There has been an ongoing battle between adults and the tonsils of their children since the advent of modern surgery.

For those children born not long after World War II, the battle was almost always won by the adults, nearly every child in this generation had their tonsils removed.

Starting in the late 1970’s and the 1980’s the tonsils fought back, leading many doctors to ask, does every child need to have their tonsils removed, and the number of tonsillectomies dropped.

In the last 5-10 years, the pendulum has swung back against the tonsil, and the number of tonsillectomies has started to rise again.

So it is with great interest that we report that a team of public health and pediatric ENT specialists at Vanderbilt have put together a major review of the evidence for and against taking out our children’s tonsils for sore throats.

http://pediatrics.aappublications.org/content/139/2/e20163490

Before reporting the findings, some background is in order.

Background on Tonsils

Let’s start with describing just what tonsils are.  The tonsils are simply a pair of lymph nodes.  They have their own name because they are visible.  The only other pair of lymph nodes that can be seen without surgery are the adenoids, but they sit on top of the palate, so you can’t see them without a mirror, which means only ENT specialists tend to be able to see them.

But tonsils are special because anyone can, and does, see them.  If you imagine looking at the back of your throat in the mirror, you will see two stretches of tissue framing the view of the back of the throat, those tissues have a fold on the right and left side of the throat where a lump of tissue sits, the tonsil.  (See the picture below).

Tonsils are also special because they are the only lymph nodes that actually touch stuff you swallow.  Every bite you eat and every drink you sip splashes over your tonsils as it goes down the hatch to your stomach.

This relates to the whole purpose of a lymph node.  We all have about 600 lymph nodes in our body.  Together with the marrow and spleen, the whole apparatus is the immune system.  The lymph nodes monitor the fluids in every part of our body and look for evidence that an unwanted cell or virus is around.  If the alarm is raised the node makes organizes the creation of antibodies and swarming of immune cells to destroy the invader.  If that happens, they get a lot bigger to make the extra antibodies and cells to go to battle.

So one of the key properties of every lymph node in the body, is that they get bigger and smaller, all the time, normally.  That is what the immune system is meant to do, lie dormant when no enemy is present, but get mobilized when the attack is upon it.  Mobilization makes the node big rapidly, dormancy allows it to slowly shrink over many weeks or months.

So it is with tonsils, they get big with colds and sore throats, and small when well.  They also have two other curious patterns.

The first is that the normal tonsil has lots of rough surface features, little crevices, valleys, crypts. They are meant to be there to catch bits of what you swallow, so the immune system can literally read what is present in your mouth.  The material held for reading often gets bleached white over time, and this is the frequently observed bits of very white material in everyone’s tonsils from time to time.

The other curious property is that kids’ tonsils are mammoth compared to adults.   This is because the immune system of a child is bigger than an adult’s.  Puberty, for unexplained reasons, makes everything bigger in our bodies, except our immune system.  Going through puberty shrinks the immune system by about a third!   A major organ of the immune system in childhood, the thymus, nearly disappears entirely by the end of puberty.  We parents have barely a thread of a thymus left.

And so it is with our tonsils.  They tend to be enormous in childhood, but shrink and nearly disappear in adulthood.  That’s why when we brush our teeth, most (not all) adults can barely see  their tonsils, even if they were never removed.  But look in your child’s mouth, and two bulging masses jump out at you, and since we don’t have them, it scares a lot of parents.

The important point here is thatc having tonsils is normal, having them get enormous in childhood is normal, having them get big and small back and forth is normal.  Having white stuff appear on them when you are well is normal.

Background on sore throats

Now let’s take a look at sore throats.   Sore throats are universal and common.  Everyone gets them, and almost always a whole bunch of them over a lifetime.  Kids get more than adults, since they are getting all their area’s viral illnesses from age 4-5 months and up.  Over time, babies and kids burn through hundreds of these viruses, and the number of new ones begins to drop, and so they become like us, getting a virus now and then, but not all the time.

Sore throats can be caused by irritation- drinking burning hot soup, dry air, and such.  Or by infection.   Sore throats from infection in kids are due almost entirely to two germs:  strep and viruses.

Strep causes about about 30% of all sore throats in kids.  So viruses cause about 70% of sore throats in kids.  That’s why when you bring your child in to see if their sore throat is from strep, it so often is not, in fact typically about 70% of the time.

The good news on sore throats from strep and viruses is that they tend to be harmless, miserable, but harmless.  Meaning, once the sore throat is done, you are fine.  Rarely a sore throat from strep can cause a complication, but that’s pretty rare, and very treatable.   For 99% or more of children, once the sore throat goes away, they are fine.

