Why Aren’t Tonsils Removed Anymore?

Tonsils are still removed, but the bar for surgery is much higher than it was a generation ago. Between 1915 and the 1960s, tonsillectomy was the single most frequently performed surgical procedure in the United States, often done at the first sign of recurring sore throats or simply as a preventive measure.¹ The decline since then reflects a confluence of factors: growing recognition that tonsils play an active role in immune defense, stricter evidence-based criteria for when surgery is justified, and research showing that the benefits for milder cases are surprisingly modest.

How Routine Removal Became the Norm

For much of the twentieth century, tonsillectomy was almost a rite of passage for children. Doctors viewed chronically inflamed tonsils as a source of infection that could seed disease elsewhere in the body, and removal seemed like a logical preventive step. By some estimates, millions of American children had the procedure during the mid-century peak. Criticisms of the practice appeared as early as the 1930s, but it took decades for the surgical culture to shift. The decline did not begin in earnest until well after 1945, and it played out slowly through debates about what counted as good evidence, how much weight to give a surgeon’s clinical experience, and which medical specialties should set the standard of care.¹

In England, data tracking children aged 4 to 15 showed a 14% drop in tonsillectomy rates between 2001 and 2012. Interestingly, rates among children under 4 rose by 58% over the same period, largely because of a different surgical indication: airway obstruction during sleep.² That pattern captures the broader story: tonsils come out less often for infection and more often for breathing problems, and the total number of procedures has shifted rather than simply collapsed.

What Tonsils Actually Do

Part of the reason the old approach fell out of favor is that researchers began to understand just how much immunological work tonsils perform. Sitting at the crossroads where air and food enter the body, the palatine tonsils act as sentinels, sampling bacteria, viruses, and other particles before they travel deeper into the respiratory or digestive tract. They are classified as secondary lymphoid organs, meaning they are one of the places where the immune system learns to recognize threats and mount targeted responses.³

One of the more important roles involves producing a type of antibody called secretory IgA, which coats the surfaces of the throat, nasal passages, salivary glands, and tear ducts. When tonsils encounter a pathogen, they generate immune cells that can migrate to these mucosal surfaces and help keep them defended. Several lines of evidence suggest tonsils are a meaningful source of these protective cells for the entire upper airway.⁴ Research comparing the immune cells in tonsils and adenoids has found they produce both the kinds of antibodies associated with systemic defense (the whole-body immune response) and the kind associated with mucosal defense (the wet surfaces that line your airways and gut), making them a bridge between the two systems.⁵

This does not mean tonsils are irreplaceable. Other lymphoid tissue throughout the body picks up much of the slack after removal. But the emerging picture of tonsils as active immune participants, rather than useless vestigial lumps, changed the calculus. Removing them stopped being seen as a zero-cost decision.

The Big Shift From Infection to Airway Obstruction

The reasons surgeons remove tonsils have changed dramatically. In 1970, upper airway obstruction accounted for about 12% of tonsillectomy indications. By 2005, that figure had risen to 77%.⁶ Recurrent infection, once the overwhelming justification, became a secondary reason. Sleep-disordered breathing, including obstructive sleep apnea in children, is now the primary driver of most pediatric tonsillectomies.⁷

This matters because the risk-benefit equation looks different depending on the indication. A child who cannot breathe properly during sleep, who snores loudly and wakes gasping, who is groggy and unfocused during the day, stands to gain a lot from having enlarged tonsils removed. The evidence for surgery as treatment for obstructive symptoms is strong and well-supported. When the indication is recurrent sore throats, the case for surgery is weaker and the threshold correspondingly higher.

Stricter Rules for When Infection Justifies Surgery

The clinical criteria used to determine whether recurrent throat infections warrant tonsillectomy are deliberately stringent. The most widely referenced standard, known informally as the Paradise criteria, requires documented sore throats of specific frequency and severity: generally seven or more episodes in a single year, five per year for two consecutive years, or three per year for three years, each confirmed by a physician and involving features like fever, swollen lymph nodes, or a positive strep test.⁸ In practice, many children referred for tonsillectomy do not actually meet these criteria when their records are examined carefully. A child who has had “a lot of sore throats” may have had four episodes in one year and two the next, which feels like a pattern to parents but falls short of the evidence-based threshold.

A few other specific conditions can justify surgery on infection grounds. PFAPA syndrome, a periodic fever condition that causes recurring bouts of mouth sores, throat inflammation, and swollen neck glands in young children, responds well to tonsillectomy. And any suspicion of a tonsillar tumor, though uncommon in children, is an immediate surgical indication.

