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:

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

4. Kids with multiple antibiotic allergies, PFAPA (periodic fevers, aphthous stomatitis, pharyngitis and adenitis), or history of peritonsillar abscess.
5. 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.

1. During the surgery there can be trauma to the teeth or really any part of the mouth/throat
2. Bleeding (either during the procedure or post op)
3. Pain
4. Risks from anesthesia
5. Vomiting
6. 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.