Should Tonsils Be Taken Out?

It is that time of year again - the time when I begin to really feel the surge of increasing patients with of upper respiratory tract infections. 

Children are especially prone to these types of infections as they pass readily through classrooms and schools. One of the more common infections I see in children is the "sore throat." Often this is related to tonsillitis ( inflammation of the lymph tissue at the back of the throat.) When tonsillitis becomes frequent, the question of a tonsillectomy (getting the tonsils taken out) comes up. 

This blog will discuss the question of tonsillectomy in children highlighting the advantages, disadvantages and reasons for having the procedure.

History of the Tonsillectomy

Decades ago, tonsillectomy was a much more commonplace procedure. Getting tonsils out back then was a rite of passage. In fact, several decades ago, the town doctor would  often visit the home and remove the kids' tonsils right there on the dining room table! 

Today, tonsillectomy is the second-most common surgical procedure in children with in excess of 500,000 performed each year in the United States.   And yet, current, more refined thinking has led to guidelines for performing the procedure considering both the benefits and the risks. 

Changing Trends in Tonsillectomy

The goal of tonsillectomy is to reduce problems associated the the tonsils themselves. Contrary to some beliefs, children can still get strep throat and sore throats after a tonsillectomy.

There is evidence that tonsillectomy actually has very limited benefits for most children as the frequency of sore throats normally decreases with age anyway. Furthermore, children with less frequent or severity infections have not been shown to benefit from tonsillectomy.

Trends do show however, that when tonsillectomy is performed for recurrent throat infections in severely affected children, benefits are seen for two years following surgery. The outcomes measured in these children were improved quality of life, reduced severity and reduced frequency of infections.

Downfalls of Tonsillectomy

• Won't Prevent Strep Throat. First, though it can reduce the incidence, tonsillectomy does not prevent strep throat. 
• Risks of Surgery. As with any surgical procedure, there are risks. About 1 out of 25 will have a post-operative complication and require re-hospitalization. A significant complication of the surgery is hemorrhage (bleeding) which often requires repeat surgery. Tonsillectomy has a reported mortality (death rate) in 1 out of 35,000 cases.
• Cost Vs. Benefit. Cost vs. improvement in quality of life is definite consideration. 
• Pain and Nausea. Lesser complications include pain and nausea. 

When is a Tonsillectomy ACTUALLY a Good Idea?

It should be noted that frequent infections are not the only reason to have a tonsillectomy. 

Sleep-disordered breathing syndrome (SDP) is a problem causing obstruction in breathing due to enlarged tonsils.  Often children with SDP suffer from poor sleep and it's consequences.  Fatigue, behavior problems, poor school performance, attention problems and malnutrition have been attributed to this illness.  SDP is diagnosed with a sleep study (observed sleep measuring oxygen levels and brain activity). 

Otherwise, to prevent premature or unneeded tonsillectomies, recommendations called the "Paradise Criteria" guide doctors' decisions to advise for the procedure. The criteria are met if:

• Frequency.There is a minimum number of sore throat episodes met (7 in 1 year's time, 5 per year for 2 year's time or 3 per year for 3 year's.
•    time)
• Severity. The sore throat episodes also include a fever, pus observed on the tonsils or a positive strep test.
• Treatment. The sore throat episodes were treated with antibiotics in an appropriate fashion.
• Documentation. The sore throat episodes were documented in a doctor's medical record.

Aside from some outlying circumstances include tonsillitis that requires hospitalization (such as cases where an abscess develops) or in cases where there is a strong family history of rheumatic fever (heart complication from strep infection), children who do not meet the criteria should simply be observed and their tonsilitis managed conservatively over at least a year. 

Sore throats are common and some children seem prone to frequent sore throat illness.  When sore throats affect quality of life, a discussion with a physician is a good idea.  This discussion should consider the "Paradise Criteria" and weigh the risks and benefits of tonsillectomy.

Source-  2011 Clinical Practice Guideline: Tonsillectomy in Children, American Academy of Otolaryngology- Head and Neck Surgery
              www.entnet.org/HealthInformation/upload/CPG-TonsillectomyInChildren.pdf

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