The tonsils are located in the back of the mouth flanking the uvula (the little dangling thing at the back) along the sides of the throat. The adenoids are located above and behind the uvula and can only be seen on endoscopy. The tonsils and adenoids are basically lymph nodes just like in your neck, but rather than being hidden under the skin, they are on the surface of your throat where you can seem them. As such, removal of the tonsils and adenoids have minimal (if any), impact on a patient's immune system as there are thousands of other lymph nodes that can pick up the slack.

The tonsils and adenoids generally regress in size with age to the point they can be quite small in adults. However, it is not unusual for children to have enormous tonsils the size of walnuts and even ping pong balls. Adenoids may be similarly enlarged.

Just because tonsils and/or adenoids are enlarged is NOT a good enough reason for surgical removal. T&A is recommended ONLY when they are actually causing a functional problem. What are some of these functional problems?

Obstruction

Sometimes the tonsils can be so large that a patient may have trouble swallowing and even affecting taste such that eating becomes a chore. Not only that, they may impact sleep as there is not much room for air to pass resulting in obstructive sleep apnea which is a serious medical condition. Symptoms of obstructive sleep apnea include:

• loud snoring
• restless sleep
• daytime sleepiness
• irritable daytime behavior
• difficulty waking
• witnessed apneas and/or struggling to breath at night
• head bent backwards while sleeping
• mouth-breathing while sleeping

When the adenoids are large, they may lead to problems breathing through the nose leading to persistent mouth-breathing and hyponasal speech. Such a situation not only causes a dry mouth, but bad breath and even occlusal problems which can cause adverse facial structural changes (adenoid facies). Large adenoids also cause symptoms very similar to recurrent sinus infections, allergies, and the persistent snotty nose. Removal of the adenoids often resolves all these symptoms which previously were erroneously attributed to such chronic sino-nasal infections and/or allergies. A trial of nasonex may be helpful to address isolated large adenoids prior to surgical removal (read the research here and Cochrane review here).

• Fever of 101 degrees F (38.3 degrees C) or higher.
• Enlarged or tender lymph nodes in the neck.
• A pus-like coating, known as exudate, covering the tonsils or the surrounding throat area.
• Evidence that the infection is streptococcal in origin.

These are just "guidelines" and depending on the particular history of any given patient, the guidelines may be relaxed. For example, if a child has had two episodes of tonsillitis that were so severe, hospitalization was required for several days each time, that may be enough of a reason to have the tonsils and adenoids removed. Suffering from a peri-tonsillar abscess is another reason one may decide to relax the criteria (usually having 2 in one year is suficient justification). Social reasons may also play a role such as when a given child has already missed 6 weeks of school due to several tonsillitis but doesn't meet the guidelines strictly.

Who decides on whether surgery is to be performed if guidelines are not set in stone? In the end, it is up to the patient (and/or guardians) after discussing with their primary physician and ENT.

Halitosis

Often, the tonsils and adenoids don't get infected per se, but are still irritated enough to the point that they just stink. Often they produce white stones called tonsiliths which also taste terrible. When conservative measures do not help, removal of the tonsils and adenoids are justified. Here is more information on bad breath.

Great! So how are tonsils and adenods removed?

In our practice, tonsils are removed by an innovative procedure called coblation that both cuts and stops bleeding simultaneously. The device uses a plasma field which literally breaks the molecular bonds that hold tissues together without releasing excessive heat resulting in minimal injury to surrounding tissues. The surgical procedure itself takes less than 15 minutes to perform generally speaking. With the addition of anesthesia, the whole procedure takes about 30-45 minutes from falling asleep to waking back up. Watch a video here of a tonsillectomy being performed and is illustrated on the right. Other less-utilized methods of tonsil removal include electro-cautery, CO2 laser, harmonic scalpel, scalpel, etc.

Click here to see what the back of the throat looks like after tonsillectomy.

The adenoids are removed by several different methods depending on the surgeon and may involve use of electro-cautery ablation or curette. Watch a video here of an adenoidectomy being performed by suction cauterization. Coblation may also be used in some situations as depicted in the illustration below.

Keep in mind that another factor that is taken into consideration prior to recommending surgery is age... If a child is less than 3 years old, there is a 20% complication rate from airway compromise in the post-op period. Click here for more info.

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