The tonsils are lumps that lie at the back of the mouth. They are lymph-gland type tissue, and important in the immune function (fighting bugs). Tonsils shrink with age and become less important over time.
Tonsil removal (tonsillectomy) carries some risks, and removes tissue that the body uses. Because of that, we only take tonsils out if there is a good reason to. This may be because of repeated tonsillitis or sleep apnoea. Often, just waiting for symptoms to resolve is a reasonable alternative to surgery.
Before the operation
After the procedure your child’s mouth will be sore and they are initially more prone to infections. It is important to plan one or two weeks off school. It is very important to let the doctors know if you there are any bleeding conditions in the family. It is also very important to let the doctors know if your child develops a cold or a sore throat the week before the operation. The doctor may need to delay the surgery if so.
Your child will be asleep under general anaesthetic. The tonsils are removed through your child’s mouth. The operation lasts about 20 minutes. Your child may be able to go home on the day of the surgery, but your child will only go home if they can eat and drink and are well enough. Some children, especially younger ones or ones with sleep apnoea may need to stay in, usually just one night.
Intracapsular and extracapsular tonsillectomy
You may read about extracapsular tonsillectomy versus intracapsular tonsillectomy. They are two different ways to do a tonsillectomy and both are widely used in UK. If your child is having tonsillectomy for recurrent tonsillitis then I typically use extracapsular tonsillectomy, but if surgery is for sleep apnoea, then I typically use intracapsular tonsillectomy.
Intracapsular tonsillectomy means that the capsule of the tonsil is preserved, whereas in extracapsular tonsillectomy the capsule is removed. The capsule is the shell surrounding tonsil tissue. In both techniques, the tonsil tissue is removed, but intracapsular tonsillectomy preserves the shell whereas extracapsular tonsillectomy removes the shell also.
Intracapsular tonsillectomy is less painful, and children tend to be pain free a couple of days earlier than in extracapsular tonsillectomy. The risk of bleeding is also less in intracapsular tonsillectomy. Both techniques are equally effective in treating sleep apnoea. In both techniques tonsil tissue can grow back, and although this is more likely in intracapsular tonsillectomy, the overall risk of tonsil regrowth is small; only 2-3% of children will need surgery again after intracapsular tonsillectomy (as a comparison, a quarter of children need grommet surgery again within two years). I am happy to offer both intracapsular and extracapsular tonsillectomy to patients, but in my view the advantages of less bleeding and pain with intracapsular tonsillectomy outweigh the small increased tonsil regrowth rate.
Tonsillectomies are generally safe, but as with any surgery there are possible risks.
Bleeding: about 4 in 100 children will bleed after the operation. Rarely, this may mean needing a blood transfusion or having to go back to theatre to stop bleeding, but even if that is required usually everything is OK in the long run. If your child bleeds after the operation once you have gone home, immediately bring them to the Emergency Department. Bleeding can happen up to two weeks after surgery.
Pain: your child’s throat will be sore after the procedure. They may also have ear pain. It is important to have regular pain control medication (as advised by your hospital), particularly before eating. Eating normal food will reduce pain with time.
Tooth damage: please let us know if your child has any loose teeth, sometimes these can be dislodged or chipped by the equipment used to see the tonsils in the operation.
Lip damage: again, because surgery is through the mouth, sometimes bruising around the lips can occur
Infection: you will recognise this because of fever, bad breath or severe pain. If you are worried, make sure you seek help by calling your hospital ward, or seeing your GP, or coming to the Emergency Department. Don't be too worried about how the throat looks though, often it looks white and that doesn't mean that it is infected.
People often ask what will happen to the immune system if the tonsils are removed. On the whole, we would not expect any effects on the immune system. The tonsils are lymph glands, but the body has lots of other lymph glands that take over the function of the tonsils.
A recent research study published in 2018 has suggested that tonsillectomy is associated with development of respiratory, allergic and infectious disease in later life. Although this was a large study, it has been criticised by some. We also need to remember that just because tonsillectomy is associated with these problems, it doesn't mean that tonsillectomy caused them. The study serves as a useful reminder that surgery should never be undertaken unless it is the right option, when you and your medical team are sure that the benefits of surgery outweigh any of the risk.
After tonsillectomy surgery
Give regular pain control medications after the operation, as advised by the hospital. Pain usually lasts 1 or 2 weeks
Encourage your child to eat and drink normally as best as they can. Sometimes acidy or spicy foods can sting, so those can be avoided. But make sure that your child has some food that requires chewing and is a bit rough. The chewing helps the area recover, and the rough food particles help clean the slough from the operated area.
If there are any signs of bleeding after the operation: immediately come to Emergency Department.
Getting tonsillectomy on the NHS
Tonsillectomy is one of the procedures that is no longer routinely funded by the NHS, unless specific criteria are met. Exactly what is funded depends on your local Clinical Commissioning Group. Usually tonsillectomy is funded for recurrent tonsillitis, obstructive sleep apnoea, quinsy (abscess around the tonsils), and suspected cancer. However, usually tonsillectomy is not funded for tonsil stones.
To get tonsillectomy for recurrent tonsillitis, you will need to prove that your child has been having the required number of episodes of acute tonsillitis. Funding will be granted if there have been seven episodes in the last year, five episodes per year for each of the last two years, or three episodes per year for each of the last three years. The catch is having to prove that your child has had that many. In the past, surgeons used to take parent's word for it, but now it usually has to be written down in your GP medical records. Therefore, any episodes that occurred and you managed yourself at home will NOT count. To get the episodes logged, you need to make sure that you see your GP on each and every occasion! It sounds quite the opposite of the usual message that says don't see your GP unless you really have to. However, with tonsillitis if you don't see your GP, the episode isn't logged, and you therefore won't have a record of the number of episodes needed to get surgery funded.
Quentin Bounduelle MRCS DOHNS
Core Surgery Doctor