What Are Tonsils and When Is Tonsillectomy Needed?

The tonsils are two collections of lymphoid tissue located at the back of the throat, on either side of the oropharynx. They form part of the immune system and participate in recognising organisms that enter through the mouth and nose.

Although tonsils have an immune function, they are not essential for maintaining immunity throughout life. In some people, the tonsils themselves become a source of repeated infection, airway obstruction or other significant problems. In such situations, tonsillectomy—the surgical removal of the tonsils—may be considered.

What Problems Can Affect the Tonsils?

Recurrent Tonsillitis

Tonsillitis is inflammation of the tonsils and may be caused by viral or bacterial infections. Symptoms can include sore throat, fever, painful swallowing, swollen tonsils, tonsillar exudate and enlarged neck lymph nodes.

Occasional episodes of tonsillitis are common and generally do not require surgery. Surgery becomes a consideration when infections are sufficiently frequent, severe and well documented.

Peritonsillar Abscess

A peritonsillar abscess (quinsy) is a collection of pus beside the tonsil, usually occurring as a complication of tonsillitis. It generally requires drainage and appropriate medical treatment. Tonsillectomy may be considered in selected patients, particularly when there are recurrent episodes or other factors that make surgery appropriate.

Obstructive Sleep-Disordered Breathing

Enlarged tonsils can narrow the upper airway during sleep and contribute to obstructive sleep-disordered breathing or obstructive sleep apnea, particularly in children.

When enlarged tonsils are an important cause of airway obstruction, tonsillectomy, often together with adenoidectomy, can improve breathing during sleep. Clinical guidelines recommend considering tonsillectomy in children with obstructive sleep apnea and tonsillar hypertrophy, with appropriate assessment of the severity and underlying factors.

Other Indications

Surgery may also be considered in selected situations such as recurrent peritonsillar abscess, certain complications of tonsillar disease, or when there is suspicion or diagnosis of a tonsillar malignancy.

When Is Surgery Recommended for Recurrent Infection?

For children, commonly used evidence-based thresholds for considering tonsillectomy are:

• At least 7 documented episodes in the previous year, or
• At least 5 episodes per year for 2 consecutive years, or
• At least 3 episodes per year for 3 consecutive years.

The episodes should be appropriately documented and associated with features such as fever, cervical lymph-node enlargement, tonsillar exudate or a positive test for group A streptococcus.

Children who do not meet these criteria are generally managed initially with observation rather than immediate surgery. Certain modifying factors, such as PFAPA, multiple antibiotic intolerance or recurrent peritonsillar abscess, may influence the decision.

What Are the Benefits?

The benefits depend on why surgery is being performed.

For patients with frequent, well-documented recurrent tonsillitis, tonsillectomy can reduce the number of future episodes of sore throat and tonsillitis, with the greatest benefit seen in those who are most severely and frequently affected. The benefit is less clear in people with infrequent infections, which is why routine removal of tonsils is not recommended for occasional sore throats.

When enlarged tonsils contribute to obstructive sleep apnea or sleep-disordered breathing, surgery can improve airway obstruction and sleep-related symptoms. In appropriately selected children, tonsillectomy with or without adenoidectomy can improve sleep and related health outcomes, although sleep-disordered breathing can persist or recur in some patients.

Thus, the benefit of tonsillectomy is not simply that the tonsils are removed; it is that surgery addresses a specific problem for which there is a reasonable expectation of clinical benefit.

How Is Tonsillectomy Performed?

Tonsillectomy is usually performed under general anesthesia. The surgeon separates and removes the tonsils from their surrounding tissues using an appropriate surgical technique. Techniques may include electrosurgery or coblation or other energy-based instruments, depending on the surgeon and clinical circumstances.

What Are the Risks?

Though it is a common operation, but it is still surgery. Important risks include postoperative bleeding, pain, nausea, dehydration and complications related to anesthesia. Throat pain can be significant for several days and may last up to two weeks, particularly in children.

For this reason, it should be recommended when the expected benefit of surgery outweighs these risks—not simply because a patient has had an occasional episode of tonsillitis.

A careful ENT assessment is therefore important.