What Happens When You Wait Instead

One of the most persuasive reasons for the shift away from routine tonsillectomy is that children tend to get better on their own. Recurrent throat infections are common in early childhood, and many children who seem like surgical candidates at age five have far fewer episodes by age seven or eight, regardless of whether they have surgery. Systematic reviews comparing tonsillectomy to watchful waiting have consistently found that both groups improve over time. Children who had surgery experienced fewer sore throat days and missed fewer school days in the first year, but these benefits did not persist. Longer-term outcomes between the two groups were similar, and quality of life was not markedly different at any time point.⁹

A Dutch randomized trial drove this point home in children with mild symptoms. Over about 22 months of follow-up, children who had their tonsils and adenoids removed experienced roughly half a sore throat less per year compared with those who simply waited. They also had slightly fewer upper respiratory infections overall. But no clinically meaningful difference appeared in quality of life, and 12 children in the surgical group experienced complications from the operation itself.¹⁰ For children who had more frequent infections at baseline (three to six episodes), surgery was more effective than for those with fewer episodes, reinforcing the idea that the operation makes sense mainly for the most severely affected kids.

A Cochrane review of tonsillectomy versus nonsurgical treatment found that children who had surgery averaged about three episodes of sore throat in the first postoperative year, compared with roughly 3.6 in the nonsurgical group. One of the three surgical-group episodes was the predictable sore throat from the operation itself.¹¹ A difference of 0.6 episodes per year, when one of your “saved” episodes is actually surgery recovery, is a hard sell for many families once the numbers are laid out plainly.

Risks That Factor Into the Decision

Tonsillectomy is a safe procedure in the vast majority of cases, but it is not risk-free. The most common serious complication is postoperative bleeding, which sometimes requires a return trip to the emergency department or even a second trip to the operating room. A large U.S. study of more than 96,000 pediatric tonsillectomies found that about 2.2% of children returned to the hospital with post-surgical bleeding. The risk was higher in older children: those over 12 had roughly two and a half times the odds of bleeding compared to younger patients.¹²

In adults, the picture is more concerning. One study found that nearly 19% of adult patients experienced postoperative bleeding, compared with 4% of children. About one in twelve adults had bleeding severe enough to require a return to the operating room for surgical control, versus about one in sixty children.¹³ Recovery is also harder for adults, with more pain and a longer return to normal eating and activity. These higher complication rates are one reason adult tonsillectomy draws extra scrutiny.

Possible Long-Term Consequences

A large population-based study using Danish health records found that tonsillectomy in childhood was associated with a roughly threefold increase in diseases of the upper respiratory tract later in life. Adenoidectomy showed a similar pattern, with about a twofold increase. Both procedures were also linked to a smaller but statistically significant bump in infectious and allergic diseases: adenotonsillectomy was associated with a 17% increased risk of infectious diseases overall, translating to about a 2% absolute increase because these conditions are already common.¹⁴ These findings are observational, so they do not prove that the surgery caused the increased risk. Children who needed their tonsils out may have been predisposed to respiratory problems regardless. But the findings do reinforce the idea that tonsils are not disposable organs and that removing them may carry a long-term cost.

A smaller, older study following tonsillectomized adults twenty years after surgery found no significant difference in the number of upper respiratory infections compared with a control group. However, it did find a higher prevalence of chronic disease in the tonsillectomy group, though the study’s small size means that result needs cautious interpretation.¹⁵ Taken together, the evidence is not alarming, but it reinforces a recurring theme: unless the benefit of surgery is clear and substantial, leaving the tonsils alone may be the safer long-term bet.

Alternatives to the Knife

For recurrent tonsillitis that does not meet surgical thresholds, conservative management is the default approach. That typically means pain relief with acetaminophen or anti-inflammatory drugs during acute episodes, and antibiotics only when there is a high probability of bacterial infection.¹⁶ The antibiotics-for-every-sore-throat era has also receded, partly because of growing awareness of antibiotic resistance and partly because most throat infections are viral.

Some research has explored low-dose, long-term antibiotic regimens as an alternative to surgery for children with frequent tonsillitis. One trial found that prophylactic antibiotics produced a reduction in recurrent infections comparable to what tonsillectomy achieves.¹⁷ This is not a widespread recommendation, and it raises its own concerns about antibiotic overuse, but it underscores how modest the surgical advantage can be for infection-based cases.

Partial Tonsillectomy as a Middle Ground

When the reason for surgery is airway obstruction rather than infection, a newer option has gained traction: partial tonsillectomy, also called tonsillotomy or intracapsular tonsillectomy. Rather than removing the entire tonsil along with its surrounding capsule, the surgeon shaves down the tonsillar tissue while leaving the capsule and a thin rim of tonsil in place. The idea is to open the airway without stripping away all of the organ’s immune tissue or exposing the raw muscle bed beneath, which is where most postoperative pain and bleeding originate.

