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Tonsils and tonsillectomy

In the third instalment of our ENT series, GP Dr Alex Watson and ENT surgeon Mr Peter Robb answer some frequently asked questions on tonsils

What are tonsils and what is their purpose?

The tonsils form part of the upper food and air passage immune sampling system in early childhood. They help to establish systemic immunity and probably become redundant after the age of three or four years.

Why do they cause problems?

Like the appendix, they may become acutely or chronically inflamed or infected.

When is tonsillectomy considered?

Generally for recurrent infections, airway obstruction or when malignancy is suspected.

Is there an age limit (both upper and lower) that tonsillectomy will be considered?

The small risk of perioperative or postoperative blood loss means that tonsillectomy is generally avoided in children under 15kg in weight, about three years of age.

There is no absolute upper age limit, as long as the patient is generally fit and the indications for surgery are appropriate.

Is there a risk of contracting vCJD from the operating equipment during tonsillectomy?

This is unknown but likely to be statistically extremely small. The National Patient Safety Agency is, at the time of writing, conducting an anonymous collection of 100,000 tonsils across the UK to assess vCJD carriage in tonsil tissue.

How are tonsils removed in the 21st century?

The standard technique remains cold dissection with instruments and ties to the bleeding points. This is a safe technique, although the blood loss at time of surgery may be higher and this is a consideration for small children having the operation. Many other techniques are available. Diathermy and coblation dissection have the advantage of less blood loss at the time of the surgery, but a slightly higher secondary bleed rate for some surgeons. Laser has fallen out of favour because of the much higher postoperative pain.

Is it true that not all tonsillar tissue is removed?

All the pharyngeal tonsil is removed at the time of tonsillectomy. The old technique of guillotine tonsillectomy sometimes left remnants the could grow back. These remnants could then become infected.

Who is suitable for day case surgery and who would require impatient stay?

Generally, adults and children who have no bleeding disorders and are American Society of Anaesthesiologists category 1 or 2 – normal healthy or with mild systemic disease – are fit for day surgery.

What is the recovery time post-op? Is there a difference between adults and children?

It is wise to allow a two-week convalescence period. Children do seem to recover more quickly than adults, although the recovery is very variable for both groups.

What are the risks of tonsillectomy?

The risk of most concern is bleeding, either during the operation or during the recovery period. The risk is about 2-5%. Pain in the throat and ears is usual and requires effective analgesia (paracetamol, ibuprofen and codeine is a common combination of post-operative painkillers). Anaesthetic complications are rare. Damage to the teeth is an uncommon potential complication.

Is there any long-term risk to having your tonsils removed (such as reduced immune function)?

There is no good evidence that tonsillectomy compromises immune function. It is probably wise to avoid tonsillectomy in children under three years of age as the tonsils may be functioning to acquire systemic immunity.

In which cases would the adenoids be removed at the same time?

The adenoid is usually removed for the symptoms of upper airway obstruction with tonsillectomy or as part of the management of glue ear with grommet insertion. As these are common conditions, more than one of these procedures may be indicated in a child at the same time.

What exactly is a quinsy, and how should it be managed?

A quinsy is a peritonsillar abscess. Initially, there is a cellulitis and then the abscess forms. Generally, admission for intravenous fluid and antibiotics is required. If the abscess is pointing it may be aspirated or lanced with topical anaesthesia. Previous quinsy is a relative indication for tonsillectomy.

This is an extract from ENT in Primary Care by consultant ENT surgeon Mr Peter Robb and Surrey GP Dr Alex Watson, published by Rila. To order go to www.rila.co.uk or call 020 7637 3544

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