Tonsils and adenoids
Mr James W Fairley BSc MBBS FRCS MS
Consultant ENT Surgeon
© 1993 – 2021 JW Fairley Content last updated 10 May 2019
- What are tonsils?
- What are adenoids?
- Why do we have tonsils and adenoids?
- Why remove the tonsils and adenoids?
- What can be done apart from surgery?
- What is the success rate of surgery?
- What are the risks of surgery?
- Is the operation more dangerous in adults?
- How is the operation done?
- Before coming into hospital
- Before the operation?
- After the operation
- How long will I be in hospital?
- What should I do when I go home?
- What do I do if it bleeds?
- Further reading / links
What are tonsils?
Acute tonsillitis – red and swollen tonsils.
t = tonsil
u = uvula
The tonsils are two fleshy lumps at the back of the throat. If you look in the mirror, with your mouth wide open, you can see them. The thing that dangles down in the middle is the uvula (you-view-la). The tonsils are either side of it. Healthy tonsils are pale pink in colour, sometimes with white spots. Infected tonsils are more red in colour. They may have yellow or green spots of pus, or grey ulcers, or a thick cheesy off-white coating.
What are adenoids?
Adenoids seen through a nasal endoscope
Adenoids are cauliflower-like swellings at the back of the nose. You can’t normally see them because they are above and behind the uvula. If the adenoids are too big, they may block the nose and cause glue ear.
Adenoidal child. Typical facial appearance, mouth breathing. The back of the nose is blocked by large adenoids.
Why do we have tonsils and adenoids?
Normal tonsils and adenoids act as a barrier to help fight infections. They are made of lymphoid tissue, part of the body’s immune system. Bacteria, virus and other particles in air and food get trapped in their folds. Immune cells sample everything. If they detect a potentially dangerous invader, they attack and destroy it with their natural chemical weapons. Some immune cells leave the battlefield and travel to the lymph glands in the neck with a message for reinforcements. The lymph glands are like factories for immune cells and antibodies. Antibodies are chemical weapons tailored specifically to one type of virus or bacterium. If the virus is new to the body, the lymph glands may be slow to react, and the invader can gain considerable ground and cause illness. But if the virus has been encountered before, the immune cells remember its structure. They rapidly switch on production of neutralising antibodies, which prevent infection from progressing. The person is immune to that virus. Unfortunately, there are hundreds of different viruses and bacteria which can cause illness. Throughout childhood, we are constantly exposed to different viruses. This probably explains why the tonsils and adenoids grow in size until around the age of 8, then, in most cases, begin to shrink. By adult life, the adenoids should have virtually disappeared, and the tonsils should be small.
Tonsils removed – yellow spots are crypt debris
Crypt debris from the tonsils comprising dead layers of shed skin, trapped decomposing food, bacteria and other micro-organisms. This debris provides a sheltered home for germs, forming biofilms. Antibiotics don’t penetrate into the crypt debris. Germs living in a biofilm state are resistant to antibiotics.
Biofilm in a tonsil crypt as seen under the microscope. Links to full size image and article in Archives of Otolaryngology Head & Neck Surgery, 2003.
Why remove the tonsils and adenoids?
Although the tonsils and adenoids, when healthy, do help fight infections, sometimes they cause much more trouble than they are worth.
- Infected tonsils can be very painful, especially on swallowing.
- Sufferers go off their food, some children fail to grow.
- Time is lost from school or work.
- Very high temperatures cause fits in some children.
- An abscess (quinsy) can form which needs emergency hospital admission.
- Very large tonsils can obstruct breathing at night.
- Bad breath can be caused by decomposing food and bacteria trapped in the deep folds of the tonsils.
- If the adenoids get too big, they cause blockage of the nose and Eustachian tube, resulting in glue ear.
- Some tonsils are chronically infected, causing constant sore throat.
If the tonsils are frequently or chronically infected, they are no longer working properly. In fact, they have been “subverted” by the enemy bacteria, acting as reservoirs for infection.
- There is plenty of other lymphoid tissue in the throat which takes over the work of the tonsils and adenoids if they are removed.
