First, not all patients have tonsils that are markedly enlarged. I would estimate that this about 5-10% of all adults with sleep apnea would be ideal candidates for tonsillectomy as a first-line treatment. This figure seems relatively small, but it still is quite a few patients who could have their tonsils removed because sleep apnea is so common.
It would be important to repeat the studies in larger groups, just to confirm the findings. Third, the studies are not what are called randomized trials. Randomized trials could include patients with sleep apnea and markedly enlarged tonsils, either performing tonsillectomy or observing them without treatment for a period of time . Unfortunately, it turns out that making people wait for surgery just to be part of a research study is incredibly difficult. Patients will prefer not to be involved in these studies if they are interested in having surgery .
Finally, there are perceptions about surgery for sleep apnea that we have to overcome. I have written before that most surgeons, other physicians, and the public think that there is only one surgery for sleep apnea. Tonsillectomy improves obstructive sleep apnea in most children. A 2015 Cochrane review found moderate quality evidence for benefits in terms of quality of life and symptoms but no benefit in attention or academic performance. It recommended that physicians and parents should weigh the benefits and risks of surgery as OSA symptoms may spontaneously resolve over time.
The procedure is recommended for those who have OSA that has been verified by a sleep study. Studies have shown that treatment success of uvulopalatopharyngoplasty with tonsillectomy increases with tonsil size. The study reviewed the historical context of the procedure and assessed whether initially reported benefits could be reproduced by other surgeons with a larger cohort of patients. The December 2016 issue of the medical journal The Laryngoscope included an interesting study examining this question.
Twenty-nine adults with markedly enlarged tonsils (size 3+ or 4+ on the Friedman scale), obstructive sleep apnea, and no substantial obesity (body mass index below 32 kg/meters squared) underwent tonsillectomy alone. One patient was lost to follow up, but the rest of the patients had sleep studies before and then 6 months after surgery. Impressively, the average apnea-hypopnea index decreased from 40 to 7 events per hour after undergoing tonsillectomy for sleep apnea, with only 2 patients having anything worse than mild sleep apnea. There were also substantial improvement in the score on the Epworth Sleepiness Scale score that measures daytime sleepiness . Tonsils are the oddly shaped masses of soft tissue located in the back of the throat , which are part of the lymphatic system designed to help fight off infections.
They vary in size and are susceptible to swelling for a variety of reasons. The removal of tonsils has been practiced for nearly 3,000 years due to chronic or severe swelling, sore throats, tonsillitis, and more recently for extreme cases of sleep apnea and snoring. There is no evidence showing that tonsillectomies weaken or impair the lymphatic systems ability to fight infections. However, there are always risks involved with any kind of surgery and should be taken seriously when considering a tonsillectomy.
Swollen and enlarged tonsils can impair breathing and cause pain for both children and adults. Tonsil removal surgery is typically recommended for severe, recurrent issues and /or chronic tonsillitis. Like an adenoidectomy, a tonsillectomy is a brief procedure that doesn't require an overnight stay. The two procedures are often performed together in children under 13 who have both enlarged adenoids and tonsils. It would be great to hear how Mark is doing, but the nice thing about these studies is that they include scientific evaluation of groups of patients. Surgery like tonsillectomy can have substantial pain during the recovery period, but the good thing about surgery is that there is nothing to wear or tolerate like there is with CPAP or a MAD.
This makes it easier for patients with insomnia to experience resolution of their sleep apnea after surgery if they are really good surgical candidates like patients with markedly enlarged tonsils. Studies show that women, especially, with sleep apnea will often seek medical care for insomnia that turns out to be mainly related to sleep apnea. However, people with insomnia and sleep apnea should not expect that their insomnia will clear up with treatment of their sleep apnea alone. For adults with obstructive sleep apnea, the standard treatment is positive airway pressure therapy . Surgery is reserved for patients who are unable to tolerate or benefit from positive airway pressure therapy.
For children, adenoidectomy and/or tonsillectomy for sleep apnea is the standard treatment. Positive airway pressure therapy is not an ideal treatment for most children. This is due to concerns over effects on facial growth and difficulty that children may have with tolerating it through the night. It is reassuring that surgical outcomes in children–while by no means perfect–are relatively good, especially when the tonsils or adenoids are enlarged and when the child is not considered substantially overweight. Oversized tonsils and adenoids—which could be genetic or the result of an infection—can make it tough for kids to breathe at night, disrupting their sleep and leading to concentration and behavioural issues during the day.