Background on surgery for sore throats

Back in the days of universal tonsil removal, all a doctor had to do was point out to a parent that their child’s tonsils were big, and they could convince them to agree to have them removed.   You now know why that worked, kids have much bigger tonsils than their parents.

Those days are over, but now we live in an era in which children with many sore throats are told that surgery can be helpful.

What’s the rationale for performing surgery to prevent sore throats?  The idea is based on the concept that the tonsil is where strep infect the throat. Take out the tonsils, no more strep infection.

That turns out to be a testable proposition.  If it is true, then taking out someone’s tonsils should lead to strep disappearing.

The other possibility, of course, is that strep infects any part of the throat, in which case taking out the tonsils won’t make much of a difference.

Ultimately, the main reason ENT surgeons propose taking out the tonsils for children with many sore throats, is to not just reduce the number of sore throats, but make the child happier, more comfortable.

Of course, one has to go into this whole question with a healthy dose of skepticism.  Surgery is a rather big deal, it involves risky cutting and also exposure to anesthesia which is increasingly seen as not such a harmless thing for the growing brain.

So the burden of proof should lie heavily on the surgery to prove it helps.  If it doesn’t, it should not be done.

The Medical Review of the Ability of Surgery to Help Children with Sore Throats.

The article is the most serious attempt to look at this issue.  It is conducted by a program devoted entirely to figuring out what medical practices help and which do not, the Vanderbilt Evidence Based Practice Center.  It is part of a very serious effort by the nation’s top agency devoted to the science of knowing if a medical intervention works, the Agency for Healthcare Research and Quality, the AHRQ.

Here is what they found, it was most fascinating:

• Over the last 25 years, 9,608 articles looked at the issue of whether taking out tonsils helps kids with sore throats.  That is a very large number of published articles.  This is a big issue.
• Of those 9,608 articles, a grand total of 7 met this study group’s threshold for being of sufficient quality to be helpful.  This is astounding (!).  That means 9,601 of 9,608 articles on the subject were not helpful.  Seven out of nearly 10,000 is a very dismal proportion.
• The seven studies delivered evidence that having your tonsils removed did reduce the number of sore throats you had.  But the reduction was from an average of 0.64 sore throats a year to an average of 0.5 sore throats a year.  The surgery did not eliminate sore throats.
• The reduction in the number of sore throats was most notable in the first year after surgery, the average number of sore throats without surgery was nearly 3 a year, and after surgery that average was 1.74, in the first year.  After the first year there was no difference in the sore throat experience if you got surgery.
• Looking at overall quality of life, the seven studies demonstrated no real improvement overall for kids who got their tonsils out.
• Looking over all 7 studies for strength of evidence, what popped out was that it appears surgery drops the number of sore throats the first year after surgery, but after that there is no real difference between kids who didn’t get their tonsils out and those who did.
• Not one study looked at differences in the experiences of kids with and without tonsils more than 3-4 years out.

BOTTOM LINES

1. Tonsils are a very normal part of our bodies.  They are lymph nodes, two of the about 600 everyone has.
2. Tonsils get white patches on them all the time and normally.
3. Tonsils are much, much bigger in childhood, and shrink dramatically during puberty, in most people.
4. Tonsils are built to get big when you have a cold, a sore throat.  They stay big for months after each.
5. Surgeons used to try to remove all children’s tonsils until about 40 years ago.  Now we still have surgeons who recommend that tonsils be removed if a child has a lot of sore throats.
6. A very important review of nearly 10,000 articles on whether taking your child’s tonsils out for sore throats helps found that there were mild benefits seen in the first year after surgery, but after that no difference between those with and without surgery was seen.

Before ending this essay, we should observe that everyone is different, and for individuals, we have seen many kids who went from one strep throat after another to none after their tonsillectomy.  So it seems to help some children.

Looking at the reported literature, however, the impact of surgery is strikingly underwhelming, for the vast majority of children.  Even at the peak of benefit, the year following a proposed surgery, the biggest benefit reported was dropping the number of sore throats from 3 to about 1 3/4.  That’s not a terribly impressive change.  And to find that the number of sore throats after the first year is no lower if you get surgery was compelling news.

We remain happy to help you think about this decision should the need arise, it still is a good idea for some children.  But for the majority of children, having many sore throats (even strep throats) does not appear to mean removing the tonsils will really help.

To your health,
Dr. Arthur Lavin