What are tonsils, and what do tonsils do?

  • Tonsils are art of the lymphoid system, like lymph nodes in the throat
  • They are meant to be the first part of the immune response to things that we swallow.
  • When tonsils are diseased, and frequently infected they are part of the problem with the patient’s immunity, not part of the solution
Figure (above): Large inflamed tonsils

Figure (above): Large inflamed tonsils

What is tonsillitis?

  • Tonsillitis is a severe infections of the tonsils, usually caused by bacteria (streptococci). It can sometimes be caused by a virus (eg glandular fever).
  • The symptoms are:
    • Severe sore throat and trouble swallowing
    • Fever
    • Bad breath
    • Worsening of snoring
Figure (above): severely infected and enlarged tonsils

Figure (above): severely infected and enlarged tonsils

  • Patients  with severe recurrent tonsillitis are frequently unwell, requiring multiple trips to the local doctor, multiple courses of antibiotics and a lot of time off. 
  • There is major disruption in day to day life for families of kids with bad tonsillitis,  with parents needing to take time off work to care for sick children.

What can be done if tonsillitis is too frequent, or too severe?

  • When tonsillitis has been present for too long , and is occurring too often, removal of the tonsils (tonsillectomy) is like flicking a switch, stopping further infections, and dramatically improving quality of life.
  • Parents of children after tonsillectomy for tonsillitis will be able sleep well again!

How is tonsillitis diagnosed?

  • History
    • There is usually a clear history of ongoing, unmanageable throat infections/ tonsillitis
    • There may be a history of other ENT complaints including ear infections, hearing loss, snoring, nasal obstruction
  • Examination
    • at the time you see the ENT surgeon the tonsils may be normal.
    • Tonsillitis may be seen if the patient is unwell at the time of review
    • there may be evidence of other ent issues in a child such as
      • large tonsils causing snoring/ sleep apnoea
      • middle ear fluid or ear infection
      • blocked nose
      • enlarged adenoids
      • nasal allergy

  • Investigation
    • Investigation is usually not necessary as the history and examination gives enough information.
    • If there is uncertainty about the diagnosis, an arrangement may be made to catch up at short notice with a flare-up of symptoms, to confirm whether or not there is an issue with tonsillitis
Figure (above): severe tonsillitis in Epstein Barr Virus infection(glandular fever)

Figure (above): severe tonsillitis in Epstein Barr Virus infection(glandular fever)

What is tonsillectomy?

  • It is the surgical removal of the tonsils, undertaken for frequent infections, or blockage of breathing and snoring related to abnormal enlargement of the tonsils.
  • When infections have been going on for too long, are too frequent or too severe, it means that the tonsil is like a Trojan horse allowing the enemy (infection) to live within the body.
  • Every time the sufferer is run down, stressed or has a viral upper respiratory infection it becomes likely that there will be another severe attack of tonsillitis requiring time off, and a course (or more) of antibiotics.
  • When this level has been reached, tonsillectomy is the only treatment that will help.
  • This is one of the satisfying parts of medical practice where a cure is guaranteed.
  • The sufferer’s life will be dramatically improved.

What are the arrangements for tonsillectomy?

  • This is a procedure requiring general anaesthetic at one of the local hospitals.
  • The patient is admitted on the day of surgery, and will usually stay overnight.
  • 2 weeks are required off work, school, kindy or daycare.

How are the tonsils removed?

  • There are many different ways to remove the tonsils
  • Dr Smith uses a state–of-the-art technique - COBLATION/ DISSECTION
  • This reduces thermal energy applied during the operation, and has minimal blood loss
  • Reduced thermal energy will theoretically reduce postoperative pain

 

What is the Preparation for Surgery?

  • Once a decision for surgery is made, Dr Smith will provide appropriate printed information, we will watch appropriate video information discuss risks and benefits of treatment, and any question you may have will be answered.
  • Information about expected costs are provided by the staff at the front desk, and if you wish we will put you in touch with our anaesthetist for the day of surgery.
  • The hospital will be in touch the working day prior to admission, and give information on fasting times, where to park what to wear, what to bring and where and when to present at the hospital.
  • We understand that the decision for surgery is a big one, not to be undertaken lightly.
  • We should only proceed to surgery when you are completely comfortable that it is the correct decision

What are the Risks of tonsillectomy?

