Tonsil talk: 5 questions with a pediatric ENT

They’re supposed to protect the body from infection, but tonsils can sometimes be a real pain in the neck. So how do you know when your child’s tonsils should be removed? Ear, nose and throat specialist Dr. Ghedak Ansari answers our questions about tonsillectomies.

What are the signs a child may need to get their tonsils out?

Tonsils are a type of normal lymphoid tissue, which means they play a role in immunity and protecting our body from infection. However, sometimes they can get too big and cause issues with obstruction, meaning when we lie on our backs, the air can’t get to the lungs easily since the tonsils are in the way. In these cases of obstruction, we’re concerned that breathing is limited and not enough oxygen gets to the brain. This can have long term implications on a person’s behavior and development.

With this obstruction, sleep apnea can develop and lead to other symptoms like bedwetting, attention deficit or hyperactivity, and over time it can even cause issues with the heart and brain. Usually, kids who are at risk for sleep apnea due to large tonsils (and/or adenoids) develop snoring as the first symptom, and parents may notice that they don’t get restful sleep, are waking up tired or have a lot of daytime sleepiness. We can confirm sleep apnea with a sleep study, but if most of the symptoms are present, we usually don’t need a sleep study to confirm the diagnosis.

Another reason for a tonsillectomy is recurrent tonsillitis. Tonsillitis is infection of the tonsils, usually due to strep, but it can result from any bacteria or virus. Other conditions such as halitosis (bad breath), tonsilloliths (tonsil stones), speech delays or oropharyngeal dysphagia (issues with feeding or swallowing) can also lead us to consider a tonsillectomy.

Can you explain more about tonsillitis?

The purpose of tonsils is to protect you from germs and viruses that enter the mouth, which means there is a high risk of infection, swelling and irritation when you’re sick. They do most of their work before and during puberty, which is why adults don’t usually suffer from tonsillitis. The tonsils are also cryptic, meaning they have lots of places where bacteria and germs can hide and cause issues, and sometimes bad breath.

Tonsils (and adenoids) tend to increase in size like all lymphoid tissue, until age 5 or 6, then they slowly decrease in size, reaching their adult size around 13-14 years of age. This is another reason adults don’t have as many infections as kids. We recommend tonsils be removed if your child suffers from frequent tonsillitis, if it doesn’t get better with antibiotics, or if there are complications of tonsillitis (such as a peritonsillar abscess). The procedure, called a tonsillectomy, is fairly common with more than half a million performed in the U.S. every year.

What does a tonsillectomy entail?

A tonsillectomy is usually an outpatient procedure, performed under general anesthesia, often in conjunction with removing adenoids. Adenoids are also lymphoid tissue but they’re all the way in the back of the nose. We would need to place scope (camera) through the nose to see them. They act similarly to tonsils, and so are usually removed at the same time as tonsils to avoid multiple surgeries.

The actual surgery only takes about half an hour, but the recovery time usually takes 2 weeks for children – 1 week off from school, and another week of no activity. Depending on the child’s age and other risk factors, we may recommend staying the night for observation.

What are the risks of a tonsillectomy?

Tonsillectomy is one of the most commonly performed surgeries, but any surgery comes with risks. With tonsil removal, there is a small risk of bleeding (2-5% in children, which increases with age and number of infections), infection and pain, as well as longer-term effects like a change in voice or taste. Dehydration is also a concern because it can be difficult to swallow after a tonsillectomy, but this is usually short term.

There are also many different ways to do a tonsillectomy. In more recent years, coblation, or partial tonsillotomies have become more common. This is a different way of removing the tonsils that shaves them down instead of fully removing them. It comes with a much lower risk of bleeding and pain, but with a slightly higher risk of regrowth (although this has recently been shown to also be very rare).

Why is it encouraged to get tonsils out before adulthood?

The recovery time is longer in adults, sometimes taking 10-14 days and the risk for severe pain may be higher. The bleeding risk is also higher in adults. At any age, seek immediate medical attention if you experience increasing fever, persistent bleeding or difficulty drinking fluids. We also recommend getting tonsils taken out before adulthood to avoid complications of tonsil infections and sleep apnea.