What are tonsils?

Tonsils are two areas of tissue at the back of the throat on its side walls. They are made of lymphoid tissue, and this is material which deals with infection in the body and is part of the immune system. However, tonsils can be the cause of more trouble than good, and people that have their tonsils removed don’t seem to suffer with any more infections as a result.

What trouble do tonsils cause?

Many people have problems arising from their tonsils, and this is why surgeons remove them. Most commonly they can get infected by viruses or bacteria, often repeatedly, and cause a sore throat, often with glands which increase in size in the neck. The patient feels unwell and feverish and this can happen quite often, making the patient miss work or school on a regular basis, for it can happen in both adults and children.

Sometimes the infection goes one stage further and localizes to one tonsil on one side. Then pus collects around the edge of that tonsil and creates what is known as a quinsy. The patient will probably need to be admitted to hospital for drainage of the pus under a local anaesthetic and antibiotics through a drip for a couple of days at least. People that develop a quinsy can’t open their mouths fully and find it difficult to eat and drink.

Tonsils can also increase in size to such a degree in children that they meet in the midline and make it difficult to eat. They may also obstruct the airway when the child sleeps, causing snoring and a cessation of breathing for some seconds. This, of course, is dangerous if it continues as oxygen levels may drop in the blood.

Tonsils can become differentially enlarged, without fever, and this asymmetry makes ENT surgeons suspicious that the tonsils may have been infiltrated by cancer, especially in smokers or those that drink spirits. We are particularly suspicious when a continuous pain is present.

When do we remove the tonsils?

Really, it is in any of the above situations, where the benefits of having tonsils and the risks of an operation, which are minimal, are outweighed by the distress that they cause. Officially, it is thought that five attacks of tonsillitis per year or three attacks in each of two consecutive years is pretty disruptive to anybody’s schedule. However, your surgeon will take your opinions into account.

Figure 1. Tonsillitis

How do we take the tonsils out?

You come into hospital.

You will be seen by a doctor for a check up a week or two before the operation – this is called preclerking. Sometimes investigations are ordered such as blood tests or chest X-rays, but these are not always required. The anaesthetist and surgeons see you on the day of the operation. When it is time to have the operation, you are taken to the anaesthetic room in the theatre suite. It is here that you will be put to sleep with an anaesthetic, this is normally done by inserting a needle into a vein on your hand and injecting some liquid anaesthetic into the bloodstream. For children and adults that are particularly worried by needles, it is possible to have some anaesthetic cream on the hand to numb it.

Then you are taken into the operating theatre. The mouth is opened and kept open with a metal retractor. There are lots of ways to remove the tonsils: using metal instruments to pull and dissect the tonsils out, diathermy forceps which burn the tonsils out using an electric current between the tips (whilst stopping bleeding), and lasers amongst many others. The fact that there are so many methods still in use, suggests that no one method appears significantly better than the other.

Any bleeding from the sockets, where the tonsils were, is controlled by inserting swabs and letting the body’s natural clotting mechanism stop the bleeding. Diathermy forceps and tying bleeding vessels are also used. The procedure normally takes between 30 – 45 minutes. When it is over, you are wheeled to the recovery area to wake up in a monitored area. When awake, you are wheeled back to the ward.

Recovery

Children can have their tonsils taken out and leave hospital the same or the next day, normally. Adults need to stay overnight. Children in general seem to tolerate having their tonsils out much better than adults. Adult suffer considerable pain for two weeks following the procedure. This is probably because the tonsils are much more embedded in the adult and adherent, especially if they have been getting infected recurrently.

You can eat any food after the operation on the ward and at home, but it is unlikely that you will tolerate any spicy food. It is important to eat and drink regularly as this is thought to decrease the likelihood of dehydration and infection at the operation site.

We suggest that you spend two weeks at home indoors to fully recover from the operation. It is better not to mix with too many other people. This decreases the possibilities of catching an infection.

Complications

No operation is without risk and tonsillectomy is no exception. There are the normal complications and risks that are inherent in any surgery: that is to say pain, bleeding, infection and those of a general anaesthetic.

Bleeding is the most important complication. It does not happen very often – about 4% of operations. If it does happen it tends to happen immediately after the operation or after 7 – 10 days. If it happens in the immediate post operative period, it is normally necessary for you to be returned to the operating theatre and put to sleep again. This allow us to identify the offending vessel and tie it off or use diathermy to seal it. If bleeding occurs after 7-10 days this is known as a secondary haemorrhage. You must seek immediate medical attention. Ring the ward and come back to hospital. Normally, this type of bleeding stops spontaneously, but it is customary to admit you to hospital for observation, take blood samples to check degree of bleeding that has occurred and to check your blood group, should a transfusion become necessary. A plastic tube is inserted into a vein again to allow you to have antibiotic inserted directly into the bloodstream. Re-admission normally lasts for at least 24 hours. Uncommonly, you will need to be taken back to the operating theatre if the bleeding does not stop.

We have already mentioned pain, and you will be supplied with painkillers to take on a regular basis. If you take these regularly before eating, it will help you tolerate food better. General anaesthetics are very safe nowadays and it is uncommon to have any problems.

Follow up

Generally, we do not follow patients up. Exceptions to this are patients that previously stopped breathing whilst asleep (obstructive sleep apnoea), those whose tonsils have been sent to a lab for analysis under the microscope if cancer needs to be ruled out, or those who have had a combination of procedures in addition.