Studies comparing partial and total tonsillectomy for pediatric obstructive sleep apnea have found that both approaches produce clear improvements in breathing symptoms and quality of life.¹⁸ The partial approach generally involves less pain, faster recovery, and a lower bleeding rate. The trade-off is that a small percentage of children experience regrowth of the tonsillar tissue and may eventually need a second procedure. Children with allergic disease appear to be at higher risk for this regrowth.¹⁹ A cost-effectiveness analysis from the Netherlands found that laser tonsillotomy had a reasonable probability of being cost-effective compared with full tonsillectomy, largely because of lower productivity losses (less time off work for parents, faster return to school for children).²⁰

How Adult Tonsillectomy Differs

In adults, the indication profile is nearly reversed from the pediatric pattern. Chronic or recurrent infection remains the most common reason for adult tonsillectomy, whereas sleep-disordered breathing dominates in children.²¹ Adults are also more likely to be referred for surgery because of tonsil stones, chronic bad breath related to tonsillar crypts, or suspicion of malignancy in an asymmetrically enlarged tonsil. The recovery is harder, the bleeding risk is substantially higher as noted above, and the time off work can stretch to two weeks. All of this means that surgeons generally want a strong justification before recommending the procedure to anyone past adolescence.

A large UK trial in adults with recurrent tonsillitis found that tonsillectomy was modestly more effective than conservative management and was likely cost-effective, with an estimated cost per quality-adjusted life-year gained of about £4,100. When participants’ own costs, like time off work and travel to appointments, were included, tonsillectomy actually came out less expensive overall.²² For adults who are genuinely suffering through repeated debilitating infections, surgery still makes sense. But a lot of adults who wonder whether they should get their tonsils out are dealing with mild, infrequent episodes that the evidence suggests will improve on their own.

Why Rates Vary So Much by Region and Background

Tonsillectomy rates are not driven purely by clinical need. They vary enormously by geography, race, insurance status, and socioeconomic factors in ways that reveal how much physician culture and access influence the decision. In the U.S., tonsillectomy utilization is consistently higher among white children than among Black or Hispanic children, higher among publicly insured children than privately insured ones, and higher in rural areas than in cities.²³ An Australian study found a more than tenfold difference in tonsillectomy rates across different areas of the same state, with higher rates in regional communities and lower rates where English-language proficiency was limited.²⁴

In Spain, tonsillectomy combined with adenoidectomy rates actually increased between 2003 and 2015, driven mainly by a rise in procedures for younger children, reflecting the global shift toward sleep-disordered breathing as the primary indication.²⁵ The persistent geographic variation suggests that the decision to operate is still partly a matter of local medical tradition rather than pure clinical science. Two children with identical symptoms may face different recommendations depending on where they live and who their doctor is.

Navigating the Decision as a Parent

If your child has been referred for a tonsillectomy, you are not facing a binary choice between an outdated surgery and doing nothing. You are facing a nuanced judgment call that depends on the specific indication, the severity of symptoms, and your child’s individual circumstances. For sleep-disordered breathing, especially when confirmed by an overnight sleep study, the evidence for surgery is strong. Guidelines recommend that children with complex medical conditions like obesity or Down syndrome be evaluated with a formal sleep study before proceeding, and some guidelines suggest sleep studies even for otherwise healthy children when the diagnosis is uncertain.²⁶

For recurrent infections, asking how many episodes are documented, how severe they were, and whether they meet established criteria is a reasonable starting point. Research on parental decision-making consistently finds that many parents arrive at the consultation already expecting surgery will be recommended and are not fully aware of the option to wait. Shared decision-making, where the surgeon lays out the trade-offs and parents weigh in based on their values and their child’s experience, leads to lower decisional conflict and more satisfaction regardless of which path the family chooses.²⁷ Some parents feel more comfortable knowing the surgeon is the expert and want a clear recommendation; others want to weigh the data themselves. Both approaches are valid, but the research suggests outcomes improve when parents at least understand that a choice exists.²⁸

What Happens to Throat Bacteria After Surgery

One concern that occasionally comes up is whether removing tonsils disrupts the microbial community in the throat in harmful ways. The answer appears to be: modestly, but without dramatic consequences. A meta-analysis of bacterial cultures taken before and after pediatric tonsillectomy found significant drops in several potentially pathogenic species, including group A strep and Haemophilus influenzae, while nonpathogenic respiratory flora stayed the same or increased slightly.²⁹ One study found a significant decrease in a major anaerobic bacterium, Bacteroides fragilis, and an increase in Propionibacterium acnes, though normal aerobic flora did not change meaningfully.³⁰ A separate study looking at periodontal bacteria on the tongue and in gum pockets found no relevant changes after tonsillectomy.³¹

In short, removing tonsils does alter the local bacterial landscape, but the shift seems to go in a generally benign direction, with fewer disease-causing organisms rather than more. This is reassuring for people who have already had the surgery, though it does not change the fundamental question of whether the surgery was needed in the first place.