Should I (or my child) have my tonsils and/or adenoids removed?

This is a common question that I'm asked by patients. There is much mystery and misinformation about tonsils and adenoids; what they do; and whether they should or shouldn't be removed and what having the operation is like. This naturally gives rise to concern about what the right thing to do is. You can read more about tonsillectomy here, here and here or adenoidectomy here

A common anxiety is that the tonsils are useful, and removing them will somehow harm the immune system or body in some way. This is an entirely understandable concern - we have tonsils and adenoids, so they must serve some kind of purpose? 

Yes, that is certainly true. Tonsils and adenoids are made of lymphoid tissue and play a role in the development of the immune system and fighting infections. However, they only really play a role in the development of the immune system in the first year or two of life.  This is certainly a relevant point, however, this benefit needs to be weighed against the harm that tonsils and adenoids sometimes cause in children under the age of two.

After the age of two, there are no adverse effects on the immune system from tonsil removal. The average person has a couple of hundred lymph glands in the head and neck region, and the lining of the mouth and throat is peppered with lymphoid tissue, so there is more than enough surplus lymphoid tissue to fight infections.

So when should tonsils or adenoids be removed? 

Sometimes the answer is obvious - if you're having severe tonsillitis every month or your snoring is so bad that you can't breathe properly a night, then the decision may be an easy one. However, in many cases it isn't quite so clear. As a consequence, guidelines have been written, and research performed, to help patients and doctors decide whether tonsils or adenoids should be removed or not. It's important to remember that guidelines are just that, guidelines, and not rules. There may be situations, such as with multiple antibiotic allergies or other health problems, that may make tonsillectomy or adenoidectomy appropriate, even if criteria are not perfectly met. Conversely, if a patient has a bleeding disorder that cannot be controlled or conditions that make a general anaesthetic hazardous, then further observation and medical management rather than surgery may be appropriate.  

Tonsil and adenoid problems can be grouped into obstructive or infective problems, which I will discuss as separate groups. 

Infective Problems

Recurrent Tonsillitis: In the UK, the most commonly followed guidance is that written by the Scottish Intercollegiate Guidelines Network (SIGN), which is broadly similar to the guidance in the United States. In summary, these guidelines recommend tonsillectomy may be an appropriate treatment if the sore throats due to tonsillitis are severe and occur:

  • Seven times in the previous year, if you have only had tonsillitis for one year. 
  • Five times a year if you have had tonsillitis for two years. 
  • Three times a year if you have had tonsillitis for three or more years. 

However, this does not mean that the tonsils should be removed. An acceptable alternative may be to continue monitoring the situation, with further courses of antibiotics being used to treat infections as they occur. Most people will 'grow out' of tonsillitis at some stage, the problem is not knowing when that is going to happen. 

Peritonsillar abscess ("Quinsy"): This is an unusual condition where a collection of pus ( an "abscess") forms next to the tonsil. If it occurs on one occasion, then tonsillectomy is usually not required, unless there is a background history of recurrent tonsillitis or blockage of the airway. If you have had two or more quinsies, then it is likely that you will have further quinsies, and tonsillectomy should be considered as a treatment. 

Tonsillar asymmetry: Occasionally one tonsil can be bigger than the other. In the vast majority of cases, this is due to previous infection, or slight differences in the anatomy of the tonsil bed on each side. Tumours or cancers of the tonsil are very rare. If there is any question or concern as to why one tonsil is larger than the other, it can be removed and sent for analysis. 

Recurrent (middle) ear infections ("recurrent acute otitis media"): These infections commonly cause symptoms of earache, raised temperature and sometimes discharge from the ear. Younger children and babies might pull their ears, or bang their head. The insertion of grommets can be very helpful if the infections are frequent. If the grommets fall out, and the problem continues, then removing the adenoids as well as putting in further grommets can help reduce the frequency of infections. 

Other conditions: There are a number of other situations where tonsillectomy might be appropriate, however good evidence from clinical trials is sometimes lacking. These conditions include:

  • Recurrent tonsil stones ("tonsilloliths")
  • Bad breath ("halitosis"), where other causes have been ruled out. 
  • Chronic tonsillitis
  • Chronic sinusitis in children. If medical treatments, such as topical steroid sprays in the nose, have not worked, then removing the adenoids is often helpful. 
  • PFAPA ("Periodic Fever, aphthous stomatitis, pharyngitis and cervical adenitis") syndrome. This is an unusual condition, that as the name suggests, causes recurrent problems with fever, mouth ulcers, sore throats, and enlarged glands in the neck. It usually settles of its own accord, although occasionally removing the tonsils is appropriate. 

