Tonsillitis: Tonsil surgery in children
Most children only have tonsillitis every now and then. Although it is unpleasant, it usually gets better after a few days. But if tonsillitis keeps coming back over several years, the option of surgically removing the tonsils is often considered.
Acute tonsillitis causes symptoms such as a sore throat, difficulty swallowing, fever and tiredness. Tonsillitis that keeps coming back within short spaces of time can greatly affect everyday life.
Children and teenagers are much more susceptible to tonsillitis than adults are. Some children get tonsillitis 4 to 8 times a year, with each episode lasting one to two weeks. They keep having to miss school as a result – and their parents often have to stay at home to take care of them.
Painkillers and antibiotics might not be effective enough, or people might not want to use too much medication. Surgery might also be considered because of complications such as the collection of pus beside a tonsil (known as quinsy or a peritonsillar abscess).
When considering surgery, it is worth weighing the pros and cons: On the one hand there is the hope that having tonsils out will reduce the number of infections, or even stop them altogether. On the other hand the surgery is associated with risks, and you can't be sure that it will actually help.
How effective is tonsil surgery?
Removing the tonsils completely (total tonsillectomy) can help reduce the number of throat infections. If tonsils have been taken out, they can no longer become infected – but the tissue surrounding the tonsils might still become infected.
Surgery is most likely to help in children who have more severe symptoms as a result of having tonsillitis multiple times. A child is considered to have "more severe symptoms" if they have tonsillitis at least 3 to 5 times per year, the tonsillitis is treated with antibiotics, the symptoms always last several days, and the sore throat is accompanied by
- fever over 38°C (100.4°F),
- enlarged or hard lymph nodes in the neck,
- pus on the tonsils, or
- the confirmed presence of certain bacteria.
Studies have shown that children with more severe symptoms have somewhat fewer sore throats after surgery:
- Those who had their tonsils removed had an average of 3 sore throats within the first year following surgery. But one of those sore throats was a result of the surgery.
- The children who didn't have surgery had an average of 4 sore throats lasting several days over the same time period.
In other words, tonsil surgery prevented one sore throat on average in the first year. The children were sick for an average of five days less per year.
What are the drawbacks of surgery?
A lot of children get tonsillitis less as they grow older, or they might stop getting tonsillitis altogether, even if they don't have any special treatment. But there is no way of knowing which children will simply “grow out of” being susceptible to tonsillitis.
Having your tonsils removed is associated with discomfort and risks: The wound may hurt and swallowing may be painful after the operation. About 20 to 50 out of 100 children say they have severe pain afterwards. Temporary nausea, vomiting, swallowing problems and loss of taste might occur. And complications such as bleeding are possible too (see below). The wound usually hurts less after a few days.
Another thing to consider is that surgery isn't always very effective. Whether an operation helps, and how much it helps, will depend on how severe the symptoms are and whether the throat infections mainly start on the tonsils or on the surrounding tissue.
Because tonsils play a role in the immune system, some parents worry that surgery might weaken their child's immune system in the long term, making allergies or respiratory tract infections more likely. There hasn't been enough research to be able to say whether these concerns are well founded. The tonsils play a more important role in the immune system during a child's first few years of life than they do later, though.
What are the possible complications of tonsil surgery?
The wound might start bleeding again after the operation. This kind of bleeding may happen within the first 24 hours after surgery (primary hemorrhage) or up to 28 days after surgery (secondary hemorrhage). It is most common within the first week. If the child swallows the blood it often goes unnoticed at first. But later the child may vomit up the blood, or the blood may enter their airways. Bleeding after surgery is considered an emergency because they could lose a lot of blood. So it's important to go to a hospital immediately or to call the emergency services by dialing 112 (in Germany and other European countries) or 911 (in the U.S.). Although the bleeding may stop on its own, a blood transfusion or another operation may still be needed.
Various factors influence the risk of bleeding after surgery. These include the surgical technique used, how old the patient is, and whether he or she already has certain other medical conditions. Research has shown that:
- About 5 out of 100 children have bleeding after surgery.
