What do tonsils do and why would we take them out?

There are some important new recommendations about tonsillectomy — taking out the tonsils — as a treatment for recurrent strep throats.

Some of us can recall a time when getting your tonsils out was one of the rites of passage of childhood. Usually a related procedure is added — an adenoidectomy, removing the adenoids as well. It’s called a T&A in the medical world, and it’s one of the most common surgical procedures done on children.

Where are the tonsils, what do they do, and why would we take them out? The tonsils are at the back of the throat, one on either side. If they haven’t been removed, you can see them peeking at you when you open your mouth wide and look in the mirror. Both are part of your immune system, similar to lymph nodes (the “glands” you can feel at the front of your neck). As part of the immune system, the tonsils fight infection; they are first line of defense in the throat, and when they are doing their job fighting infections, you get a sore throat. The tonsils usually swell a bit and get red when that’s happening.

The connection between tonsils doing their job and strep throats is that a common cause of tonsillitis in children is a strep infection. Before we had antibiotics, removing the tonsils was one way to combat recurrent strep infections. As soon as penicillin, one of the first antibiotics, came along, though, we instantly had an effective nonsurgical treatment for strep tonsillitis. Nearly all of the time it works, primarily because the strep bacteria has maintained its sensitivity to penicillin — we haven’t seen the antibiotic resistance that bedevils our ability to treat other bacterial infections.

But children do get a lot of strep infections, and some children have recurrent strep, sometimes multiple times each winter. For those children, doctors often recommended taking the tonsils out. Before I went into critical care, I first trained and practiced as a pediatric infectious disease specialist, and I was consulted many times about such children. My bias was nearly always against tonsillectomy. My reason, shared by most infectious disease experts, was that we have effective antibiotics to treat strep. Why risk the surgery?

A key point is that recurrent strep tonsillitis nearly always gets better with age no matter what we do. This makes tonsillectomy look good, because the natural history of the illness is to improve. I’ve met dozens of parents who say their child (or themselves as children) had constant strep infections until the tonsils came out. Often these same parents (and especially their grandparents) had had their tonsils out as children and more or less regarded tonsillectomy as something children need, like vaccinations. But frequent courses of penicillin, one of the safest medications on the planet (if your child is not allergic to it, of course), nearly always ultimately lead to the same favorable result as the tonsillectomy. (If your child is allergic to penicillin, we have other safe options.)

The important thing to remember is that tonsillectomy, like any surgery, is not without risk. It’s not just a routine thing like getting a vaccine shot. Compared with other surgical procedures the risk is low, but it is not zero. There are risks of bleeding afterward, sometimes life-threatening, and there are other risks associated with the anesthesia needed. Every year I see at least one child in the PICU who has suffered a complication from a tonsillectomy.

There still is a place for tonsillectomy for some cases of strep. Abscesses around the tonsils are one example. Tonsillectomy can also be very helpful for persons whose tonsils are so large that they block the airway, especially when they sleep (a condition called sleep apnea). But for the bulk of children with recurrent strep throats, it’s generally best to wait it out, treating each infection with antibiotics.

With everything we do in medicine, it’s important to weigh the benefit of the treatment against its risks: for recurrent strep tonsillitis, most of the time the calculus favors antibiotics. The importance of these new guidelines is that such a viewpoint is now the standard one.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • Anonymous

    I was a victim of wait-and-see and was unable to persuade 2 out of 3 doctors that my tonsils were abscessed and needed to come out. Doctor #3 agreed but unfortunately had the least experience. Having your tonsils dissected out by a neophyte at age 22 is no joke. Please listen to your teenaged patients – they aren’t so dumb.

  • http://twitter.com/ChrisJohnsonMD Christopher Johnson

    Abscesses are definitely one of the reasons for tonsillectomy.

  • http://twitter.com/ChrisJohnsonMD Christopher Johnson

    Abscesses are definitely one of the reasons for tonsillectomy.