Obstructive Problems

Sometimes tonsils and adenoids can cause problems by virtue of their size. Depending on the circumstances, removal of the tonsils and adenoids can sometimes be helpful. 

Snoring with obstructive sleep apnoea (OSA): Snoring is the noise generated by obstructed airflow through the upper airways whilst asleep. Sometimes, the obstruction can be temporarily complete, that is to say for a short time breathing stops. This caused obstructive sleep apnoea, or "OSA". If this is severe, and the tonsils and adenoids are enlarged, then in most cases, removal of the adenoids and tonsils is advisable. In moderate or mild cases, it is often advisable to remove the tonsils and adenoids if the problem persists, although sometimes a further period of observation may be appropriate, as in many cases, children will grow out of this problem. 

Nasal obstruction: Sometimes in children, and much less commonly in adults, enlarged adenoids can cause a blocked nose. They can also give rise to a change in the quality of the voice, so it sounds as if you have a blocked nose when you speak (this is known as 'hyponasal speech'), and can sometimes affect the sense of smell. Removing the adenoids can be very helpful in relieving such symptoms. However, it is important that other causes of a blocked nose, such as allergic problems, a bend in the middle partition of the nose or chronic sinus infections are also identified and treated if present.

Less common obstructive problems where adenoidectomy or tonsillectomy may be helpful, although there is not good research evidence to support it include:
Swallowing problems ("dysphagia") caused by very large tonsils
Change in voice quality due to large tonsils or adenoids    

When should tonsils and adenoids not be removed? 

Sometimes removing the tonsils or adenoids can be especially risky, or likely to cause more problems than it solves. In these cases, it is often a good idea to avoid surgery. Such situations include:
A severe bleeding disorder: as with most operations, there is a (small) risk of bleeding when removing the tonsils or adenoids. If your body isn't able to clot properly, this can be a serious problem and surgery may be best avoided. 
Developmental problems of the palate or upper airway, such as cleft palate. In these conditions, the tonsils can play an important part in the swallowing mechanism. If the tonsils, and particularly the adenoids are removed, there is a higher risk of developing nasal regurgitation (food and especially drink, entering the nose when swallowing) and a type of nasal speech ('hypernasal' speech, collectively known as 'velopharyngeal incompetence'. Sometimes surgery is best avoided or modified to minimise this risk.
Neurological or muscular problems of the throat: operating in this situation also carries the risk of velopharyngeal incompetence (see above).
Active infection: If the tonsils are actively infected, the risk of bleeding at the time of, or after surgery is increased. In most cases, it is advisable for surgery to be postponed for two to three weeks after an episode of tonsillitis. 

What questions should I ask my surgeon?

As with any procedure, there are several factors that need to be considered:

  • What does surgery involve, and what is the recovery like?
  • What are the benefits and outcomes (ideally the surgeon's own outcomes) of doing the operation, or not doing the operation?
  • What are the risks of the operation, but importantly, what are the risks of not having an operation? When talking about surgery, there is a natural tendency to focus solely on the risks of surgery, which will usually occur within a defined period of time. However, there are also risks of not doing surgery, such as problems developing with the heart and lungs with untreated obstructive sleep apnoea or infections from the tonsils spreading to other parts of the body. 
  • Importantly, what are the alternatives to surgery?

Know your symptoms: when blocked ears or nose or a sore throat get serious

One of the things that makes ENT such an interesting speciality is the wide variety of symptoms that patients present with. However, as a patient this one of the reasons ear, nose and throat symptoms can be so worrying. These symptoms often give rise to anxiety, which can lead to other problems such as poor concentration, sleeplessness and forgetfulness, which makes matters worse.  

National Stop Snoring Week - 25th-29th April 2016

National Stop Snoring Week - 25th-29th April 2016

Snoring. Most of us do it occasionally, and the majority of people see it as just a minor annoyance. However, it can be a symptom of more serious conditions, such as sleep apnoea, so if you are aware that you snore regularly and are worried you might have sleep apnoea (see below) it might be worth seeking expert advice.

