Tonsil - believed to be the proverbial bread-n-butter of an E.N.T. Surgeon ; structures that can be easily implicated in a variety of maladies (with or without reason) and hence resected to add to the proverbial moolah of the E.N.T. Surgeon. There was a time that tonsillectomies were advised for any malady under the sun, especially in children. Child with poor appetite, child not gaining weight or height, high fever or just a plain sore throat and a Tonsillectomy was advised. Failure to achieve the expected results slowly became apparent and the pendulum has gradually swung to the other extreme where when Tonsillectomies are considered absolutely unnecessary. Every tonsillectomy advised is eyed with suspicion. Are Tonsillectomies really unnecessary? Is there a logic when Tonsillectomies are advised ? Can Tonsil removal be harmful ?
Rational thinking in this regard demands an understanding of the physiological role of the tonsil and its role in disease process.
"Soldiers for bodily defence" - is what some people call the tonsils. An eponym believed in now-a-days only by those who fail to keep up with advancing science and research. It is now proved beyond doubt that the tonsil have little or no role in body immunity. There is absolutely no relation between the size of the tonsil and immunological status of a patient ; nor is the immunological tolerance altered by a tonsillectomy.
For the sake of an analogy, the bodily defence can be likened to the defence capability of our country. The defensive capability afforded by the tonsil, can be likened to the barbed wire fence that exists at our borders - a structure which affords little protection against infiltration even against smugglers & drug peddlers ; let alone terrorists or enemy. It is mainly the strong military that protects the integrity of our borders. So also our body has far superior mechanisms of defence than that afforded by our tonsils.
Now suppose this wire fence were to act as a cover for the enemy activities, would a rational mind give even a second thought to its demolition ?
Having established that tonsil removal is not exactly harmful ,we can now approach the question - Whether tonsil removal is totally unnecessary as it is often made out to be. Certainly not. Consider the case of this young 6 year old girl who had consulted me with tonsils really meriting removal but who chose to be misguided and refused a tonsillectomy. She landed up a year later on the operation table for a tonsillectomy ; this time however a high surgical risk having Rheumatic carditis secondary to the tonsillar focus and almost a social cripple unable to climb up to her house on the second floor. The results of course may not always be so disastrous. Though modern antibiotic therapy has succeeded to a large extent in curbing the incidence of uncontrolled tonsillar infection warranting their surgical removal, there still exist situations when their surgical removal becomes necessary. What one must realise is that there is an emerging logic ; and criteria for a tonsillectomy are being defined after extensive study and research. The following section attempts to answer this question.
Indications for a tonsillectomy :
1. When the tonsils are prone to 'repeated' infection Clinically, we can define 'repeated' as being more than 4 attacks of acute tonsillitis per year. A word of caution here : one has to be sure that during each attack, the infection originates primarily in the tonsil. It is not unusual to label a pharyngitis as a tonsillitis or to fail to identify a post nasal sinus drip as a primary cause of the tonsillar inflammation. In such cases, a tonsillectomy is not exactly necessary.
LOGIC: The tonsils have deep crypts on their surface where antibiotic penetration may be poor and there is a likelihood of pathogenic bacteria persisting which infect the tonsil opportunistically again. If more 4 attacks per year occur, we presume that such a situation exists.
2. Chronic sore throats in the absence of a pharyngitis when the number of attacks exceed 5 per year. This should be compounded with the following clinical signs: a) Flushing of the anterior pillars. b) Jugulodigastric lymph-node enlargement c)Tonsils tender to palpation or expression of inspissated pus from the tonsil on palpation.
LOGIC: When the above clinical signs are present, there is enough reason to presume that a chronic infection is lurking in the tonsils enough to cause a repeated sore throat.
3. Even a single attack of peritonsillar abscess. These have to be drained immediately and a tonsillectomy planned after 3 weeks.
LOGIC: A peritonsillar abscess invariably leaves a potential space where bacterial eradication is inadequate.
4. When the tonsil acts as a focus for systemic infection as in streptococcal glomerulonephritis or rheumatic endocarditis.
LOGIC: When the tonsil is a focus of infection in systemic disease, a tonsillectomy is a small price to pay to reduce the possibility of a life threatening complication.