- About 2 out of 100 children need more surgery as a result.
Like any operation, this procedure is associated with general risks, for example due to the anesthetic.
What does the surgery involve?
The operation is typically performed in a hospital. Children are given a general anesthetic beforehand.
The tonsils are removed using special surgical instruments. It takes about 15 to 30 minutes to perform the operation. After that, the child usually has to stay at the hospital for a few days.
What are the different types of surgery?
Nowadays tonsils can be removed in many different ways. The surgical procedures can generally be divided into two main types:
- Total tonsillectomy: The (palatine) tonsils are removed completely. This operation is performed in a hospital.
- Partial tonsillectomy (tonsillotomy): The tonsils are only partially removed. This is sometimes done as a day procedure.
There are different surgical techniques as well:
- Procedures that use heat (diathermy): These approaches involve removing tonsil tissue using radiofrequency energy to produce a lot of heat. The heat is also used to seal the wound immediately after the operation. Newer approaches use a lower temperature. This is called coblation.
- Procedures that do not use heat (dissection): These approaches involve removing tonsil tissue using surgical instruments such as scissors or a snare.
Which is better: Partial or complete surgical removal of the tonsils?
If the tonsillitis comes back often and is bacterial, doctors usually suggest removing the tonsils completely (total tonsillectomy). This is because the benefits of partial removal have not yet been studied enough.
The partial removal (partial tonsillectomy) has the advantage of being somewhat more gentle because less tissue is removed overall and the surgical wound is smaller. In the days following the procedure, children have much less pain and can start eating sooner than after a total tonsillectomy. The risk of bleeding after surgery is probably lower too. It's not clear how effectively partial tonsillectomy can prevent future tonsillitis, though. There has hardly been any research comparing the effectiveness of the two methods. As a result, statutory health insurers in Germany usually don't yet cover the costs of partially removing tonsils.
What can you do to feel more comfortable after surgery?
Pain is the biggest problem after surgery. It usually gets better after a few days. Until that happens, the pain can be relieved using medication in the form of tablets, suppositories, drops, an intravenous infusion (a “drip”) or lidocaine spray. People can also use medication to reduce nausea and vomiting.
It is thought that doing certain things can help you recover faster and lower the risk of bleeding after surgery. For example, people are advised to rest during the first few days after the operation, and only start doing sports again after a few weeks. It may also make sense to avoid solid foods at first, to go easy on the wound. Spicy foods and acidic foods such as fruit juices and citrus fruits may irritate the wound. Using mouth rinses can have the same effect.
Children sometimes find it difficult to deal with not being able to speak or eat properly after surgery. It is then important that parents, other people close to them or nurses are there for them. Chatting, reading to them or watching TV together can distract children, making it easier for them to feel more relaxed. Before the operation, children should be informed about what will happen afterwards and how they can cope.
A second medical opinion may help
Various factors will influence the decision about whether to have tonsil surgery: How often does the child have tonsillitis? How severe are their symptoms? How likely is it that the procedure will be successful? What are the chances that they will have tonsillitis less often even without surgery?
Sometimes different doctors give different advice. If your child is advised to have tonsil surgery, it might be a good idea to seek a second medical opinion – in other words, to talk with a doctor in a different practice or hospital. Our decision aid may be helpful, too. It provides a brief summary of the main pros and cons of the different treatment options.
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Fedorowicz Z, van Zuuren EJ, Nasser M, Carter B, Al Langawi JH. Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy. Cochrane Database Syst Rev 2013; (9): CD007806.
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Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Tonsillotomy for recurrent acute tonsillitis and for hyperplasia of the tonsils: Final report; Commission N15-11. January 06, 2017. (IQWiG reports; Volume 475).
Lock C, Baker R, Brittain K. 'I've just taken you to see the man with the CD on his head': the experience and management of recurrent sore throat in children. J Child Health Care 2010; 14(1): 95-110.
Morad A, Sathe NA, Francis DO, McPheeters ML, Chinnadurai S. Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review. Pediatrics 2017; 139(2).
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