Tristan often complained about being tired and had snored nightly since he was little. But she didn't realize how serious the problem was until they went for a sleep test last June. Tristan stopped breathing 16 times in the night and was diagnosed with mild sleep apnea. Surgery is not recommended for those with fewer than 7 documented throat infections in the last year, fewer than 5 each year for the last 2 years, or fewer than 3 each year for 3 years. Severely affected children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not. Specifically one review of five randomized controlled trials, found a decrease from 3.6 to 3.0 episodes in the year following surgery.
In less severely affected children, surgery results in an increase, rather than a decrease of sore throats when the sore throat directly following surgery is included. Surgery results in a reduction in school absence in the year after surgery, but the strength of evidence is low. Surgery does not result in an improvement in the quality of life. Those with frequent throat infections often spontaneously improve over a year without surgery. Therefore, a certain number of people who undergo surgery will do so unnecessarily as they would not have had further episodes of tonsillitis had they not had surgery. Evidently, there are several research studies that have come up to the conclusion that there is a negative impact of tonsillectomy on children's immunity.
They claim that the immune system is under development in children and hence, undergoing a tonsillectomy can increase the relative risk of respiratory diseases to triple fold. A child who undergoes a tonsil removal surgery is more likely to develop chronic obstructive pulmonary disorder, upper respiratory tract diseases and conjunctivitis in their later stages of life. He would also make them aware that they might have minor postoperative complications and very rarely life threatening complications.
Patients are advised to consult their physicians regarding their personal health. Getting your tonsils removed is a procedure called tonsillectomy, and is done for various reasons. The most common reason it is done is if a person is suffering form recurrent sore throats. The tonsils are located in the back of the throat, and are made up of a mass of lymphatic tissue. Their exact purpose isn't known, but it is thought to have something to do with the immune system. The most effective treatment for problems with the tonsils is to have them removed, but the full effect that this may have on the body is still largely unknown.
A common question I'm asked is 'the tonsils are there for a reason, am I more likely to have coughs and colds, or is my immune system likely to be affected by having my tonsils removed? This is a good question, that is difficult to answer definitively, as the research that has conducted on this matter doesn't give a clear answer. It could be that surgery caused the increased risk, or alternatively it could be that children who had a tendency to these conditions were also more likely to have tonsil and adenoid problems requiring surgery. Another study has shown a 30% reduction in asthma flare-ups in children with asthma who have their tonsils removed. The conventional treatment for this medical condition is complete removal of the tonsils by a variety of surgical procedures . Since the tonsils are located in the back of the mouth, the main symptom is sore throat.
Sometimes the pain is severe enough that children will only eat food that is easy to swallow. Fever, headache, and stomach ache are additional symptoms that may be present. The tonsils tend to become swollen and inflamed while the lymph nodes in the neck become enlarged and tender. An important factor in diagnosing tonsillitis is that nasal drainage, cough, and hoarseness are not present.
These symptoms are more consistent with a cold or upper respiratory infection, not tonsillitis. Intracapsular surgery is generally offered to children, as the benefits are very clear. Children presenting with very big tonsils and/or adenoids are ideal candidates for an intracapsular procedure. At ENT Surrey, we also have very good experience of intracapsular techniques in children with recurrent tonsillitis. Surgery needs to be more meticulous in these cases to avoid the possibility of on-going symptoms. In our most recent study, on-going or recurrent symptoms were exceptionally rare.
We are also using this technique in adults, but at the moment there is a lack of widespread evidence to understand the long-term outcomes. Early suggestions are that this is a useful technique in adults, but the benefits of reduced bleeding and faster recovery may not be quite as obvious as in children. If you are considering a tonsillectomy as an adult, you should ask your surgeon of their personal experience of intracapsular surgery. A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay.
Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a circle of poor fluid intake. Tonsillectomy appears to be more painful in adults than children. Controlling the pain following tonsillectomy is important to ensure that people can start eating again normally following the procedure.
Tonsillectomy is mainly undertaken for sleep apnea and recurrent or chronic tonsillitis. It is also carried out for peritonsillar abscess, periodic fever, aphthous stomatitis, pharyngitis and adenitis , guttate psoriasis, nasal airway obstruction, tonsil cancer and diphtheria carrier state. For children, tonsillectomy is usually combined with the removal of the adenoid. However, it is unclear whether the removal of the adenoid has any additional positive or negative effects for the treatment of recurrent sore throat.
But patients younger than 2 years old may have a higher risk of respiratory complications with this surgery. To determine whether the procedure is truly needed, your child's healthcare provider may require more preoperative testing, such as polysomnography . Tonsillitis Tonsillitis is a contagious infection with symptoms of bad breath, snoring, congestion, headache, hoarseness, laryngitis, and coughing up blood. Tonsillitis can be caused acute infection of the tonsils, and several types of bacteria or viruses . Acute tonsillitis lasts from one to two weeks while chronic tonsillitis can last from months to years.
