Saturday Special (04/15/2023): Your tonsils are fine right where they are

When I was growing up the family doctor was a gentleman by the name of Chester Warth. He looked like something out of a Norman Rockwell painting.

The good doctor was always kind and reassured; seemed to always know the right thing to say.

For example, throughout my years in grade school just about every kid I knew was having tonsils removed. You know the drill. A stay in the hospital, the operation, and then guaranteed ice cream.

Except me.

If I got a bad sore throat which was often Mom would ask Dr. Warth if it was time for my tonsils to go. He never hesitated to put the kibosh on the idea.

Those tonsils are very good to have he claimed. They offer positive protection. And that was fine. Doggone it, Mom, I didn’t want to go to no stinkin’ hospital.

And it turns out Dr. Warth was right decades ago and still is.

Kids, hang on to those babies. Mom and Dad, leave them be.

Tonsillectomy: A ‘Minor’ Procedure With Major Long-Term Risk
April 12, 2023

—Yuhong Dong, M.D., Ph.D., is a senior medical columnist for The Epoch Times. She is a former senior medical scientific expert and pharmacovigilance leader at Novartis Headquarters in Switzerland, and was a Novartis award winner for four years.

—Makai Allbert is a health writer based in New York.

Tonsillectomy, or surgical removal of the tonsils, is a common surgical procedure performed more than 500,000 times annually in the United States on children younger than 15 years old. While tonsillectomy may reduce patients’ short-term symptoms, many are unaware of the long-term consequences.

In fact, some diseases are associated with this so-called minor operation.

Summary of Key Facts

  • Tonsillectomy is often a treatment for severe tonsillitis with enlarged tonsils.
  • A 2018 JAMA study of almost 1.2 million children reported that removing the adenoid or tonsils in childhood was associated with a significantly increased relative risk of later respiratory, allergic, and infectious diseases. Increases in long-term absolute disease risks were considerably larger than improvements in the disorders these surgeries aimed to treat.
  • A Taiwan national cohort study showed that patients with a history of tonsillectomy had a risk of deep neck infection 1.71 times greater than others.
  • A Canadian study suggests a strong association between a history of adenotonsillectomy and the development of retropharyngeal or parapharyngeal abscesses.
  • Cumulative evidence of long-term associated risks of infection has proven the irrefutable role of tonsils in our immunity. The mechanism of increased infection relates to various functions of the tonsils in the immune system.

When Is Tonsillectomy Considered?

Although the tonsils, particularly the adenoid at the upper part, serve as a front line of defense against infection, their role often isn’t adequately recognized.

The tonsils and the adenoid normally shrink with age, being at their largest in children and absent in adults, suggesting that their absence might not affect adult health. However, their activity in early life is essential for normal immune system development and long-term immune function.

When the tonsils are in an intense battle with invading pathogens and don’t get enough support, they may become inflamed and appear larger. As a consequence, these severely enlarged tonsils may cause difficulty swallowing and can obstruct breathing. Since recurrent throat infections and sleep-disordered breathing can significantly affect a child’s health and quality of life, these two factors are common determinants for recommending a tonsillectomy.

In some instances, the adenoid may also be removed through a surgical procedure called adenoidectomy. Generally, physicians recommend the removal of both the tonsils and the adenoid.

According to guidelines from the American Academy of Otolaryngology–Head and Neck Surgery, a tonsillectomy is recommended when a child has had seven or more tonsil infections in a single year, five per year for the preceding two years, or three per year for the preceding three years, in addition to other factors, such as sleep-disordered breathing.

Tonsillectomy: Beneficial or Not?

Will removing the tonsils or adenoid successfully treat illnesses such as recurrent throat infections or obstructive sleep apnea in the long term?

Not necessarily.

The swelling is primarily caused by a buildup of lymph fluid containing viruses, germs, and increased immune cells. Swollen tonsils indicate that too many “soldier” immune cells are injured, suggesting a significant battle between viruses and the immune system. Accordingly, the root cause of tonsillitis is weakened immunity, making it difficult for our body to overcome viruses when more support is needed.

If the tonsils or the adenoid are removed without addressing the underlying cause of the infection—a weakened immunity—relief may be only temporary. The absence of tonsillitis doesn’t mean the viruses or germs are gone, but rather that the guardians are.

In the long term, removing our tonsils leads to the absence of the body’s major first line of defense against viruses and bacteria, leaving us vulnerable to a host of other problems.

Numerous clinical studies have investigated the short- and long-term effects of tonsillectomies on the body. Let’s have a look at the data.

Short-Term Benefits, Long-Term Risks

A 2017 meta-analysis in the journal Pediatrics analyzed illness rates and quality of life for children with recurrent throat infections who had a tonsillectomy versus those instead subjected to “watchful waiting.”

The researchers at Vanderbilt University found that although the benefits of reduced throat infections were evident within a year of tonsillectomy, they didn’t last any longer.