- It is not true that removing the tonsils and adenoids makes you more likely to get chest or stomach infections.
What can be done apart from surgery?
Tonsillitis can get better on its own. Simple treatment with
- plenty of fluids
- such as paracetamol or aspirin (not aspirin for children under 12 years) may be sufficient.
More severe infections can be treated with antibiotics. To prevent attacks, ensure
- a healthy balanced diet
- regular exercise
- plenty of fresh air
- Do not smoke
- do not expose children to passive smoking.
- If your child is a fussy eater, give multivitamin supplements.
- Encourage oral hygiene restrict sweets, and brush teeth at least twice daily.
- Insist on sensible bed times – lack of sleep can depress the immune system.
Many children go through a phase of repeated attacks of tonsillitis, especially when they start school and become exposed to a greater variety of viruses and bacteria. I usually recommend waiting at least a year or two, to see if the attacks will stop. A further bout of repeated attacks of tonsillitis is common in the teenage years, often following glandular fever. Again, it is sensible to wait and see for at least a year, to see if they will settle down. On the other hand, this is an important time at school for study and examinations. If it seems likely that the attacks will continue and disrupt education, operation may be the best solution.
What is the success rate of surgery?
- Removing the tonsils is completely effective in stopping tonsillitis.
- But you can still get ordinary sore throats. They will not be as bad as tonsillitis.
- Removing the adenoids is very effective at restoring the ability to breathe through the nose, unless it is blocked for some other reason e.g. allergy or sinusitis.
- Adenoidectomy is about 70% effective in treating glue ear, but the beneficial effect takes several months to develop.
What are the risks of surgery?
Tonsillectomy and adenoidectomy are very safe procedures in modern medical practice. But no operation is totally risk free.
- At worst, you could die or suffer brain damage – but you are more likely to be injured in a road accident. A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment.
- There is a risk of excessive bleeding, either during or up to two weeks after the operation.
- About 2% of patients may need a second operation to control bleeding, readmission to hospital, or a blood transfusion.
- Most serious bleeds happen in the first few hours after operation.
- During this recovery period, trained nurses will monitor your condition carefully.
- There is a risk of picking up an infection in the recovery period. Infection is more likely if you don’t eat and drink properly. That is why you should make sure you take painkillers half an hour before meals, so that it won’t be too sore to swallow.
- If you do get an infection, you may get some further bleeding and might need antibiotics, or you might need to be re-admitted to hospital for treatment.
- Your voice will change character after removing the tonsils or adenoids, ususally for the better, but some might not like it.
- There may be some numbness of the tongue or side of the mouth. This will normally be temporary, occasionally it is permanent.
- There may be some change in the sense of taste. This will normally be temporary, occasionally it is permanent.
Is the operation more dangerous in adults?
No. Tonsillectomy is relatively safe at any age, but it is more painful in adults and teenagers than in young children. There are no absolute age limits. The youngest patient I have operated on was six months, for breathing obstruction. The oldest was 93, for cancer of the tonsils.
Position for removal of tonsils and adenoids under general anaesthetic
How is the operation done?
Tonsils and adenoids are removed under general anaesthetic (fully asleep) in the operating theatre. The anaesthetist usually sends you to sleep by giving an injection. The drug injected acts very rapidly, within a few seconds. To stop the needle from hurting children, the ward nurse puts special cream on the back of the hand. It numbs the skin, so the needle doesn’t hurt. Sometimes, if a vein can’t be found or the child is too frightened, we send you to sleep with gas. This may take several minutes to work. Once you are asleep, the anaesthetist puts a plastic tube in your mouth. It goes to the trachea (windpipe) so that you can breathe during the operation. A special gag holds the mouth wide open. Both tonsils and adenoids are removed through the mouth. There is no external cut. Any excessive bleeding is controlled by a combination of pressure swabs, diathermy (electric cautery) and stitches. If you do need stitches, they will be self-dissolving. They will not need to be removed.
