Tossing out tonsils

TONSILS are two fleshy lumps at the sides of the inside of our throats.

They are usually quite big in children. However, they become smaller as we grow older.

The majority of us will not have any problem with our tonsils. However, a small percentage of us may develop bacterial infections.

When this happens, the tonsils become red and inflamed, giving rise to a sore throat. Sometimes, it can be so severe as to cause high fever and pain on swallowing.

Occasionally, the infection can reach the voice box, giving rise to a husky voice - a condition called laryngitis.

Mild tonsillitis usually resolves on its own without any medical treatment. The more severe ones, on the other hand, require antibiotics.

Sometimes, hospitalization for intravenous administration of antibiotics and painkillers is required to control the symptoms.

A common operation

The operation to remove tonsils (tonsillectomy) has been mentioned in some reference to Hindu medicine as far back as 3,000 years ago.

It is the second most common operation to be performed in children in the United States (530,000 in 2006), second only to myringotomy and insertions of ventilating tubes (grommets) in the ears.

Controversy over whether tonsils should be removed has been around for many centuries.

In the early 1930s, the theory that tonsils played a role in the creation of blood, and that they were organs that fulfil important tasks in protecting and detoxifying the body brought tonsillectomy operation into great disrepute.

In decades to come, many people suffered from complications of tonsillitis, like abscesses in the throat, bacterial infections of the blood (septicaemia), and occasionally, difficulty with breathing (stridor) and death.

Since then, it has been generally agreed that tonsillectomy may be indicated to prevent such complications.

When it needs to go

When it needs to go

The latest clinical practice guideline on tonsillectomy in children was published in the January supplement to Otolaryngology - Head and Neck Surgery, an official journal of the American Academy of Otolaryngology - Head and Neck Surgery Foundation.

The American experts advised that a tonsillectomy operation, with or without adenoidectomy (removal of the adenoid), should be considered if the child suffers from the following:

- Recurrent throat infections with a frequency of:

* at least seven episodes in the past one year, or
* at least five episodes per year for two years, or
* at least three episodes per year for three years;

with documentation in the medical record for each episode of sore throat, and one or more of the following:

*temperature of more than 38.3°C,
*neck nodes enlargement
*tonsillar exudates, or
*positive throat swab test for group A beta-haemolytic streptococcus bacteria.

- Recurrent throat infections and do not meet the above criteria, but have multiple antibiotic allergies or intolerance, periodic fever, aphthous stomatitis (small ulcers that appear in the mouth), pharyngitis (pain and inflammation at the back of the throat) and adenitis (inflammation or swelling of lymph glands), or history of peritonsillar abscess (collection of pus beside the tonsil).

- Sleep disordered breathing (difficulty with breathing during sleep) due to enlarged tonsils associated with growth retardation, poor school performance, bed-wetting (enuresis), and behavioural problems.

- Abnormal sleep studies (polysomnography) due to tonsillar enlargement and sleep disordered breathing.

Similar guidelines for tonsillectomy in children and adults have been advocated by the Scottish Intercollegiate Guidelines Network in April 2010.

What happens after

What happens after

A tonsillectomy operation is not to be taken lightly.

Although it is quite a safe and straightforward operation, it also carries some risks.

The main complication of tonsillectomy is bleeding. This can happen during the operation (peri-operative haemorrhage), soon after the operation (primary haemorrhage) or after the patient is discharged from hospital (secondary haemorrhage, usually from post-operative infection).

Patients may also experience significant pain especially on swallowing. This can last for up to two weeks after the operation.

Although tonsils are made of lymphoid tissues that form part of our immune system, removal of tonsils has not been associated with any increase in incidences of other infections.

Studies have shown that children with frequent attacks of tonsillitis became healthier after their tonsils were removed.

Guidelines are there to help guide physicians in making clinical decisions. They are not meant to be rigid rules.

These guidelines help doctors to make a balanced decision as to whether the child or adult requires a tonsillectomy.

On one hand, doctors do not want patients to suffer from frequent attacks of tonsillitis, which affects their daily lives, or complications of recurrent tonsillitis.

On the other hand, they should also think about the complications that may arise from this operation.

It is best to seek a medical opinion when one suffers from frequent attacks of sore throat.

Doctors should be able to differentiate between viral or bacterial pharyngitis (infection of the back of the throat) and tonsillitis.

Ear, nose and throat specialists are able to make a balanced decision as to whether a tonsillectomy operation is indicated.

Occasionally, tonsils may be removed if cancer is suspected.

Children undergoing any form of operation will be frightened. Parents and doctors can help by reassuring the child that this is a simple procedure.

The operation is carried out with the child fully asleep under general anaesthetic. The two tonsils are removed from the opening of the mouth, and there will not be any wound on the skin.

Once reassured, most children are cooperative and recover well with no complication.

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