Pass the cheese, Grommet

You may be wondering what Nick Park’s lovable plasticine characters have to do with ear, nose or throat conditions – the answer is, very little other than sharing a name with a medical device which can help alleviate ear problems in young children.

Painful ear infections

Children can be prone to suffering from ear infections. These can be very painful, resulting in repeated trips to the doctor and time off school. There is, however, an effective treatment for recurring ear infections, a tiny tube called a grommet that is inserted into the middle ear.

The very short procedure takes place while the child is under general anaesthetic. The grommet’s tubular shape allows air to pass through into the middle ear (behind the ear drum) which helps drain the excess fluids which cause ear infections.

Treatment for glue ear

Grommets can also help treat ‘glue ear’, which is a condition that commonly affects children. It is caused when the middle section of the ear becomes filled with fluid due to the malfunction of the tube that drains the middle ear to the back of the nose (the Eustachian tube). Often the first symptom of glue ear is that children struggle to hear clearly, although it is not usually painful.

If glue ear doesn’t settle of it’s own accord, grommets can help the excess fluids drain away, providing an easy and effective solution to this problem.

Grommets are tiny plastic tubes, a couple of millimetres wide, that come out of their own accord, usually after ten to twelve months. There is no need for a follow up procedure to remove the grommet. As a general rule, children will grow out of conditions such as repeated ear infections and glue ear. Grommets can help alleviate matters whilst this occurs.

Preparing your child for surgery

Going into hospital can be unnerving for people of any age, but is especially so for children. However, the operation is quick and it won’t be long before it’s time to go home – generally patients can expect to go home around two hours after the procedure has been completed. Most children need only one day off school.

Mr Julian Hamann, a father of three, is experienced at putting children at ease before their procedure. He understands that explaining the process in terms they can understand is important in alleviating their anxiety.



Understanding nosebleeds

Nosebleeds are unpleasant, and happen for a number of reasons. Most nosebleeds are relatively harmless, although very rarely they may be a symptom of something more serious. In most cases, simple preventative steps can be taken to try and reduce their frequency. In order to establish whether or not you should seek medical attention, it is helpful to understand why nosebleeds occur.

There are two broad types of nosebleed:

  1. Anterior – this means the bleeding has started towards the front of your nose
  2. Posterior – these are less common and start at the back of your nose

What causes anterior nosebleeds?

Anterior nosebleeds are more common, and are rarely a cause for concern. They result from the delicate blood vessels near the entrance to your nose bursting.

This may be due to physical causes, such as an injury or bump to the nose; blowing your nose very hard; inserting fingers into the nose (a common problem in small children) or nasal complaints such as a cold or sinusitis.

Environmental factors can also cause anterior nosebleeds. These include allergies such as hay fever; changes in altitude; rapid changes of air temperature; dry air or overuse of over-the-counter decongestant sprays.

Anterior nosebleeds are generally self-limiting.

More serious conditions

Posterior nosebleeds can be more serious. The blood is coming from larger arteries, located further back in the nose. Therefore, the flow can be harder to control. The blood is also more likely to run into the throat.

These nosebleeds can result from head or facial injury. Very rarely, they may be symptomatic of nasal tumours. Some people are more prone to this type of nosebleed.

Both anterior and posterior nosebleeds can be exacerbated by certain types of medicine, such as those prescribed for blood thinning (for example, aspirin or warfarin). Some herbal medicines, such as gingko biloba, can also increase the risk of bleeding.

People suffering from high blood pressure may have an increased susceptibility to nosebleeds. Nasal problems such as a bend in the middle partition of the nose (septal deviation) or chronic rhinitis or sinusitis also leave people more vulnerable to nosebleeds.

When to seek medical advice

Nosebleeds are rarely serious, and it is important to stay calm. You can apply pressure to the middle partition at the front of the nose by pinching the nostrils, and most nosebleeds will stop of their own accord. If you think you may be suffering from one of the more serious types of nosebleed, or you have been experiencing blood flow for more than 20 minutes, it is sensible to seek medical attention.

If you are experiencing frequent nosebleeds you may be referred to an ENT surgeon. Consultant ENT surgeon Mr Julian Hamann can investigate and treat nosebleeds. Treatment is often simply a matter of cauterising the ‘bleeding point’ in the nose, sealing it to prevent recurrence of the problem.