The tonsils are masses of lymphoid tissue located at the back of the throat, acting as sentinels for the body’s immune system. They are part of a larger ring of tissue called Waldeyer’s ring, strategically positioned to encounter pathogens entering the body through the mouth and nose. When these tissues become frequently infected or chronically enlarged, a common dilemma arises regarding whether the risks of leaving the tonsils in place outweigh the risks associated with their removal. Deciding against a tonsillectomy shifts the focus to managing the complications that may arise from recurrent infection or persistent physical obstruction.
The Normal Function of Tonsils
The tonsils are composed of immune system cells, including T cells, B cells, and macrophages. Their primary function is to sample inhaled and ingested antigens, initiating an immune response against foreign invaders. This strategic location at the junction of the respiratory and digestive tracts allows them to serve as a first line of defense, producing antibodies like Immunoglobulin A (IgA) to support mucosal immunity.
Specialized structures on the tonsils, known as crypts, increase the surface area available for capturing microbial antigens. Because of their role in the early development of immunity, doctors prefer to maintain the tonsils unless they become a detriment to health. While their immune function is highest in early life, other lymphoid tissues can compensate for their removal later on.
Specific Risks of Untreated Recurrent Tonsillitis
Leaving recurrent or chronic tonsil infections untreated can lead to several complications. One local complication is a peritonsillar abscess, often referred to as Quinsy, which is a collection of pus that forms between the tonsillar capsule and the throat muscle. This condition causes unilateral throat pain, difficulty swallowing (dysphagia), and a muffled “hot potato” voice, often requiring emergency drainage to prevent airway compromise.
Chronic inflammation can also result in the formation of tonsilloliths, which are calcified accumulations of bacteria, debris, and dead cells within the tonsillar crypts. While not medically dangerous, these formations are a frequent cause of chronic bad breath (halitosis) and an uncomfortable sensation in the throat. The concerning risks are the systemic complications that can follow an infection caused by Group A beta-hemolytic Streptococcus (GABHS).
If a GABHS infection is not adequately treated with antibiotics, the body’s immune response can mistakenly target its own tissues, leading to secondary conditions. These complications include acute rheumatic fever, which can cause inflammation and permanent damage to the heart valves, joints, skin, and nervous system. Another post-streptococcal complication is glomerulonephritis, involving inflammation of the filtering units in the kidneys that can lead to kidney damage. The risk of these systemic issues highlights the importance of accurately diagnosing and treating bacterial tonsillitis, even when a tonsillectomy is avoided.
Health Impacts of Chronic Tonsil Enlargement
Beyond infection, the physical size of the tonsils, called hypertrophy, can cause mechanical problems, even without active infection. When tonsils are chronically enlarged, they can obstruct the upper airway, leading to Obstructive Sleep Apnea (OSA). During sleep, the throat muscles relax, and the enlarged tonsils can cause repeated partial or complete blockages of the airway, resulting in snoring, gasping, and pauses in breathing.
In children, untreated OSA can lead to chronic poor sleep quality. Symptoms manifest as daytime fatigue, poor school performance, and behavioral issues often mistaken for ADHD. In adults with tonsil hypertrophy, this leads to chronic daytime sleepiness, which impairs quality of life.
The size of the tonsils can also interfere with eating, causing difficulty swallowing, or dysphagia. Children with tonsil hypertrophy and OSA are more likely to experience swallowing issues, which often resolve following tonsil removal. Leaving the tonsils in place means managing these obstructive symptoms, which impact daily functions and affect long-term physical and cognitive development.
When Doctors Recommend Watchful Waiting
The decision not to remove the tonsils, known as watchful waiting, is a common management strategy when symptoms are mild or infrequent. This approach is advised for recurrent throat infection if a patient has had fewer than seven episodes in the past year, five episodes per year for two years, or three episodes per year for three years. In these cases, the body’s natural immune response and the use of antibiotics for acute flares are considered sufficient to manage the condition.
Watchful waiting involves monitoring the frequency and severity of infections and the progression of any obstructive symptoms. However, a surgical recommendation may still be made even if the frequency criteria are not strictly met, especially if the patient has complicating factors. These modifying factors can include a history of a peritonsillar abscess, antibiotic allergies, or a diagnosis of Obstructive Sleep Apnea confirmed by a sleep study. If the tonsils are left in, it is based on the medical judgment that the patient’s health is not severely compromised by the current level of infection or enlargement.