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Tonsillectomy: What to Expect

Tonsillectomies are among the most common medical procedures that children undergo. A recent article from the National Institutes of Health estimates more than 500,000 tonsillectomies are performed on children under 15 years of age annually.  

Tonsillectomies are fairly common among adults, too. The most current data gathered by the CDC in 2006 shows there were a total of 737,000 tonsillectomies performed that year, with 297,000 being done on individuals older than 15.  

The Role of Tonsils and Adenoids

Part of the lymphatic system, tonsils and adenoids are located in the back of the throat and nose. They function similar to lymph nodes and are the first line of defense in fighting disease in the mouth and nose. Because of this role, however, they can often become inflamed and infected themselves.

“Sometimes the tonsils and adenoids can end up causing more harm than good, leading to frequent illness, strep throat, ear infections, snoring, and sleep apnea,” says Jill Jeffe, MD, a pediatric otolaryngologist at University of Utah Health. When children develop these types of complications, a tonsillectomy and/or adenoidectomy may be recommended.

Normal vs inflamed tonsils

There are, however, conflicting opinions as to whether removing the tonsils and adenoids affects the risk of infection later in life. But Jeffe stresses that it’s not possible to remove all of the tonsil tissue in the back of the nose and throat. “There will always be some adenoid tissue that remains, as well as tonsil tissue on the back of the tongue,” she says. “At University of Utah Health, we only consider surgery in patients where we feel the benefits of tonsillectomy outweigh the risks.”

Tonsillectomies and Step Throat

For children with recurrent strep throat, many studies have been done to determine how many infections are too many.

“Criteria that we have used for surgery is seven infections in a year, five a year for two years in a row, or three a year for three years in a row,” Jeffe says. “We have a lot of patients coming in that have had three or four strep infections in the past year. And, generally we do not recommend surgery in those instances, as infections do tend to decline over time. That said, if children are missing a lot of school or having significant disruption to their lives because of recurrent infections, we sometimes consider performing a tonsillectomy even if those criteria are not met.”

Jeffe notes that children can still get strep infections after having their tonsils removed, but in many cases the number of infections decrease. For recurrent or persistent sore throat not due to strep, it is less clear whether tonsillectomy will be of benefit. 

Tonsillectomies and Pediatric Sleep Apnea

About 10% of children snore, and 2-3% are estimated to have sleep apnea. In recent years, it has become more common to remove tonsils and/or adenoids when children experience sleep-disordered breathing or sleep apnea. In fact, according to Yale Medicine, it is estimated that 80% of the tonsillectomies performed are done because of pediatric sleep apnea.  

Jeffe says that children experiencing sleep apnea may exhibit a number of behavioral problems such as daytime fatigue, difficulty paying attention, or hyperactivity. They may also be difficult to wake in the morning, even if they get a good amount of sleep, because their sleep is poor quality. "With sleep apnea, the airway collapses and oxygen levels fall throughout the night,” Jeffe says. “Your brain will not let you go without oxygen and will pull you out of a deep stage of sleep to ensure you keep breathing.”

Enlarged tonsils and adenoids are the most common cause of sleep apnea in children, though obesity, asthma, and low muscle tone can be important factors as well. These and other factors are more commonly the cause of sleep apnea in adults, who often will not get the same benefit from tonsillectomy and adenoidectomy. 

Unlike tonsils, adenoids cannot be easily seen through the mouth. These often require an X-ray or nasal camera exam to visualize, so it is more common to just evaluate these at the time of surgery. 

What About Adults?

A 2021 journal article published by the NIH National Library of Medicine discusses growth of the tonsils. After puberty, the tonsils’ immune function declines, making tonsillitis more uncommon among adults.  

The National Institutes of Health suggest that surgery for adults should be considered if the individual has: 

  • Bacterial tonsillitis at least three to five times a year
  • Taken antibiotics for tonsillitis several times
  • Symptoms that greatly affect their everyday life

Several other conditions might make a tonsillectomy necessary, including cancerous tissue, recurrent bleeding from blood vessels near the surface of the tonsils, and severe bad breath caused by debris in the crypts or pits of the tonsils. One large-scale U.S. study of tonsillectomies among adults found that 57% underwent the surgery due to recurrent infections. The same study also found that it is a largely safe procedure.  

As in children, having tonsils removed does not mean that adults won’t develop another throat infection. 

Tonsillectomy Recovery

Jeffe stresses that recovering from a tonsillectomy takes a full two weeks. She wants to make sure that patients know this often means a full two weeks of no school and no strenuous activity, with a bad sore throat that can make swallowing difficult. It is not uncommon for children to become dehydrated after surgery, so it is very important to monitor fluid intake closely.

One of the biggest risks of tonsillectomy is the risk of bleeding. Around 2% of children that have their tonsils removed may experience some bleeding from their throat. This can occur at any point in the two weeks after surgery. The most common times to bleed are within the first 24 hours and 7-10 days after surgery when the scabs start to fall off.

For this reason, it is important to follow a soft food diet after surgery. A soft food diet includes foods that are bland, easy to digest, usually have a soft texture, and are low in fiber. The foods are usually liquid or ground, mashed, or pureed.

Both children and adults may experience nausea, low-grade fever, bad breath, and swelling of the tongue and throat. Patients may also snore or have difficulty breathing immediately after surgery, but this usually improves as the swelling goes down.

“Tonsillectomy is a very common surgery, but it’s still surgery,” Jeffe says. “It’s important to talk with your doctor about all of the risks and benefits of surgery. But for the majority of patients, this procedure can lead to a great improvement in quality of life.”