a scheduled rotation of medications, typically acetaminophen and ibuprofen, often supplemented by a dose of intravenous dexamethasone during surgery to reduce pain and nausea.
Maintaining hydration is paramount during recovery, as dehydration can lead to complications and worsen pain. Children should be encouraged to drink cool liquids, and a diet of soft, non-irritating foods is recommended for up to two weeks. The total recovery period is generally 7 to 14 days, with most children returning to school after about a week and avoiding strenuous activity for two weeks to prevent the risk of post-operative bleeding.