Acute tonsillitis - red and swollen tonsils.
Key:
t = tonsil
u = uvula

Adenoids seen through a nasal endoscope

Adenoidal child. Typical facial appearance, mouth breathing. The back of the nose is blocked by large adenoids.

Why remove the tonsils and adenoids?

Although the tonsils and adenoids, when healthy, do help fight infections, sometimes they cause much more trouble than they are worth.

• Infected tonsils can be very painful, especially on swallowing.
• Sufferers go off their food, some children fail to grow.
• Time is lost from school or work.
• Very high temperatures cause fits in some children.
• An abscess (quinsy) can form which needs emergency hospital admission.
• Very large tonsils can obstruct breathing at night.
• Bad breath can be caused by decomposing food and bacteria trapped in the deep folds of the tonsils.
• If the adenoids get too big, they cause blockage of the nose and Eustachian tube, resulting in glue ear.
• Some tonsils are chronically infected, causing constant sore throat.

If the tonsils are frequently or chronically infected, they are no longer working properly. In fact, they have been "subverted" by the enemy bacteria, acting as reservoirs for infection.

• There is plenty of other lymphoid tissue in the throat which takes over the work of the tonsils and adenoids if they are removed.
• It is not true that removing the tonsils and adenoids makes you more likely to get chest or stomach infections.

What can be done apart from surgery?

Tonsillitis can get better on its own. Simple treatment with

• rest
• plenty of fluids
• painkillers
• such as paracetamol or aspirin (not aspirin for children under 12 years) may be sufficient.

More severe infections can be treated with antibiotics. To prevent attacks, ensure

• a healthy balanced diet
• regular exercise
• plenty of fresh air
• Do not smoke
• do not expose children to passive smoking.
• If your child is a fussy eater, give multivitamin supplements.
• Encourage oral hygiene restrict sweets, and brush teeth at least twice daily.
• Insist on sensible bed times - lack of sleep can depress the immune system.

Many children go through a phase of repeated attacks of tonsillitis, especially when they start school and become exposed to a greater variety of viruses and bacteria. I usually recommend waiting at least a year or two, to see if the attacks will stop. A further bout of repeated attacks of tonsillitis is common in the teenage years, often following glandular fever. Again, it is sensible to wait and see for at least a year, to see if they will settle down. On the other hand, this is an important time at school for study and examinations. If it seems likely that the attacks will continue and disrupt education, operation may be the best solution.

Tonsils removed - yellow spots are crypt debris

Crypt debris from the tonsils comprising dead layers of shed skin, trapped decomposing food, bacteria and other micro-organisms. This debris provides a sheltered home for germs, forming biofilms.Antibiotics don't penetrate into the crypt debris. Germs living in a biofilm state are resistant to antibiotics.

Biofilm in a tonsil crypt as seen under the microscope.

What is the success rate of surgery?

• Removing the tonsils is completely effective in stopping tonsillitis.
• But you can still get ordinary sore throats. They will not be as bad as tonsillitis.
• Removing the adenoids is very effective at restoring the ability to breathe through the nose, unless it is blocked for some other reason e.g. allergy or sinusitis.
• Adenoidectomy is about 70% effective in treating glue ear, but the beneficial effect takes several months to develop.

What are the risks of surgery?

Tonsillectomy and adenoidectomy are very safe procedures in modern medical practice. But no operation is totally risk free.

• At worst, you could die or suffer brain damage - but you are more likely to be injured in a road accident. A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment.
• There is a risk of excessive bleeding, either during or up to two weeks after the operation.
• About 2% of patients may need a second operation to control bleeding, readmission to hospital, or a blood transfusion.
• Most serious bleeds happen in the first few hours after operation.
• During this recovery period, trained nurses will monitor your condition carefully.
• There is a risk of picking up an infection in the recovery period. Infection is more likely if you don't eat and drink properly. That is why you should make sure you take painkillers half an hour before meals, so that it won't be too sore to swallow.
• If you do get an infection, you may get some further bleeding and might need antibiotics, or you might need to be re-admitted to hospital for treatment.
• Your voice will change character after removing the tonsils or adenoids, ususally for the better, but some might not like it.
• There may be some numbness of the tongue or side of the mouth. This will normally be temporary, occasionally it is permanent.
• There may be some change in the sense of taste. This will normally be temporary, occasionally it is permanent.

