Tonsil Problems & Tonsillectomy (Tonsil Removal)
Tonsillectomy is one of the commonest procedures I perform. This article is about what the tonsils are; why and how they are removed; and how to prepare for surgery. I’ll also discuss recovery from a tonsillectomy and the risks and benefits of the operation.
The tonsils are lumps of tissue that sit on each side at the back of the throat. They are made of lymphoid tissue, are part of your immune system and play a role in fighting infection. They also help with the development of the immune system in the first one or two years of life. There are also 100-200 other lymph glands in the neck, lymphoid tissue at the back of the tongue and nose and in the lining of the nose and throat, so there is plenty of other lymphoid tissue if the tonsils are removed. The body also has many other clever ways of fighting infection.
Why are tonsils removed?
Tonsils are removed for a number of reasons:
Infection - The most common reason is infection. Many people have recurrent problems with tonsillitis several times a year. Tonsillitis causes a very sore throat or pain on swallowing (also called odynophagia) and is often associated with a fever of more than 38 degrees celsius. It can also cause a cough or headache, and it is quite common to have earache too, as the tonsil bed and ears share a nerve supply and you can have what is called a ‘referred’ pain. Tonsillitis usually settles after a few days but can last for a week or two.
Some people can develop problems with chronic tonsillitis, which is a sore throat that is present for longer periods of time, often with occasional flare-ups of acute tonsillitis.
Occasionally, an abscess, or collection of pus, can form around the tonsil. This is called a quinsy, or peritonsillar abscess, and usually requires drainage of the pus as an emergency.
When should you think about removing the tonsils? If you have had recurrent tonsillitis for one year only, and have had more than seven times in the last year; five times a year for the last two years; three times a year for three years or more, then you may want to consider having a tonsillectomy. If you have had more than one quinsy, then the chances are that it will happen again, so tonsillectomy should be considered.
You can still have sore throats after having your tonsils removed, but they are usually much less frequent.
Snoring and sleep apnoea - Large tonsils can cause the upper airway to become partially blocked when sleeping. This causes the soft tissues to vibrate, generating the sound of snoring. In extreme cases, the airway can become temporarily completely blocked, causing the person to stop breathing for a few seconds. This is a condition known as obstructive sleep apnoea or OSA. In children, large tonsils are often associated with large adenoids and can contribute to snoring and OSA. Adenoids can be removed at the same time as removing the tonsils.
Different sized (asymmetrical) tonsils - Most people have tonsils that are about equal in size. If one tonsil is obviously bigger than the other, it is sometimes advisable to remove the tonsils and send them for examination by a pathologist to identify why they are different in size. In the majority of cases, there is no cause for concern, and the difference is caused by infection or variant anatomy.
Less common reasons Occasionally tonsils can lead to bad breath (halitosis) due to food debris that becomes trapped in the tonsils. In some cases, tonsil stones (tonsilloliths) can form. These are like white or cream pieces of grit in the tonsils that can be uncomfortable. In particularly severe cases, the tonsils can be removed.
If the tonsils are very large, they can cause swallowing problems, and again, occasionally tonsillectomy can be required.
Preparing for tonsillectomy
Before having any operation, the healthier you are, the less likely you are to have problems both during and after your operation when recovering. There is an increasing trend for patients to prehabilitate before surgery, that is to say, to get themselves as fit as possible before having an operation. Whilst this isn’t always essential before a tonsillectomy, it can be helpful, Surgery has been compared to other physical activities, such as running. Like running, if you train and prepare you will do better, and an increasing number of studies have shown this to be the case. Optimising your physical fitness through exercise; a healthy diet; reducing alcohol consumption, and importantly stopping smoking will reduce the likelihood of problems both during and after surgery.
One issue that is important with tonsil removal, is infections. Ideally, tonsils are not removed when active infection is present, as this increases the risk of infection and bleeding following surgery. Optimising your health will reduce the likelihood of this occurring. If the tonsil infections are particularly frequent, a course of antibiotics can be prescribed in the run-up to surgery. If you do have tonsillitis, or a cold or chest infection, you should let the hospital know beforehand.
