Tonsils & tonsillectomy
What are tonsils?
The tonsils are the two irregularly shaped, roundish structures at the back of the throat on a bed of muscle, one on either side. They are made of lymphoid tissue and are part of the immune system.
Do they have a function?
Because of their position at the back of the throat, tonsils are one of the first areas to be exposed to viruses and bacteria that might be inhaled in during breathing, or swallowed. They then send signals to the rest of the immune system to initiate a response to potential infection. In this way, the immune system matures and can prepare itself for similar infections more quickly and efficiently in the future (adenoids at the back of the nose function in a similar way). As very young children such as toddlers are being exposed to various viruses and bacteria for the first time (especially when they start daycare where they are exposed to more bugs), their tonsils are often much larger than in other age groups, but as the child’s immune system matures, tonsils tend to get smaller as the child gets older. Tonsils are not thought to have much function in children past the age of 2 or 3 and removing them makes no difference to a child’s long term immunity or ability to fight infection.
What kind of problems can tonsils cause?
Tonsils may be problematic when they are enlarged and therefore mainly give problems in young children as they are the age group most likely to have enlarged tonsils for reasons explained above. Enlarged tonsils may result in sleep disturbance in the form of snoring or sleep apnoea. Tonsils can also be affected by recurrent tonsillitis, quinsy and tonsilloliths. Read more about each of these conditions on their relevant pages in this website.
When should the tonsils be removed?
Removal of the tonsils (tonsillectomy) is considered in the following circumstances:
For recurrent tonsillitis (read more about when tonsillectomy is required for tonsillitis here)
In patients who have had 2 or more episodes of quinsy
In patients with tonsilloliths (tonsil stones that cause chronic sore throats and halitosis)
Mr Trinidade can discuss with you whether tonsillectomy is right for you or your child.
How is an tonsillectomy performed?
Tonsillectomy is performed under general anaesthetic, usually as a day case procedure, with you or your child being allowed home the same day, but overnight admission in hospital may sometimes be required in those who have other medical problems, or who live more than 30 minutes from the hospital. The procedure lasts about 20 to 30 minutes.
The tonsils are removed through the mouth. They are removed either using the “cold steel” method, in which steel instruments are used to remove the tonsils and sutures are used to tie off the blood vessels. Bipolar electrocautery can also be used, in which a pair of electric forceps is used instead of steel instruments to cauterize (burn) the tonsils out and simultaneously stop bleeding with further cautery. Both cold steel and electrocautery methods are equally as effective and often both are used at the same time, with cold steel methods used to remove the tonsils and a combination of sutures and electrocautery used to control the bleeding. Mr Trinidade uses both methods.
What are the risks of tonsillectomy?
Tonsillectomy is a commonly performed procedure in children and less commonly in adults. The majority are performed risk-free. However, there are some risks to be aware of. The main risk of tonsillectomy is a small risk of bleeding post-operatively. If this occurs, it is often light bleeding but can sometimes be heavy and require further surgery to stop the bleeding. A clotting disorder or a family history of one can increase the risk of bleeding. The risk of bleeding is about 1 to 2% using the cold steel method and slightly higher at 3 to 5% using the electrocautery method.
Teeth can sometimes be chipped or knocked loose during instrumentation of the mouth. Usually these teeth are already loose (milk teeth or teeth with cavities). Rarely they can be inhaled into the lungs after being knocked loose and an additional procedure (a bronchoscopy) needs to be performed to retrieve the lost tooth.
Burns or cuts to the lips or around the mouth can sometimes occur during tonsillectomy, but these are usually minor and quickly heal.
Some people can experience a disturbance of taste following tonsillectomy. This is due to injury of a nerve that supplies the back of the tongue and which runs near the lower part of the tonsil (known as the lingual tonsillar branch of the glossopharyngeal nerve). Symptoms are usually temporary but may take several months to settle.
What is the post-operative care following tonsillectomy?
Tonsillectomy is a painful procedure and throat pain will be experienced for a few days, which is usually controlled with paracetamol and ibuprofen. Sometimes stronger pain medicine is required. Many people also experience referred pain to the ears after tonsillectomy as the nerves that supply sensation to the tonsils also supply the ears. It is advisable to take pain medicine regularly as prescribed for the first several days after surgery instead of only taking it when you feel pain. This will allow you to get back to a regular diet as soon as possible. A numbing throat spray such as Difflam can also help to ease symptoms.
There may be a period of halitosis (bad breath) for a few days due to dead tissue called slough (pronounced sluff) at the back of the throat. This slough will cause the back of the throat to look white in colour during the early healing phase. This is normal and should not be taken as a sign of infection. A normal diet and normal activities should be resumed as soon as possible after the operation (usually 1 to 2 days). A normal diet helps to remove the slough at a faster rate than only eating soft foods like jelly and ice cream. This can help to prevent infection than can cause bleeding.
Some bleeding mixed with saliva is not uncommon after tonsillectomy and quickly settles after the first day following surgery. Patients and parents should observe for any signs of heavier bleeding, however, which usually presents as bleeding from the mouth. Sometimes, bleeding occurs as a slow drip down the back of the throat that is swallowed over time and then vomited up all at once. The vomit has the appearance of coffee grounds and represents digested blood. In all of cases of heavy bleeding, you should go immediately to the nearest A&E Department for stabilization, assessment and management by the ENT surgeon on call. Call an ambulance if necessary. You should not eat or drink as you may need to be taken to the operating room urgently to have the bleeding stopped. Most cases of problematic bleeding will settle on their own with only observation and intravenous antibiotics and fluids, however. Bleeding can occur at any time up to about 10 days following tonsillectomy. Bleeding in the first 48 hours following surgery is usually due to a burst blood vessel or a slipped suture at the back of the throat. After this time, bleeding is most likely to be due to an infection.
Most cases of tonsillectomy recover with no issue after 5 to 7 days with most people returning to school or work after 2 weeks.
This picture shows the back of the throat at 2 days following tonsillectomy. The uvula in the middle is slightly swollen. White slough can be seen at the back of the throat and is normal for up to 5 to 7 days following surgery.