This study was prospective, randomized, and single blinded. The study protocol was reviewed and approved by the research ethical committee of the of Department of Otorhinolaryngology–Head & Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland. Forty patients aged 18 to 65 years admitted for elective tonsillectomy at the ENT unit of Helsinki University Central Hospital entered the study. The indications for tonsillectomy were recurrent infections, chronic infection, airway obstruction, or history of quinsy. Exclusion criteria included patients with bleeding disorders and any significant chronic illness that would interfere with expected recovery.
The electrosurgery system was also contraindicated in patients with pacemakers or other electronic device implants. Each patient was randomly assigned to either the TEtrad or TErfta group by the surgeon's (L.B.) picking a card from a pack of cards. The first author (L.B.) did all the procedures, and the same anesthesiologist (M.P.) administered the anesthesia. We are in the midst of a major change in rethinking sleep apnea surgery–for all parties involved. The goal is developing a tailored approach to sleep apnea treatment with an approach that is often called personalized medicine. I see many young adults with markedly enlarged tonsils who are struggling with positive airway pressure therapy, including many with mild sleep apnea who are not overweight.
For these patients, I think it is very reasonable to think about surgery as a first-line option instead of being on positive airway pressure for the rest of their life. These patients have a greater than 90% chance of clearing up their sleep apnea with tonsillectomy alone. Not every one of them will want to have surgery, but this should be part of the discussion because the results will be so good, based on everything we know about sleep apnea surgery outcomes. Adenotonsillectomy is one of the most commonly performed surgeries in the pediatric and young adult populations.
The postoperative morbidity of this surgical procedure is often significant, including odynophagia, dysphagia, fever, halitosis, loss of weight and reduced oral intake. Intracapsular tonsillectomy has been pioneered for use in children and is mainly used for large tonsils causing obstruction . There is also now increasing evidence for it to also be offered to children suffering with recurrent tonsillitis.
Intracapsular surgery has the advantage of reduced risks of bleeding as well as a much speedier recovery. One of the major downsides of conventional extracapsular surgery is the risk of bleeding after the operation with rates quoted between 2 and 5%. With intracapsular techniques the risk of bleeding is thought to be as low as 0.2%. Most children who have an intracapsular operation can return to school or nursery within a week whereas those that undergo extracapsular procedures will need 14 days off school.
Making the decision to have a tonsillectomy is often based on how many times the patient has had tonsillitis. Weighing the pros and cons of a single surgery to three or four rounds of antibiotics and sore throats each year can often make the decision easier. In addition, if the tonsils are contributing to other health issues like sleep apnea, it might be time to consider removing your tonsils.
The common symptoms include snoring, interrupted breathing during sleep, breathing preferably through the mouth, restless sleep, regular waking, bedwetting, complicated swallowing, frequent colds, etc. Being caused by enlarged tonsils or adenoids, snoring and sleep apnea create the risk of developing heart disease and even type 2 diabetes. If the tonsils are enlarged but are not causing symptoms, often no treatment is recommended. This is because as your child gets older, most of the time enlarged tonsils will become smaller and smaller. If the tonsils are causing problems with sleep, your ENT surgeon may recommend tonsillectomy. This is needed for patients who have Obstructive Sleep Apnea with enlarged tonsils.
If your child is having disturbed sleep that results in problems with sleepiness or behavior in the daytime, tonsillectomy may also be recommended. Commonly, when the tonsils are enlarged, the adenoids are also enlarged and will be removed during the same surgery. After a tonsillectomy, you'll likely deal with short-term throat pain, but it should lead to fewer sore throats and better breathing at night in the long term. Ask your healthcare provider if you have any questions about what to expect before and after the tonsillectomy. They'll discuss the risks and benefits and help you determine whether a tonsillectomy is the best treatment for you. Watchful waiting may be a reasonable alternative, as they typically get smaller as the child gets older.
They usually are at maximum size around six years of age and have substantially reduced in size by around 12 years. Adult snoring and sleep apnea are seldom due to enlarged tonsils and adenoids. The issue usually is not whether the child will outgrow the problem.
Instead, the issue is the impact on the child's quality of life while waiting for conditions to improve. The other concern is any long-term consequences on the heart, lung, or facial development. Though there are myriad confounders that could not be measured in such a large population-based database study, the authors did attempt to adjust for many potential ones. They combined several different national registries to compile comprehensive health and socioeconomic histories for all individuals included in the analysis.
