The tonsils are fleshy bits of tissue at the back of the throat on either side. They, along with the adenoids (behind the nose), and the lingual tonsils (that sit at the back of the tongue), create a ring of tissue called the Waldeyer’s ring. During evolution, they formed part of the immune system, but sometimes they can cause more trouble than good. If they are removed, other parts of the immune system take over their function, causing no problems with immune response.
The most common problem with the tonsils is that they can get infected. They develop white spots, the throat becomes sore, it becomes difficult to eat and drink, and a fever develops. It can be caused by bacteria or viruses. This can happen recurrently, requiring time off work or school, and trips to the GP to get antibiotics. If you get 7 episodes of tonsillitis in a year, 5 episodes in 2 consecutive years, or 3 episodes in 3 consecutive years you may need your tonsils out to prevent further infections. Glandular fever (Epistein-Barr virus) can cause tonsillitis which is particularly difficult to control with antibiotics, as it is virus, rather than a bacteria. Often high dose steroids can control the pain and swelling, but once they wear off, then the pain and swelling can rebound. The patient often has a "hot potato voice". It sounds like they have a hot potato in the throat whilst they talk.
Another reason for doing a tonsillectomy (sometimes combined with an adenoidectomy) is if the tonsils are large and are blocking breathing during sleep. If a child stops breathing for more than 10 seconds at a time, this indicates sleep apnoea and is worth treating. Snoring, on its own, is not a reason to pursue surgery.
It would be helpful if you could take a video of your child sleeping and any apnoeic episodes, so that I can see this during the consultation. This might be as useful as a dedicated sleep study, when the child sleeps in the hospital or at home wired up to an oxygen monitor which records over a period of hours. The only significance of doing a tonsillectomy in this setting is the child has to stay in overnight for observation, and can go home the next morning.
Acute Tonsillitis
Sometimes one tonsil can become bigger than the other. Rarely, this can be because the tonsil has a cancer growing within it. This can be because of a cancer of the tonsil (squamous cell carcinoma or lymphoma). Normally, if one tonsil is bigger than the other, I would suggest a tonsillectomy for histology i.e. an operation when both tonsils are removed and sent off to the lab to check for cancer.
Cancer of the right tonsil
Tonsillectomy
This involves coming into hospital. Having a general anaesthetic, so you are fully asleep. When asleep, I use a clamp to keep the mouth open, and use an instrument to remove the tonsil. There are different instruments that can be used. In children, I use a coblator wand to dissolve the tonsil without breaching the edge of the tonsil (the capsule). It is a bit like scooping out the flesh of half of an avocado, with a spoon, but leaving the skin intact. This technique is much less painful for the child, but can uncommonly result in regrowth of the tonsil. In adults, I use a dissector to remove the tonsil and then a cautery forceps to seal any bleeding vessels. Once the operation is done, we wake you up and you go to the recovery area for up to one hour. Then you go back to the ward for up to 6 hours. This operation is done as a daycase procedure so you are in and out the same day. You will need to spend two weeks at home recovering from the operation. In adults, the operation is very painful, so you will need to take painkillers, such as paracetamol, codeine, and ibuprofen regularly. As they are different types of drug, you can take all three at the same time if necessary. You will also need to keep eating a mixed diet: soft and hard foodstuffs.
The risks are pain, bleeding, infection, and general anaesthetic, damage to the lips, teeth and gums, and 20% risk of mortality if COVID positive at the time of the anaesthetic.
Of these complications, bleeding is the most important. It happens in about 2% of patients. It can happen in the first 24 hours, in which case you have to be taken back to the operating theatre, for another general anaesthetic. The bleeding is stopped by sealing the offending vessel with cautery.
Otherwise, it can happen after 24 hours, normally 7-10 days after surgery when the pain reaches its maximum, you might stop eating, then the throat becomes infected, and then it may bleed. You should go to your local accident and emergency department immediately, and be admitted for 24 hours of intravenous antibiotics (through a drip in your vein). A return to theatres and a general anaesthetic is not often necessary.
After 2 weeks, the pain will subside and you can come to clinic for a check up. In the post operative period, the tonsillar beds heal with a white or yellow cheesy material. This is normal. A non ENT doctor or nurse might look at this, mistake it for infection and give you antibiotics. After a few weeks this turns to pink to match the colour of the lining of the throat.