The tonsils are two oval-shaped pads of lymphatic tissue located at the back of the throat, one on each side. As part of the immune system, their function is to act as a first line of defense, trapping germs that enter the body through the mouth or nose and producing antibodies to fight infection. Tonsillitis is the inflammation or infection of these tissues, which causes them to become red, swollen, and often painful. When tonsil issues become chronic, severe, or start causing significant health problems, a surgical procedure called a tonsillectomy may be considered.
Defining Chronic and Recurrent Tonsillitis
The most common reason for considering tonsil removal is a history of frequent infections. Medical guidelines establish specific thresholds for what constitutes “recurrent” tonsillitis, which is a major factor in the decision-making process for a tonsillectomy. These criteria help determine when the benefit of surgery outweighs the risks for patients suffering from frequent throat infections.
A patient is typically considered a candidate for tonsillectomy if they have experienced at least seven documented episodes of tonsillitis in the past year. Alternatively, the criteria are met if there were at least five episodes per year for the past two consecutive years. The guidelines also apply to those with at least three episodes per year for three consecutive years.
For an event to count as a documented episode, the infection must be severe and confirmed by a healthcare provider. This documentation often requires evidence of a sore throat combined with one or more specific physical findings. These findings include a temperature greater than 101°F (38.3°C), swelling of the lymph nodes in the neck, or the presence of pus-like fluid, known as exudate, on the tonsils.
The severity of the infection can also be confirmed by a positive test for Group A beta-hemolytic streptococcus (strep throat). These frequency and severity standards ensure that surgery is reserved for cases where the tonsils have become a liability rather than an asset to the immune system.
Tonsils Causing Structural Issues
Tonsillectomy is also frequently performed for reasons related to physical obstruction, independent of infection frequency. Enlarged tonsils can block the upper airway, leading to significant breathing problems, particularly while sleeping. This situation is the primary indication for tonsillectomy in many patients, especially children.
The most concerning structural issue is obstructive sleep apnea (OSA), where the enlarged tonsils partially or completely obstruct the airway during sleep, causing breathing to stop briefly. Untreated OSA can lead to restless sleep, daytime tiredness, behavioral issues, and, in children, problems with growth and school performance. Removal of the tonsils often resolves the breathing difficulties and the associated sleep disruption.
Other physical problems caused by enlarged tonsils include chronic mouth breathing and difficulty swallowing, medically known as dysphagia. Tonsils can also develop tonsil stones (tonsilloliths), which are calcified bacterial and cellular matter. If these stones cause persistent bad breath (halitosis) and cannot be managed otherwise, tonsil removal may be appropriate.
Surgery may be needed to investigate specific serious medical conditions. This includes a severe peritonsillar abscess, which is a pocket of pus that forms behind the tonsil, or if one tonsil is noticeably larger than the other. Unilateral enlargement, or asymmetry, may warrant removal to rule out rarer conditions affecting the tonsil tissue.
Alternatives to Surgery and the Decision Process
When tonsil problems arise, surgery is typically not the immediate first step. For patients with recurrent infections that do not meet the strict frequency criteria, a period of watchful waiting is usually recommended. This approach involves monitoring the symptoms without immediate surgical intervention, allowing the body’s natural defenses to manage the issue.
Acute infections, especially those caused by bacteria, are managed with appropriate antibiotics to treat the current episode. However, antibiotics are not a long-term solution for frequent tonsillitis due to the risk of resistance and do not address physical obstruction. For tonsils enlarged due to inflammation, nasal steroid sprays may be used, although they are generally more effective for enlarged adenoids.
The decision to proceed with a tonsillectomy balances the risks of surgery against the long-term impact of the chronic condition on a person’s quality of life. This evaluation is performed by a specialist, typically an Otolaryngologist, also known as an ENT doctor. They consider the frequency and severity of infections, the degree of airway obstruction, and the overall health of the patient.
If the primary issue is obstruction, an alternative surgical procedure called a tonsillotomy may be considered, which involves partial removal of the tonsil tissue. This less invasive option aims to reduce the size of the tonsils while preserving some immune function, and it is primarily used for sleep-disordered breathing. The final decision is reached after counseling the patient or caregivers about the potential benefits and surgical risks.