When is tonsil surgery a good idea in adults?
Recurrent tonsillitis not only occurs in children, but in adults too. Although surgery can prevent tonsillitis, it is associated with certain risks. The main one is bleeding after surgery.
Inflammation of the palatine tonsils can lead to a sore throat and difficulty swallowing. If the inflammation is caused by bacteria, it is often treated with antibiotics at first. If the tonsils keep on becoming inflamed, doctors may suggest having them (partially) removed instead. It’s important to carefully consider this option before making a decision: On the one hand, there’s the hope that surgery will reduce the number of throat infections or make them go away completely. On the other, the surgery carries risks and there’s no guarantee that it will help in the long term.
Surgery is only considered if
- the person has bacterial tonsillitis at least three to five times a year,
- they have taken antibiotics for it several times, and
- the symptoms greatly affect their everyday life.
If possible, it is also important to rule out that the infections are being caused by a virus. It’s not always easy to tell the difference between bacterial and viral tonsillitis. Bacteria can be detected using a throat swab.
The typical symptoms of bacterial tonsillitis are:
- Fever (above 38°C / above 100.4°F)
- Swollen and painful lymph nodes in the neck
- A white or yellow coating on the tonsils
- No cough
Surgery may also be considered if complications occur, such as a build-up of pus around the tonsils (known as a peritonsillar abscess or quinsy).
What are the benefits of tonsil surgery?
Surgery to completely remove the tonsils (total tonsillectomy) can help to reduce the number of throat infections. Once the palatine tonsils have been removed, they can no longer become infected – but other areas of tissue in the throat can still become infected.
Two small studies suggest that adults who have their tonsils removed are less likely to have throat infections afterwards. But the studies only lasted half a year, so it’s not clear whether the benefits of tonsil surgery last in the long term too. The studies showed the following:
- Without surgery: The people in the study who didn’t have surgery had about 2 to 7 sore throats in the six months after the study started.
- With surgery: The people who had surgery had about 1 sore throat in the first six months after the procedure. Depending on the study, they also had between 10 and 35 fewer days of illness than the participants who didn’t have surgery.
How much the surgery helps will depend on how severe the symptoms are and whether the infections tend to start on the tonsils or in the surrounding tissue.
What are the reasons not to have surgery?
Sometimes people start having fewer episodes of tonsillitis after a while anyway, even without surgery. It’s not possible to say whether that will happen, though. So it may be a good idea to wait and see whether things get better on their own. If they don’t, you can still consider having surgery then.
The first few days after having tonsil surgery are often unpleasant because the wounds hurt and it can be painful to swallow too. These problems may go away after a few days, but they sometimes last one to two weeks. Temporary nausea, vomiting, swallowing problems and loss of taste might occur. There may also be complications such as bleeding.
Some people are afraid that removing their tonsils will weaken their immune system and increase the likelihood of getting things like coughs and colds. There’s not enough scientific research in this area to be able to say whether that’s true, though. But the tonsils are known to play a more important role in the immune system in the first few years of life than they do later in life.
What are the possible complications of tonsil surgery?
The wound might start bleeding again after the operation. This “post-operative bleeding” usually occurs in the first week after having the procedure, but it is still possible up to four weeks after tonsil surgery. The main warning signs are frequent swallowing and blood in your saliva (spit). The blood may also get into your airways or be vomited up.
Post-operative bleeding is considered to be an emergency because it can lead to a lot of blood loss. So it’s important to go to a hospital immediately – either by asking someone to drive you there or calling for an ambulance (112 in Germany and many other countries, 911 in the U.S.). Although bleeding sometimes stops on its own, a blood transfusion or another operation may be needed.
The risk of post-operative bleeding will depend on things like the surgical technique that is used, the age of the patient, and whether there are other factors that increase the likelihood of bleeding. Studies have found the following:
- Post-operative bleeding occurs in about 5 out of 100 adults.
- About 1 of those 5 people needs to have another operation.
Your voice may sound nasal for a while. Sometimes food and liquids come out of your nose, but that will stop – usually after a few days or weeks.
Like all operations, tonsil surgery is associated with general risks such as wound healing problems, infections or side effects of the anesthetic.
What happens during tonsil surgery and what are the different approaches?
The operation is usually done in a hospital, under general anesthetic. The tonsils are operated on using special surgical instruments. It takes about 15 to 30 minutes. You will then stay in the hospital for a few days.
The tonsils can be removed in many different ways. There are two main approaches:
- Total tonsillectomy: The tonsils are removed completely. This is done 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 or laser energy. Both of these devices produce a lot of heat, which is used to seal the wound immediately after the operation. Other 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?
The partial removal (partial tonsillectomy) is somewhat more gentle because less tissue is removed overall and the surgical wound is smaller. In the days following the procedure, you 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 approaches. As a result, statutory health insurers in Germany generally don't yet cover the costs of partially removing tonsils.
If the tonsillitis comes back often and is bacterial, doctors usually suggest removing the tonsils completely (total tonsillectomy).
What can you do to feel more comfortable after surgery?
Pain is the biggest problem after tonsil 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 a throat spray. People can also use medication to reduce nausea and vomiting.
It is thought that doing certain things can help you recover faster and reduce the risk of bleeding after surgery. For example, people are advised to rest during the first few days after the operation, to avoid carrying heavy objects and only start doing sports again after a few weeks. It can also be a good idea to avoid having hot showers or very warm baths. Spicy foods and acidic foods, including fruit juices and citrus fruits, may irritate the wound. Gargling with mouth rinses can have the same effect.
A second medical opinion may help
Various factors will influence the decision about whether to have tonsil surgery: How often do you get tonsillitis? How severe are the symptoms? How likely is the procedure to be successful? What are the chances that you will start having tonsillitis less often anyway, even without surgery?
Sometimes different doctors give different advice. If you are advised to have tonsil surgery, the doctor has to inform you that you have a right to seek a second medical opinion – in other words, to consult 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.
Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2014; (11): CD001802.
Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC). Therapie entzündlicher Erkrankungen der Gaumenmandeln – Tonsillitis (S2k-Leitlinie). AWMF-Registernr.: 017-024. August 2015.
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.
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 6, 2017. (IQWiG reports; Volume 475).
Powell J, O'Hara J, Carrie S, Wilson JA. Is tonsillectomy recommended in adults with recurrent tonsillitis? BMJ 2017; 357: j1450.
Royal College of Surgeons of England. National Prospective Tonsillectomy Audit. Final Report of an audit carried out in England and Northern Ireland between July 2003 and September 2004. May 2005.
Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage following tonsil surgery: a multicenter prospective study. Laryngoscope 2011; 121(12): 2553-2560.
Seshamani M, Vogtmann E, Gatwood J, Gibson TB, Scanlon D. Prevalence of complications from adult tonsillectomy and impact on health care expenditures. Otolaryngol Head Neck Surg 2014; 150(4): 574-581.
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