  • http://www.facebook.com/DoctorStevenPark Steven Park

    These are statistics cited by David Newman in his book, Hippocrates’ Shadow: What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach:

    Another commonly cited reason for treating strep throat is to prevent rheumatic fever. Now that rheumatic fever is almost nonexistent, it’s estimated that you need to treat 1 million people with strep throat to prevent one case of rheumatic fever. What most doctors don’t realize is that every time you give antibiotics, you have a 10% chance of developing a rash, 10% chance of having diarrhea, and 10% of of suffering from a yeast infection. That’s potentially 300,000 complications. Furthermore, 0.24% of people will suffer a potentially life-threatening allergic reaction, and of these, about 1 out of every 10 will die (240 people). What’s worse, only about 1/3 of people with rheumatic fever will develop long-term heart disease. So you’ll have to treat 3 million people with antibiotics to prevent one case of heart disease. That means 900,000 people will suffer complications and about 720 people may die. Ten million antibiotics are prescribed in this country every year for throat infections.

    I’m not sure about the number of people who die as a result of tonsillectomies, but it’s likely to be a far lower number than that due to anaphylactic reactions from antibiotic use.

    It’s also been shown that when antibiotics are given for sore throat (the most common indication), strep is the cause in only 30% of children and 10% of teens. You can argue the validity of these numbers, but I think everyone will agree that antibiotics are severely overused. 

    http://doctorstevenpark.com

  • http://twitter.com/MartinYoung Martin Young

    This post irritates me.  Perhaps it is because the title makes it appear as if the post addresses all reasons for doing tonsillectomies, and the outcome is that medical treatment is always better.  That may be an editorial decision rather than the author’s alone.

    For a start, the author asserts the adenoids and tonsils are the only lymph gland protections in the upper airways. Not true. There is a ring of protective lymph glands in the area, as many as 1000, known as Waldeyer’s ring.   Adenoids and tonsils are the three only problematic glands of that ring, and when removed, function goes on exactly as before.  So the assumption that people miss their adenoids and tonsils when they are gone is misleading.  The ONLY risks are those surrounding the immediate surgery and anaesthetic.  To my knowledge there are no other negative long term consequences.

    I cannot disagree with most of the comments and observations taken in isolation. It is true than surgery is never risk free.  Neither is medication.  But to say that medication is always a better option for recurrent streptococcal tonsilitis is to overlook the facts that most episodes of tonsilitis are viral, and respond without antibiotics, and that to know the difference the parent has to see a doctor with the child, have a test for streptococcal infection, wait for the results (may be immediate with a rooms based test kit) and then get the treatment.  Four, five, six times a year, this year, next year and the year after.  The broader economic costs are considerable, and medical treatment does not cure the condition. Adenotonsillectomy does.

    I also see many kids with ill-defined conditions like recurrent upper and lower respiratory tract conditions, sinusitis, recurrent glue ear, chronic suppurative otitis media, poor appetite, tummy ache, mouth breathing, snoring, and for many adenotonsillectomy is a good idea, even if absolute indications are lacking.

    Then there is chronic tonsillitis, due to tonsils with large crypts full of necrotic, bacteria filled debris for which there is no effective medical treatment.

    In all cases surgery should be a shared decision by parents and doctor, with full disclosure of the risks, benefits, costs and consequences.

    Sure, bad things follow tonsillectomy in very rare cases.  Tragedies happen. As they do with bicycles and roller skates. We doctors never forget them.

    But what bugs me most of all is that the author presents himself as an expert, not an ENT surgeon, and one who is unlikely to deal with these issues many times a day, day after day, year after year.  This is reminiscent of Dr Oz, cardiac surgeon, happy to present advice on colonoscopy, HRT, osteoporosis, etc, etc, without being the best person to do so. 

    As a regular medical blogger I hope I am never so presumptious.

    • http://twitter.com/ChrisJohnsonMD Christopher Johnson

      Yes, many, if not most sore throats are viral, not streptococcal — of course I was considering those proven to be streptococcal.

      You are concerned with my qualifications to give an opinion on this issue. As it happens, I am fellowship-trained in pediatric infectious diseases and practiced that subspecialty for many, many years before changing my practice to critical care. As an infectious disease practitioner, I was asked to consult on many, many children with recurrent streptococcal infections. So, in fact, I am an expert in the subject, but I expect I do address it from a different perspective than that of an ENT surgeon. Some of those children I sent to the surgeon, but most I did not. And of course this is a joint decision made with the parents.

      Thus I, as do most of my colleagues, argue for a fairly limited role for tonsillectomy in recurrent strep infection. The point of my post, my “presumptuous” opinion, is that this is now the mainstream.

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