5. Rarer indications include : tonsilloliths or tonsillar stones, suspected tonsillar malignancies, for an approach during a styloidectomy or glossopharyngeal neurectomy Uvulo-palato-pharyngo-plasty (UPPP for snoring),etc.
Before we go ahead, a few words of caution regarding the selection of cases for a Tonsillectomy. Remember the following contraindications:
contraindications for a tonsillectomy:
1. The presence of an associated granular pharyngitis. This is one condition which should be carefully looked for. Lymphoid tissue in these phrayngeal islands may hypertrophy after a Tonsillectomy. This is a relative contraindication because if one is absolutely sure by observation of the evolution of an acute attack of sore throat that the focus is in the Tonsil, one may still advise a Tonsillectomy.
2. Bleeding disorder: Assessment of Bleeding Time (B.T.), Clotting time (C.T.) is absolutely mandatory.
3. Children less than the age of 4 years unless absolutely necessary; in which case, blood should be kept ready.
4. The presence of tonsillar keratosis. This is a condition which is often mistaken for a chronic tonsillitis because of the white keratin horns are often mistaken for inspisated pus of a chronically infected tonsil. The differentiating feature being that keratosis is not restricted to the tonsils but extends to the pharynx and base of the tongue.
5. The presence of submucous fibrosis especially in tobacco chewers.
It would be worthwhile now to consider a few myths that exist about a tonsillectomy.
MYTHS ABOUT TONSILLECTOMY:
1. Tonsillar size is a reflection of the degree of tonsillar infection: Actually usually, most tonsils meriting removal are small and fibrosed due to chronic inflammation.
2. Tonsillectomy is followed by an increase in the height and appetite: This may be true only if repeated attacks of tonsillitis have caused the patient to be unwell chronically and thereby affected nutrition.
3. Tonsils recur after removal: Tonsils can never recur after removal unless a part of the tonsil has been left behind due to a faulty surgical technique. Symptoms of sore throat recurring after a tonsillectomy are usually due to improper case selection.
4. Tonsillectomy causes change of voice: Certainly not if the tonsillectomy is well performed. However tonsils if very large and obstructing, when removed can cause changes in the pharyngeal resonance which always changes the voice for the better. Temporary change of voice occurs immediately after a tonsillectomy because of the pain after the operation.
5. Tonsillectomy causes a general decrease in the immunity and the body becomes prone to other infections: Certainly not. Nothing can be further from the truth. It has been established beyond doubt that removal of the Tonsil in no way affects the immunity of a person
Rational thinking in this regard demands an understanding of the physiological role of the tonsil and its role in disease process.
"Soldiers for bodily defence" - is what some people call the tonsils. An eponym believed in now-a-days only by those who fail to keep up with advancing science and research. It is now proved beyond doubt that the tonsil have little or no role in body immunity. There is absolutely no relation between the size of the tonsil and immunological status of a patient ; nor is the immunological tolerance altered by a tonsillectomy.
For the sake of an analogy, the bodily defence can be likened to the defence capability of our country. The defensive capability afforded by the tonsil, can be likened to the barbed wire fence that exists at our borders - a structure which affords little protection against infiltration even against smugglers & drug peddlers ; let alone terrorists or enemy. It is mainly the strong military that protects the integrity of our borders. So also our body has far superior mechanisms of defence than that afforded by our tonsils.
Now suppose this wire fence were to act as a cover for the enemy activities, would a rational mind give even a second thought to its demolition ?
Having established that tonsil removal is not exactly harmful ,we can now approach the question - Whether tonsil removal is totally unnecessary as it is often made out to be. Certainly not. Consider the case of this young 6 year old girl who had consulted me with tonsils really meriting removal but who chose to be misguided and refused a tonsillectomy. She landed up a year later on the operation table for a tonsillectomy ; this time however a high surgical risk having Rheumatic carditis secondary to the tonsillar focus and almost a social cripple unable to climb up to her house on the second floor. The results of course may not always be so disastrous. Though modern antibiotic therapy has succeeded to a large extent in curbing the incidence of uncontrolled tonsillar infection warranting their surgical removal, there still exist situations when their surgical removal becomes necessary. What one must realise is that there is an emerging logic ; and criteria for a tonsillectomy are being defined after extensive study and research. The following section attempts to answer this question.
