The perception that tonsillectomies are no longer performed is a common misconception, stemming from a dramatic shift in medical practice over the past several decades. While the procedure is far less routine than it was in the mid-20th century, it remains a common surgical intervention today, particularly for children. This change reflects a move toward evidence-based medicine, where surgery is reserved for specific, medically necessary criteria rather than being used as a common preventative measure. Understanding the tonsils’ function and the reasons for this medical shift clarifies why removal is now a selective decision.
What Tonsils Actually Do
Tonsils are active components of the immune system, classified as lymphoid tissue. They are strategically located at the entrance of the respiratory and digestive tracts, forming part of a defensive ring known as Waldeyer’s ring. Their primary function is to act as immunological sentinels, trapping inhaled or ingested pathogens like bacteria and viruses.
The tissue contains specialized immune cells, including B cells and T cells, which initiate an immune response. B cells mature and produce immunoglobulins, especially secretory IgA, a key antibody for mucosal immunity. This localized defense mechanism helps the body develop immunity and memory against common microbes, particularly during a child’s early years.
The Shift in Medical Practice
In the early to mid-20th century, tonsillectomies were performed frequently, peaking around 1.4 million procedures in the United States in 1959. This practice was influenced by the “focal infection theory,” which suggested that chronic infections in the tonsils could spread to cause systemic diseases. Since antibiotics were less available or effective then, physicians often viewed the tonsils as a primary source of recurring illness.
The dramatic decline in routine surgery began when researchers questioned the procedure’s benefit compared to its risks. Studies showed that high rates of tonsillectomy did not correlate with lower rates of childhood illness, suggesting the surgery was often unnecessary. A major turning point occurred in the late 1970s when a National Institutes of Health panel concluded there was insufficient evidence to support preemptive tonsillectomy.
This shift established the principle of evidence-based medicine, recognizing the tonsils’ immune function and the inherent risks of general anesthesia and surgery. Medical guidelines narrowed significantly, restricting the procedure to cases where the benefits clearly outweighed the risks. Today, tonsillectomy rates are significantly lower, reflecting a more cautious, selective approach.
When Tonsillectomy Is Still Necessary
Modern surgical guidelines strictly define when tonsil removal is appropriate, focusing on two main categories: recurrent, severe infection and upper airway obstruction.
Recurrent Infection Criteria
For recurrent infections, the criteria are specific regarding the frequency of documented tonsillitis episodes. Surgery is typically considered if a patient has experienced:
Seven or more episodes in the preceding year.
Five or more per year for two consecutive years.
Three or more per year for three consecutive years.
These episodes must be fully documented, often requiring the presence of several symptoms:
- A sore throat.
- Fever above 38.3°C.
- Tonsillar exudate.
- A positive test for Group A beta-hemolytic streptococcus.
Upper Airway Obstruction
The second, and now most common, indication is upper airway obstruction, often resulting from enlarged tonsils causing Obstructive Sleep Apnea (OSA). In children, enlarged tonsils and adenoids can block the airway during sleep, leading to loud snoring, gasping, and interrupted breathing. Removal is highly effective in treating OSA in children and is also considered for adults with tonsillar hypertrophy causing significant breathing difficulty during sleep. Other serious indications include a recurring peritonsillar abscess or a highly asymmetrical tonsil, which raises concern for malignancy.
Non-Surgical Management Strategies
Since most tonsil-related issues are managed conservatively, non-surgical strategies are the first line of defense when strict surgical criteria are not met. For acute tonsillitis, which is frequently viral, supportive care is the primary treatment. This includes rest, adequate fluid intake, and pain relievers like acetaminophen or ibuprofen for symptom control.
When the infection is bacterial, targeted antibiotic therapy is used, typically penicillin. Watchful waiting is often employed for recurrent infections that do not meet frequency guidelines, as tonsil issues can resolve spontaneously as a child ages. Managing underlying conditions, such as chronic inflammation or allergies, can sometimes reduce tonsil size and relieve symptoms without surgery.