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Tonsillectomy

 

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.

 

Tonsillectomy surgery

 

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.

There are different ways of doing the surgery. For the most part, the surgical tool that the surgeon uses doesn't matter much. Actually, evidence shows that the "old fashioned" method with scissors and stitches is in fact excellent. People often read about new methods and ask about lasers, but lasers are not as good for tonsillectomy as the scissors method. 

Tonsillectomy versus tonsillotomy

 

You may also read about tonsillectomy or complete tonsillectomy, as opposed to partial tonsillectomy (also known as intracapsular tonsillectomy or tonsillotomy).  Both methods are widely used, although in the UK total tonsillectomy is the predominant method. The surgeon performing tonsillotomy often uses an instrument called coblator to do the surgery.

Tonsillotomy leaves a tiny area of tonsil tissue behind, which protects the area where the surgery was. This makes it less painful than a total tonsillectomy, with children usually pain free a couple of days earlier. The risk of bleeding is also less. However, because the tonsil wasn't removed completely, there is a risk that problems may come back, tonsils could regrow and recurrent tonsillitis start again. Although the risk of recurrent symptoms is there, in practice probably only about 2 or 3 out of 100 patients will need repeat surgery.

Some children are only suitable for one method or the other, in which case your surgeon probably won't even discuss choices with you. If your surgeon / hospital offers both methods and your child is suitable, the doctor may well discuss the two options with you and ask you for your preferences. Remember that both methods are tried and tested, both are good, and there is no right or wrong answer, just some parents want one or the other for whatever reason. If you have a preference, do talk to your surgeon about it.

Tonsillectomy risks

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.

Section contributor:

Quentin Bounduelle MRCS DOHNS

Core Surgery Doctor