Almost 400,000 tonsillectomies and/or adenoidectomies are performed each year in the United States. "T&A" (short for tonsillectomy and adenoidectomy) is the second most common operation performed for children, and it is not unusual for an adult to require a tonsillectomy. Although T&A is not recommended as often as before the days of antibiotics, it is still a valuable operation that improves the health of many children and adults. Recent studies indicate that adenoidectomy may be beneficial treatment for some young children affected by chronic otitis media with effusion (fluid in the ears).

What Is the Purpose of Tonsils and Adenoids?

Tonsils and adenoids are composed of tissue that is similar to the lymph nodes found in the neck, groin, and other places in the body. The adenoids are located high in the throat behind the nose and soft palate (roof of the mouth) and, unlike tonsils, are not visible through the mouth without special instruments. The tonsils are the two masses of tissue on either side of the back of the throat. Tonsils and adenoids are strategically located near the entrance to the breathing passages where they can catch incoming infections. They "sample" bacteria and viruses and can become infected themselves. It is thought that they then help form antibodies to those "germs" as part of the body's immune system to resist and fight future infections. This function is performed in the first few years of life, but it is less important as the child gets older. In fact, there is no evidence that tonsils or adenoids are important after the age of three. One recent large study showed, by laboratory tests and follow-up examinations, that children who must have their tonsils and adenoids removed suffer no loss whatsoever in their future immunity to disease. There is a popular myth that tonsils and adenoids filter bacteria out of what we swallow and breath, somewhat like a kitchen strainer. This is untrue. Any filter that could strain out microscopic bacteria would not allow the passage of any food particles and would make eating impossible. The most common problems affecting the tonsils and adenoids in children are recurrent infections (causing sore throats) and significant enlargement (causing trouble with breathing and swallowing). Recurrent acute infections of the tonsils also occur in adults and so do abscesses around the tonsils, chronic tonsillitis, and infections of small pockets (crypts) within the tonsils that produce bad smelling, cheesy-like formations (concretions). Tumors can also grow in the tonsils, but they are rare.

How Are Diseases of the Tonsils and Adenoids Treated?

Bacterial infections of the tonsils, especially those caused by "strep" are initially treated with antibiotics. Removal of the tonsils and/or adenoids may be recommended for some children and adults. The two primary reasons for tonsil and/or adenoid removal are:

• Recurrent infection despite antibiotic therapy.
• Difficulty breathing due to enlarged tonsils and/or adenoids. Obstruction to breathing causes snoring and disturbed sleep patterns that lead to daytime sleepiness in adults and behavioral problems in children. Many orthodontists believe chronic mouth breathing from large tonsils and adenoids causes malformations of the face and improper alignment of the teeth.
• Chronic ear disease. Chronic infection in the tonsils and adenoids can also affect nearby structures such as the eustachian tube, the passage between the back of the nose and the middle ear. This can lead to frequent or chronic ear infections with earaches and hearing loss.

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may progress to a point of obstructing the airway. For these patients, treatment with steroids is sometimes helpful.

How Should the Patient Prepare for Surgery?

Parents should discuss openly the child's feelings about the surgery and provide strong reassurance and support throughout the process. Encourage the child to think of this as something the doctor will do to make him healthier. Try to be with the child as much as possible before and after the surgery. Children should be aware they will have a sore throat after surgery, but it will only last a few days. They should also be reassured the operation does not remove important parts of their body, and they will not look differently afterward. If there is a friend who has had this surgery, it may be helpful for the child to talk to the friend about it. If the patient develops any new illness the week before surgery, notify the surgeon since the surgery may need to be rescheduled. For two weeks before any surgery, especially tonsillectomy or adenoidectomy, the patient should not take aspirin or other medications that contain aspirin since these increase the risk of bleeding. Tylenol is a good substitute. The surgeon should be informed of any problems the patient or the patient's family may have had with anesthesia. If the patient has sickle cell disease, bleeding disorders, is pregnant, has specific views on blood transfusions, or if the patient has used steroids in the past year, the surgeon should be informed. Generally, after midnight before the operation, nothing may be taken by mouth. Medicine can usually be taken with a sip of water, but this should be discussed with the surgeon or the anesthesiologist. If this restriction is broken, the operation may be delayed because anything in the stomach may be vomited at the beginning of the anesthesia, and this is dangerous. When the patient arrives at the outpatient surgery center or hospital, he/she will go to the Pre-Op holding area while preparations are made for surgery. There the anesthesiologist or nursing staff will meet with the patient and family to review the history. Often a sedative medication is given to reduce anxiety. The patient will then be taken to the operating room and given an anesthetic. Children are usually given a gas through a mask to go to sleep. Adults are usually given medications through an IV in the arm placed in the Pre-Op area. Intravenous fluids are usually given during and after surgery. After the operation, the patient will enter the recovery unit. Initially, while the patient is still sleepy from the anesthesia, no visitors are allowed. Observation will be continued until the patient is adequately recovered from surgery and safe to be discharged, usually 2-3 hours. Sometimes local anesthetic medication is also used around the tonsils during surgery so patients may have more pain a few hours after surgery than when they first wake up. Occasionally patients with certain medical conditions are kept in the hospital overnight for observation.

What May Occur After Surgery?

Most patients complain about throat and ear pain following surgery. This seems worse for adults than for children. Most patients stay out of school or work for one week. For some the pain lasts up to two weeks. The surgeon must be informed if the patient is unable to drink fluids. Low-grade fevers of 99-100oF are not uncommon after surgery. Call your surgeon for fever over 100.5oF. Some patients notice a small amount of blood in the back of the mouth. This can occur up to 10 days after surgery. Try gargling or drinking ice water to stop the bleeding. If there is a large amount of blood or if the bleeding is persistent you must call your surgeon or go to the emergency room.

Surgical Risks

Bleeding - In general there is very little blood loss during tonsillectomy and adenoidectomy, but there is always a small risk of serious bleeding during surgery or in the days following surgery. The risk of bleeding requiring blood transfusions is very small.

Dehydration – Although everyone has some difficulty swallowing after surgery, occasionally a patient is unable to drink enough fluids and must be given IV fluids in the hospital for a few days.

Velopharyngeal Insufficiency – Removing the tonsils or adenoids increases the size of the space connecting the back of the mouth and the back of the nose. This passageway is closed by the soft palate (back of the roof of the mouth) when we speak or drink. Rarely, this closure is incomplete after surgery resulting in "hypernasal" speech or even liquids coming out of the nose when drinking. When this occurs it usually resolves within a few weeks as swelling resolves and the throat muscles strengthen. Very rarely this can be a permanent problem requiring speech therapy or surgery to correct.

Anesthesia – We are fortunate to have general anesthesia that is extremely safe. There are some risks, and your anesthesiologist will discuss these with you before surgery.

This page is an adaptation of an American Academy of Otolaryngology - Head and Neck Surgery Public Service Brochure.