Indications for a tonsillectomy :
1. When the tonsils are prone to 'repeated' infection Clinically, we can define 'repeated' as being more than 4 attacks of acute tonsillitis per year. A word of caution here : one has to be sure that during each attack, the infection originates primarily in the tonsil. It is not unusual to label a pharyngitis as a tonsillitis or to fail to identify a post nasal sinus drip as a primary cause of the tonsillar inflammation. In such cases, a tonsillectomy is not exactly necessary.
LOGIC: The tonsils have deep crypts on their surface where antibiotic penetration may be poor and there is a likelihood of pathogenic bacteria persisting which infect the tonsil opportunistically again. If more 4 attacks per year occur, we presume that such a situation exists.
2. Chronic sore throats in the absence of a pharyngitis when the number of attacks exceed 5 per year. This should be compounded with the following clinical signs: a) Flushing of the anterior pillars. b) Jugulodigastric lymph-node enlargement c)Tonsils tender to palpation or expression of inspissated pus from the tonsil on palpation.
LOGIC: When the above clinical signs are present, there is enough reason to presume that a chronic infection is lurking in the tonsils enough to cause a repeated sore throat.
3. Even a single attack of peritonsillar abscess. These have to be drained immediately and a tonsillectomy planned after 3 weeks.
LOGIC: A peritonsillar abscess invariably leaves a potential space where bacterial eradication is inadequate.
4. When the tonsil acts as a focus for systemic infection as in streptococcal glomerulonephritis or rheumatic endocarditis.
LOGIC: When the tonsil is a focus of infection in systemic disease, a tonsillectomy is a small price to pay to reduce the possibility of a life threatening complication.
5. Rarer indications include : tonsilloliths or tonsillar stones, suspected tonsillar malignancies, for an approach during a styloidectomy or glossopharyngeal neurectomy Uvulo-palato-pharyngo-plasty (UPPP for snoring),etc.
Before we go ahead, a few words of caution regarding the selection of cases for a Tonsillectomy. Remember the following contraindications:
contraindications for a tonsillectomy:
1. The presence of an associated granular pharyngitis. This is one condition which should be carefully looked for. Lymphoid tissue in these phrayngeal islands may hypertrophy after a Tonsillectomy. This is a relative contraindication because if one is absolutely sure by observation of the evolution of an acute attack of sore throat that the focus is in the Tonsil, one may still advise a Tonsillectomy.
2. Bleeding disorder: Assessment of Bleeding Time (B.T.), Clotting time (C.T.) is absolutely mandatory.
3. Children less than the age of 4 years unless absolutely necessary; in which case, blood should be kept ready.
4. The presence of tonsillar keratosis. This is a condition which is often mistaken for a chronic tonsillitis because of the white keratin horns are often mistaken for inspisated pus of a chronically infected tonsil. The differentiating feature being that keratosis is not restricted to the tonsils but extends to the pharynx and base of the tongue.
5. The presence of submucous fibrosis especially in tobacco chewers.
It would be worthwhile now to consider a few myths that exist about a tonsillectomy.
MYTHS ABOUT TONSILLECTOMY:
1. Tonsillar size is a reflection of the degree of tonsillar infection: Actually usually, most tonsils meriting removal are small and fibrosed due to chronic inflammation.
2. Tonsillectomy is followed by an increase in the height and appetite: This may be true only if repeated attacks of tonsillitis have caused the patient to be unwell chronically and thereby affected nutrition.
3. Tonsils recur after removal: Tonsils can never recur after removal unless a part of the tonsil has been left behind due to a faulty surgical technique. Symptoms of sore throat recurring after a tonsillectomy are usually due to improper case selection.
4. Tonsillectomy causes change of voice: Certainly not if the tonsillectomy is well performed. However tonsils if very large and obstructing, when removed can cause changes in the pharyngeal resonance which always changes the voice for the better. Temporary change of voice occurs immediately after a tonsillectomy because of the pain after the operation.
5. Tonsillectomy causes a general decrease in the immunity and the body becomes prone to other infections: Certainly not. Nothing can be further from the truth. It has been established beyond doubt that removal of the Tonsil in no way affects the immunity of a person