Before the operation, you will be seen by the preoperative assessment team, who will give advice on what to do before your operation. If you are taking any medicines that thin your blood, such as aspirin, you may need to stop them before surgery.
The operation is performed whilst you are asleep (under a general anaesthetic). You should not have anything to eat or drink for 6 hours before your operation. Your anaesthetist will be able to give you advice on the specific details, and often some water can be drunk for some time after this point. A lot of useful information about anaesthesia can be found on the website of the Royal College of Anaesthetists. I’ve put a link to the frequently asked questions section on this webpage.
How are tonsils removed?
As I have mentioned, the tonsils are removed whilst you are asleep under a general anaesthetic. There are many ways that tonsils can be removed. They can be removed using metal surgical instruments, often called a ‘cold steel tonsillectomy. Cautery or ties (small pieces of thread) can be used to stop bleeding during the procedure. Diathermy can be used to dissect the tonsils out, and with diathermy, an instrument, usually a pair of forceps (or tweezers), is used and an electric current is used to generate heat which destroys the tissue and coagulates the blood vessels at the same time. Lasers and ultrasound have also been used to removed tonsils, and occasionally what are called microdebriders are used. A microdebrider is a small tubular instrument that has a rotating cutting blade inside and suction is used to suck the tissue into the tube to be cut away. And sometimes a combination of techniques is used. But, an important distinction is whether an intra-capsular or extracapsular tonsillectomy is performed. So what is the difference between intra and extracapsular tonsil removal?
The tonsil has a fibrous capsule that separates it from the other tissues of the throat. In a traditional (extracapsular) tonsillectomy, the capsule of the tonsil is removed with the tonsil. With an intracapsular tonsillectomy, the tonsil capsule is left behind. Why does this matter? Larger blood vessels are located outside the tonsil capsule. They subdivide into much smaller blood vessels within the tonsil itself. This means that if an intracapsular tonsillectomy is performed, these larger blood vessels are not exposed in the same way, and the risk of heavy bleeding is significantly reduced, which has been confirmed in a number of studies comparing the two techniques. Research has also revealed that the intra-capsular technique is less painful to recover from. Intracapsular tonsillectomy is usually performed using coblation. This involves using a probe, or wand, that allows the tonsils to be carefully dissolved away at low temperatures (typically 40-60 degrees celsius). One small drawback of intra-capsular tonsillectomy is that small amounts of tonsil tissue are occasionally left behind. In about 2% of cases, this can regrow and require further surgery if it becomes problematic.
All of the surgery is performed through the mouth. There are no cuts or scars to the skin. The operation usually takes about 15 minutes to perform.
Most of the time, tonsils are removed as a day case procedure, that is to say, that patients will normally go home a few hours after the procedure. Very occasionally patients are kept in overnight for observation, usually if they have other medical problems or are particularly at risk of having complications from surgery.
What is the best way to remove tonsils?
The two principal problems that can occur after tonsillectomy are pain and bleeding. There is now a lot of evidence showing that intracapsular coblation tonsillectomy is associated with a shorter recovery time; a considerably reduced risk of bleeding; and less pain. For these reasons, intracapsular coblation tonsillectomy is my preferred technique in children. However, in adults, and some children, due to the extent of the scarring it is not always possible and an extracapsular approach is preferable.
Are there any alternatives to tonsillectomy?
Recurrent tonsillitis often improves with time, although this is difficult to predict and it can be a problem for many years. If the tonsillitis is relatively mild, you may wish to simply monitor the situation in the first instance. Tonsillitis is usually treated with over the counter painkillers (such as paracetamol and ibuprofen) as in most cases antibiotics don’t help the symptoms or shorten tonsillitis. In more severe or lengthy cases, a course of antibiotics may be prescribed.
What are the risks of tonsillectomy?