  • There is a small chance of bleeding (<2%) that may require readmission to hospital, and possible repeat surgery in the first 2 weeks.
  • There is a tiny (<0.1%) chance of bleeding requiring blood transfusion
  • Rarely in children, there may be a change in voice (hypernasality)
  • We will have a more detailed discussion at the time of booking surgery, and you will be given a printied information brochure on the surgery from the Royal Australian College of Surgeons.

What is the recovery like after tonsillectomy?

  • There can be significant pain requiring regular pain killers up to the 2 week mark.
  • Pain is usually more severe in the adult age-group, than in kids.
  • The pain often gets worse between day 5 to day 10, before starting to settle.

Kids’ pain control after tonsillectomy

  • Regular Paracetamol (following dosage for weight from bottle)
  • Regular Nurofen (following dosage for weight from bottle)
  • Occasionally stronger pain relief such as Oxycodone may be required

        Pain medication may be required regularly for up to 2 weeks

Adults’ pain control after tonsillectomy

  • Panadol 1g 4 X day regularly
  • Nurofen 200mg 3X day
  • Endone 5-10 mg as required, 4th hourly
    • It is likely to be a significant struggle for up to 2 weeks postoperatively
    • With all these medicines, constipation is quite common.
    • It is often worth speaking to the pharmacist about a gentle laxative to help with this problem (Sorbilax, Duphalac)
    • If pain control is not working, please call for advice as there is almost always something that can be done to help as an outpatient
    • In the most severe cases, readmission to hospital for further pain relief may be required

How long is needed off Work, School, Kindergarten or Daycare after Tonsillectomy?

  • 2 weeks off is routinely required
  • 3 weeks is required before return to full physical activity
  • Gentle exercise can recommence at 2 weeks, and gradually increase towards normal

How long is it before it is OK to fly after tonsillectomy?

  • Flying, or travel to remote areas should be avoided for 4 weeks after surgery

How much tonsillitis is too much?/

How bad does tonsillitis need to be to need tonsillectomy?

  • If there are more than 6 episodes of tonsillitis in a year, tonsillectomy may be considered
  • If tonsillitis has been going on for some years, fewer episodes per year may be enough to suggest the need for tonsillectomy.
  • The decision is made when the history up to that point has been bad enough, and with a high enough chance of continuing to justify the pain, inconvenience and risk of the procedure

What are the results after Tonsillectomy?

  • Tonsillectomy is curative in almost all cases for recurrent tonsillitis.
  • Very rarely a small amount of residual tonsil can grow back and cause problems down the track.
  • Tonsillectomy is one of the most successful modern operations.
  • Despite the difficult recovery, patients are almost always delighted with the long term results

Can the tonsils grow back after surgery?

  • With modern tonsillectomy techniques (such as Coblation/ dissection used by Dr Smith) regrowth of the tonsil is almost never seen.
  • Regrowth used to be relatively common with old-fashioned tonsillectomy techniques, where only part of the tonsil was removed.
  • Occasionally, a tiny amount of residual tonsil, or some lymph tissue on the back of the tongue can cause infections requiring further treatment.

What are the alternatives to tonsillectomy?

  • If the tonsillitis is severe or frequent enough, there is no other treatment that is likely to be as effective as tonsillectomy.
  • Sometimes tonsillitis will get spontaneously better. It can be worth a wait and see approach if the severity of symptoms is borderline.
  • Tonsillitis is more likely when you are more run-down or stressed, so maintaining good general health, and diet can help.
  • Long term antibiotics have been used in the past, and sometimes will still be tried when there is a particular wish to avoid surgery due to patient/ family preference, or because of other health issues.
  • There is no good evidence that long term antibiotics help in the longer term, and the treatment carries significant potential risks of  gastric/ intestinal problems, and antibiotic resistance

The dentist says my child has large tonsils. 

Should I be worried?    

  • If the large tonsils are associated with symptoms of severe recurrent tonsillitis, or sleep apnoea,  tonsillectomy will be curative.
  • Large tonsils which are not causing either of these issues will not require specific treatment.

Does removing the tonsils or adenoids lower immunity, leading to more infections?

  • This is a common misunderstanding, and has never been scientifically demonstrated.
  • This operation has been performed for generations, and there has never been a demonstrated problem from not having tonsils.
  • For patients who have tonsillectomy with appropriate medical indications, such as severe recurrent tonsillitis, or obstructive sleep apnoea, overall wellbeing is substantially improved.
  • Many patients who have had recurrent tonsillitis go from requiring extremely frequent antibiotics, to almost never requiring them.