Is the operation more dangerous in adults?

No. Tonsillectomy is relatively safe at any age, but it is more painful in adults and teenagers than in young children. There are no absolute age limits. The youngest patient I have operated on was six months, for breathing obstruction. The oldest was 93, for cancer of the tonsils.

Position for removal of tonsils and adenoids under general anaesthetic

How is the operation done?

Tonsils and adenoids are removed under general anaesthetic (fully asleep) in the operating theatre. The anaesthetist usually sends you to sleep by giving an injection. The drug injected acts very rapidly, within a few seconds. To stop the needle from hurting children, the ward nurse puts special cream on the back of the hand. It numbs the skin, so the needle doesn't hurt. Sometimes, if a vein can't be found or the child is too frightened, we send you to sleep with gas. This may take several minutes to work. Once you are asleep, the anaesthetist puts a plastic tube in your mouth. It goes to the trachea (windpipe) so that you can breathe during the operation. A special gag holds the mouth wide open. Both tonsils and adenoids are removed through the mouth. There is no external cut. Any excessive bleeding is controlled by a combination of pressure swabs, diathermy (electric cautery) and stitches. If you do need stitches, they will be self-dissolving. They will not need to be removed.

 A sore throat is pain, scratchiness or irritation of the throat that often worsens when you swallow.

A sore throat is the primary symptom of pharyngitis — inflammation of the pharynx, or throat. But the terms "sore throat" and "pharyngitis" are often used interchangeably.

The most common cause of a sore throat is a viral infection, such as a cold or the flu. A sore throat caused by a virus usually resolves on its own with at-home care. A bacterial infection, a less common cause of sore throat, requires additional treatment with antibiotic drugs.

Other less common causes of sore throat may require more complex treatment.

• Red, swollen tonsils
• White or yellow coating or patches on the tonsils
• Sore throat
• Difficult or painful swallowing
• Fever
• Enlarged, tender glands (lymph nodes) in the neck
• A scratchy, muffled or throaty voice
• Bad breath
• Stomachache, particularly in younger children
• Stiff neck
• Headache

• Drooling due to difficult or painful swallowing
• Refusal to eat
• Unusual fussiness

• A sore throat that doesn't go away with the first drink or two in the morning
• Painful or difficult swallowing
• Extreme weakness, fatigue or fussiness

• Has difficulty breathing
• Has extreme difficulty swallowing
• Is drooling

 At-home care

• Encourage rest. Encourage your child to get plenty of sleep and to rest his or her voice.
• Provide adequate fluids. Give your child plenty of water to keep the throat moist and prevent dehydration.
• Provide comforting foods and beverage. Warm liquids — broth, caffeine-free tea or warm water with honey — and cold treats like ice pops can soothe a sore throat.
• Prepare a saltwater gargle. If your child can gargle, a saltwater gargle of 1 teaspoon (5 milliliters) of table salt to 8 ounces (237 milliliters) of warm water can help soothe a sore throat. Have your child gargle the solution and then spit it out.
• Humidify the air. Use a cool-air humidifier to eliminate dry air that may further irritate a sore throat, or sit with your child for several minutes in a steamy bathroom.
• Offer lozenges. Children older than age 4 can suck on lozenges to relieve a sore throat.
• Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat.
• Treat pain and fever. Talk to your doctor about using ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others) to minimize throat pain and control a fever. Aspirin has been linked with Reye's syndrome, so use caution when giving aspirin to children or teenagers. Though aspirin is approved for use in children older than age 2, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. Talk to your doctor if you have concerns.

• More than six episodes in one year
• More than four episodes a year over two years
• More than three episodes a year over three years

• Obstructed sleep apnea
• Breathing difficulty
• A peritonsillar abscess that doesn't improve with antibiotic treatment