Tonsillitis: Tonsil surgery in children

Removing the tonsils completely (total tonsillectomy) can help reduce the number of throat infections. The tonsils 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.

The children were ill for an average of five days less per year.

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, increasing the risk of allergies or respiratory tract infections. 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.

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, the patient’s age, and whether they already have 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.

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.

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 requires a hospital stay.
• 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 or laser energy. Both of these devices produce a lot of heat, which is 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.

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 is 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.

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 films or shows 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.

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.