A tonsillectomy, the surgery to remove tonsils, is one of the most common surgeries done in the United States. It’s no wonder parents often wonder if their child should have his or her tonsils out. While it is a very common surgery, one should be careful not to take it lightly. There are risks and complications, so we want to take care to ensure every child who undergoes the procedure really needs it.

Who should get tonsils out?

There is a panel of experts that look at all the scientific evidence to determine guidelines. In this case it is the American Academy of Otolaryngology-Head and Neck Surgery (ENTs), which drafted the current recommendations. The guidelines are as follows:

Watchful waiting (medical jargon for do nothing) if there have been fewer than 7 throat infections in the past year.
Watchful waiting if there have been fewer than 5 throat infections per year in the past 2 years.
Watchful waiting if there have been fewer than 3 episodes per year in the past 3 years.

OR, exceptions to the above, which favor tonsillectomy

Kids with multiple antibiotic allergies, PFAPA (periodic fevers, aphthous stomatitis, pharyngitis and adenitis), or history of peritonsillar abscess.
Kids who have sleep-disordered breathing (e.g., sleep apnea) with problems that result from poor sleep (e.g., poor growth, poor school performance, behavior problems).

Risks of the surgery

I will never forget the first child I took care of who had been admitted to the Pediatric Intensive Care Unit after a complication from a tonsillectomy. The little girl had undergone a routine tonsillectomy, but had lots of bleeding and throat swelling. She ended up on a ventilator (with a tube down her throat) to protect her airway. She stayed like that for 3 days, ultimately recovering (but not before giving her poor mother major stress). The potential risks (albeit relatively rare) are real.

During the surgery there can be trauma to the teeth or really any part of the mouth/throat
Bleeding (either during the procedure or post op)
Pain
Risks from anesthesia
Vomiting
Trouble breathing (usually due to swelling of the throat/airway)

What good are the tonsils anyhow?

The tonsils are lymphoid tissue that is supposed to act as a guard to further infection of bigger internal organs. The problem is that the tonsils don’t always do a great job and can get infected in the attempted first line of defense.

Does my child need antibiotics with the surgery?

The current recommendations are NO (not routinely). This includes the period just before surgery, during surgery, and immediately following surgery. The evidence doesn’t show that it improves outcomes (i.e., there isn’t less infection) and just ends up causing side effects.

How will I manage my child’s pain?

Most children will get an IV dose of dexamethasone during the surgery, which will help reduce pain. Additionally, your ENT should give your child a prescription for pain medications and help educate you on what to expect. Keeping your child hydrated is a big part of the post-op care.

Soon to change guidelines

FYI, the American Academy of Otolaryngology-Head and Neck Surgery (the governing body of ENTs) states that the clinical practice guideline: tonsillectomy in children, is undergoing an update. The new recommendations should be available Spring 2018. I’ll keep you posted when/if things change.

Have you ever noticed little white, hard balls that appear to be stuck in your kid’s tonsils? I’m not talking the white coating/pus that happens when your kid is sick. Usually, the child doesn’t appear ill and it’s something you just happen to notice. If you have, you may be dealing with tonsil stones, or tonsilloliths. Tonsil stones are relatively uncommon in children, but fairly common in teens and adults. While tonsil stones are generally considered a benign condition, they can be a nuisance.

What are tonsil stones exactly?

The tonsils are the pink, balls of lymphoid tissue that stick out from the sides of the back of the throat. They are supposed to help protect the throat from bacteria and infection. The problem is that often times they aren’t very good at the job and end up getting infected. Tonsil stones happen when little bits of bacteria, food, debris, dead cells, and mucous get trapped in the little nooks, crevices, and crypts of that tonsil tissue. The trapped junk gets hard and calcifies into a little stone. It is much more common in people who suffer from chronic inflammation or tonsillitis. This is in part why it is much more common in adults (who have more cases of repeated tonsillitis). Usually, people end up just swallowing the little stones and don’t even notice them.

What are the symptoms?

No symptoms: Often tonsil stones are an incidental finding and they don’t cause a problem.
Bad breath (halitosis): Surprising, I know, but pockets of calcified bacteria, food, mucous and dead cell don’t smell good.
Sore throat: It may be difficult to differentiate pain from the stone from pain from infection (they often go hand-in-hand), but if the stones are large they can cause pain.
Swollen tonsils: If there are large stones inside the tonsil, they can cause the tonsils to get large.
Ear pain: This may seem tricky. The throat and ear are connected by nerves, so pain in one area can send messages to the brain that cause the brain to perceive pain in the other location. (This is called “referred pain.”)
Trouble swallowing: If the stones are big enough, they can impede swallowing. This is uncommon.

What’s the risk with tonsil stones?

Tonsil stones don’t generally cause major problems, but can be bothersome. They can contribute to bad breath, chronic sore throats, and a feeling of something “stuck in the throat” (see symptoms above). Tonsil stones don’t cause infection (they can be the result of infection). They also do NOT cause cancer. Tonsil stones are NOT contagious (although many throat infections which contribute to stones are contagious).

How do I prevent/treat tonsil stones?

Treatment and prevention go hand-in-hand on this one. Careful oral hygiene is important. Brush your child’s teeth and tongue regularly. Try to prevent throat infections as much as possible (e.g., hand washing, don’t share drinks). Drink plenty of water when eating to wash down food particles. Also, try not to eat just before going to bed (it’s easier for food particles to get lodged while sleeping).

If stones are present, try a salt water gargle that helps decrease swelling and dislodge visible stones. (Try 1 teaspoon of salt to 1 cup of warm water). A water pick can be a handy little device to help wash out/dislodge stones. (Just try not to gag yourself in the process). Because the stones are benign, it’s very common that doctors will advise you to do nothing about tonsil stones. If there is a particularly large, bothersome stone that you can’t easily dislodge, sometimes a doctor will have to extract the stone. I’ve used a long, sterile swab before to gently “milk” a stone out of a tonsil. Very rarely do ENTs (Ear, Nose, and Throat specialists) take out tonsils for stones. Usually, if tonsils are taken out it is for chronic infection reasons, which indirectly can contribute to the stones. In select circumstances (not commonly), antibiotics may be prescribed to help in the treatment. Be advised that antibiotics have side effects, only work if there was infection present, and generally aren’t a long-term fix.

How do I know if my child has tonsil stones?

The best way to determine if your child suffers from tonsil stones is to look in his or her throat with a small light. (Simple trick: Have your child stick out his/her tongue and “pant like a puppy” to see into the back of the throat). You’ll see the little white stones sticking out of the tonsils. Sometimes there are lots of little stones and sometimes there is just one. Sometimes a child will have stones and you can’t see them. Those cases either go undetected or get discovered when a child has imaging (like an X-ray or CT scan) for another reason.

Tag: tonsil

Should I Have My Child’s Tonsils Removed?