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Until 1970's, it seemed that nearly every American child whose parents could afford the procedure had his or her tonsils taken out. In the twenty-first century, tonsillectomy is recommended much less often, but is still a very common operation.

The Problem with Tonsils

Everyone is born with three tonsils (or four, if you count the adenoids, which are in the same ring of tissue). The tonsils that are visible when you say "Aaaaah" are the palatine tonsils, but there is tonsil tissue around the tongue and the throat.

However, if there are regular high fevers, if the child tests positive for strep throat, or if tonsillitis is causing mouth sores or sleep apnea, the child may be fast-tracked for surgery,

If tonsil surgery is indicated, the child still will be evaluated through several rounds of testing.

1.    Children are not given tonsillectomies if there are indications bleeding will be a problem. In the era when children were often treated with surgery, it was not unusual for bleeding to require an emergency run back to the hospital almost as soon as children were discharged to go home. Now doctors recognize that about 4% of children who are given standard coagulation tests may have blood clotting problems that the old tests did not pick up. Pre-operative testing now usually includes  an activated partial thromboplastin time (aPTT) and a platelet count. Doctors will make sure children do not have undiagnosed hemophilia or other blood clotting disorders.

2.    Doctors now recognize that "throbbing tonsils" usually indicate an unusual placement of the carotid artery—which cannot be nicked during surgery. Doctors look for unusual pressures around the tonsils that may suggest that the carotid artery is closer than expected to the tonsils, and do magnetic resonance arteriography (MRA) to locate blood vessels. MRA is a procedure very similar to MRI, only intended to locate circulation.

3.    Antibody testing is used to determine if the problem might be that the child simply has not been given the right antibiotic. Antibodies to streptolysin indicate that the child has had previous infection with group A beta-hemolytic streptococcus (GABHS). These are the bacteria that cause "strep throat" instead of just "sore throat." If they have not been treated properly, it may be better from a medical standpoint to treat with antibiotics than with surgery.

4.    Sometimes tonsillitis is made worse by allergies. Children with frequent infections of the adenoids and tonsils tend also to have allergies. If treating the allergy makes the tonsillitis more bearable, surgery may not be needed.

5.    Tonsillitis usually causes the same amount of swelling on both sides of the mouth. When swelling is assymetric, one tonsil more inflamed than the other, doctors may do a biopsy just to make sure that there is no cancer before they do an operation. Cancer of the tonsils in children, however, is very, very rare.

Children who have Down syndrome often also have "loose" vertebra at the base of the brain, which also must be evaluated before surgery.

Insurance companies usually try to make tonsillectomy an out-patient procedure. Some children should go into the hospital when they have their tonsils taken out. These include children who have sleep apnea (cessation of breath for a few seconds up to a minute repeatedly through the night, due to swelling of the tonsils), children who are on medications for ADHD or seizures, children who have other breathing disorders, and children of parents who object to blood transfusions on religious grounds. Children who live far away from a medical treatment center usually should also stay close by for about a week.

The pain of tonsillitis goes away immediately after surgery, and then is even worse about 3 days later. Giving pain medication on a regular schedule is usually better than giving it only when the child cries or complains of pain. The new guidelines recommend giving a shot of steroids to minimize pain and swelling after tonsil surgery. Antibiotics, however, are discouraged.

Laser ablation or radiofrequency surgery is sometimes used for tonsils that are just too large, rather than large and inflamed. There is good evidence that tonsillectomy will stop recurrent sore throats and make nighttime breathing easier, but there are no good medical studies that show that it treats halitosis, or it does not.