There are risks associated with any type of surgery. The risks of surgery need to be balanced against the risks of not doing surgery and the benefits of surgery. Tonsillectomy is a routine procedure, and it is unusual for problems to arise. More common and serious complications of tonsillectomy include:
Bleeding. About one in twenty (5%) of patients will have some bleeding after surgery. In most cases this is minor, but about one in a hundred (1%) will need a second trip to the operating theatre to stop the bleeding with an extracapsular tonsillectomy. Bleeding can occur up to two weeks after the operation and is usually caused by an infection. Bleeding requiring a trip to the operating theatre is less common in younger children, and very rare in children having a coblation intracapsular tonsillectomy. If you or your child has bleeding after tonsillectomy, you should attend your nearest Accident and Emergency department. Whilst most bleeding is managed without surgery, it is usual for patients to be admitted overnight for observation, where they will usually receive antibiotics and mouthwashes.
Infection. This can cause a worsening of the sore throat often with a fever.
Dehydration. Dehydration can occur following tonsil surgery, usually because of a sore throat. This is one of the reasons it is important to take regular painkillers for a week after surgery, and you should drink water regularly throughout the day. Being well-hydrated also helps reduce the pain following tonsillectomy.
In order to perform a tonsillectomy, the mouth is held open by a metal splint. As a result, it is not uncommon for people to have slight stiffness of the jaw joints, and in rare cases, the jaw joint (also known as the temporomandibular joint) can be dislocated, although this is almost always apparent straight after the operation has been performed and is treated then.
Injury to lips, tongue or teeth. This is unusual but occasionally occurs as both the anaesthetist and surgeon need to put instruments into the patient’s mouth. If you have loose, capped or crowned teeth you should let the surgeon and anaesthetist know before your operation, as damage to your teeth is more likely in this scenario.
Breathing difficulties very occasionally occur following tonsillectomy. It is rarely serious and most commonly occurs when tonsils are removed to treat severe obstructive sleep apnoea.
There are risks with a general anaesthetic. Modern anaesthetics are usually very safe. If you have other health problems, this can increase the risk of anaesthesia. The anaesthetist will discuss the risks of anaesthesia before your operation.
It is natural to focus on the risks of surgery, but it also important to remember the risks of not doing surgery. If you do not have your tonsils removed, there are other rare problems that can occur such as breathing difficulties, abscesses in the neck or in the lungs or rheumatic fever and other unusual complications of tonsillitis.
As with many activities in life, there is a very small risk of death following tonsillectomy. The risk of this happening is slightly less than the risk of being killed in a road traffic accident in a one year period in the United Kingdom.
Whilst it is natural to be concerned about the risks of surgery, it is also necessary to keep in mind the risks of not having surgery. For example, tonsil infections can be severe and spread to other parts of the body, and untreated snoring with obstructive sleep apnoea can give rise to problems with the circulation within the chest and heart. The question of whether or not to have surgery is to a large extent based around the balance of the risks and benefits of surgery, compared to the risks and benefits of not.
Longterm consequences of tonsillectomy
A common question I’m asked is ‘the tonsils are there for a reason, am I more likely to have coughs and colds, or is my immune system likely to be affected by having my tonsils removed?’. This is a good question, that is difficult to answer definitively, as the research that has conducted on this matter doesn’t give a clear answer. One large Dutch study has shown that children under the age of 9 who had their tonsils and adenoids removed were more likely to have respiratory or allergic problems, such as asthma, eczema and chest infections, in later life. However, it didn’t establish the direction of causation. It could be that surgery caused the increased risk, or alternatively it could be that children who had a tendency to these conditions were also more likely to have tonsil and adenoid problems requiring surgery. Another study has shown a 30% reduction in asthma flare-ups in children with asthma who have their tonsils removed. So the answer to this question is not clear.
What is recovery from tonsillectomy like?
Please click here to read more about recovery from tonsillectomy.
I hope this has been helpful, but please contact me if you need any further information.
How much does it cost to have your tonsils removed?
Please click here to read more about this.
Some useful information on tonsillitis and tonsillectomy can be found at the following links:
Links
Link for Royal College of Anaesthetists advice on anaesthesia
http://www.patient.co.uk/health/tonsillitis-leaflet
http://www.bupa.co.uk/health-information/directory/t/tonsillitis
https://www.entuk.org/sites/default/files/files/Adult%20Tonsil%20Surgery%20(09001).pdf