- Further information on General Anaesthesia for children
- Further information on General Anaesthesia for adults
Before coming into hospital
If you smoke, you should give up, because smokers are more likely to suffer complications after operation. Parents should also consider giving up, as children must not be exposed to passive smoking during recovery. Make sure you have supplies of soluble paracetamol (Calpol for children) for when you come home. Do not plan anything important during the two weeks after operation.
Before the operation
Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation, but you can drink clear fluids up to two hours before. The six hour rule does not apply to medicines – these should be taken as usual. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will
be asked by the Resident Medical Officer, and possibly by the anaesthetist. Please don’t get upset if you are asked the same question several times. This is a routine to help avoid mistakes – like an airport checking your travel documents more than once. You will be examined and checks made to ensure you are fit for anaesthetic. If you have any worries or questions, this is a good time to ask.
After the operation
After the operation, you will wake up in the recovery area, where a nurse will look after you. You will be asked to spit out the plastic tube in your mouth. There may be some blood in the mouth or nose. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. Your throat will feel sore, you will feel thirsty and tired, and you may be sick. Spit out any blood or secretions; if swallowed it will make you feel sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.
How long will I be in hospital?
Most patients operated in the morning are able to go home later the same day. If your operation is done in the afternoon, or if your recovery is slow, you may need to stay in overnight.
What should I do when I go home?
It is most important to eat and drink regularly – this helps the healing process. Your saliva contains lysozymes (lie-so-zimes) – natural antibiotics, and eating helps clean the operation area. Chewing and swallowing are like physiotherapy exercises for the throat.
- Start with fairly bland foods like buttered toast.
- Don’t have hot spices, vinegar or sharp citrus fruits, but do eat things that need chewing.
- Chewing gum – preferably sugar free e.g. Wrigley’s Orbit – between meals is very helpful.
- The throat will be especially sore when swallowing, so take a painkiller (Soluble paracetamol) half an hour before mealtimes.
- Tonsillectomy pain is often felt in the ears, earache doesn’t mean an ear infection.
- A white or yellow coating on the back of the throat, where the tonsils were removed, is normal and does not mean it is infected.
- After a day or two of rest, begin gentle exercise.
- Start just pottering around the house, then short walks outside, but avoid strenuous physical activity.
- You will need ten days off school or work after adenoidectomy, two weeks for tonsillectomy.
- Keep away from crowds or anyone with a cold, ‘flu or other infection.
- Keep strictly away from cigarette smoke.
- Avoid dirty or dusty environments.
- Take any antibiotics as prescribed for the full course.
What do I do if it bleeds?
- Most bleeds are very minor, but there is a risk of serious haemorrhage up to two weeks after operation.
- If any bleeding occurs from the nose or throat you should telephone Mrs Fairley for advice.
- If you get the answering machine, leave a message and telephone the hospital where you had the surgery.
Although we will do our best to help, we are not a 24/7 service. Also, the private hospitals are set up for planned, elective surgery, not for emergency admissions. The emergency on-call rota for ENT in East Kent is based in the NHS Rotary Ward at the William Harvey Hospital, Ashford.
- In a more urgent situation, you may need to use the 24/7 NHS emergency ENT Service based on the Rotary Ward, William Harvey Hospital.
- William Harvey is the only hospital in East Kent which maintains 24 hour emergency ENT cover.
- You should phone the Rotary ward and speak to the nurse in charge or the on-call ENT doctor.
Rotary Ward Direct tel. (3 lines)
- In case of severe bleeding or airway / breathing problems, call 999 for an ambulance or go directly to your nearest Accident & Emergency department.
- Do not waste time by attempting to contact your GP surgery, they will only refer you to hospital.
Further reading / links
- Adenoids and Tonsils – Patient UK
- Tonsil surgery – ENT.UK / British Association of Otolaryngologists Head & Neck Surgeons
- ENT.UK Position Paper on Tonsillectomy (2009)
- T14 Questionnaire Paper (2010) Parent Reported Outcome Measure for Children’s Throat Disorders
- Latest (2010) Evidence for Tonsillectomy and Adeno-Tonsillectomy: UK Health Technology Assessment North of England and Scotland Study of Tonsillectomy and Adeno-tonsillectomy in Children (NESSTAC)