A study examined the effect of tonsillectomy on children with obstructive sleep-disordered breathing. A follow-up one year after the tonsillectomy revealed that these children did have better sleep outcomes than children who didn’t undergo a tonsillectomy, but longer-term outcome measures were lacking.

Despite being viewed as a relatively insignificant surgery, tonsillectomy in children poses a significant risk of complications such as bleeding, respiratory difficulties, burns, nausea, vomiting, pain and, in severe cases, even death.

A Cincinnati Children’s Hospital Medical Center study reviewed 233 claims from the LexisNexis “Jury Verdicts and Settlements” database. The researchers examined claims filed from 1984 through 2010 for “deaths and complications during and following tonsillectomy.”

Of the 233 claims, 96 were deaths, and nearly half (48 percent) were related to surgery. Nonfatal injuries included postoperative bleeding, impaired function, anoxic events, and postoperative opioid toxicity.

Large JAMA Study Revealed Long-Term Risks

A research paper published in JAMA Otolaryngology in 2018 reported the long-term relative risk for 28 diseases after removing tonsils or the adenoid. The study had surprisingly shown that children with their tonsils, adenoid, or both removed before age 9 were at significantly increased risk for a broad range of diseases as they grew older.

The study followed a large cohort of more than 1.18 million Danish children for 10 to 30 years. Of the children analyzed, 17,460 received adenoidectomy, 11,830 underwent tonsillectomy, and 31,377 had both removed; a group of 1,157,684 children composed the control group.

The researchers found that tonsillectomy was associated with a nearly tripled risk of upper respiratory tract diseases, most of which were infections, including rhinitis, pharyngitis, tonsillitis, and laryngitis, which are considered common conditions that everyone experiences during their lifetime.

Furthermore, adenoidectomy was associated with twice the risk of chronic obstructive pulmonary disorder and nearly double the relative risk of upper respiratory tract diseases and conjunctivitis. Additionally, adenotonsillectomy was associated with a 17 percent increased risk of infectious disease.

For 78 percent of the 28 disease groups examined, there were slight but notable rises in relative risk for a variety of diseases.

Those who underwent surgery may also have a higher risk of breathing difficulties, sinusitis, chronic sinusitis, and ear infections.

This highlights the importance of the adenoid and tonsils for normal immune system development and suggests that removal early in life may slightly but significantly disrupt many processes important for health later in life. The authors concluded that it’s important to consider long-term risks when considering tonsillectomy or adenoidectomy.

The JAMA study also found that although surgery to remove tonsils and the adenoid can improve short-term sleep disorders and tonsillitis, long-term risks are similar to not having the surgery.

Increased Risk of Deep Neck Infection

A retrospective, nationwide cohort study using data from the Taiwan National Health Insurance Claims database, which covered more than 98 percent of the population and medical institutions, identified that the risk of deep neck infection is significantly increased among patients who have undergone a tonsillectomy.

A total of 9,915 tonsillectomized patients and 99,150 comparison cohorts between 2001 and 2009 were enrolled in this study. Deep neck infections in the study included abscesses of the throat and neck and cellulitis.

After accounting for confounding factors, those with a history of tonsillectomy had a 1.71-fold higher risk of deep neck infection, according to both statistical models.

Increased Risk of Throat and Neck Abscess: Canadian Study

A Canadian study found that children who had undergone an adenotonsillectomy were more likely to develop a retropharyngeal or parapharyngeal abscess—a buildup of pus in the throat or neck region.

The study examined 180 children with these abscesses and 180 age-matched children without abscesses. Results showed that 13.9 percent of children with an abscess had previously had an adenotonsillectomy, six times more than the 2.2 percent of children in the control group.

The study suggests a strong association between a history of adenotonsillectomy and the development of retropharyngeal or parapharyngeal abscesses.

Mechanism of Increased Risk of Infection

Why is removing the tonsils and the adenoid linked with a greater risk of respiratory diseases and infections?

First, during childhood and early life, the tonsils play a pivotal role in the maturation of the immune system, acting as advanced scouts of bacteria and viruses in food and the air.

Second, an Iran case-control study published in 2020 found that antibody levels after tonsillectomy in 64 children aged 9 to 15 years were significantly lower after four to six years than in the control group.

Additional studies observed a decrease in the serum antibody immunoglobulin A (IgA) level of patients post-tonsillectomy at one to four months, four to six years, and up to 20 years later.

IgA is the major isotype of protective proteins in the surface layer of the respiratory tract and plays a key role in protecting against bacterial, viral, and other infections. Falling IgA levels could contribute to an increased proinflammatory status and an increased risk of infection.

Third, the tonsils—specifically palatine tonsils—express several antimicrobial peptides, including defensins and cathelicidins. They have direct antimicrobial activities protecting the host from microbial invasion and can indirectly modulate adaptive immunity.

Fourth, the tonsils act as a key link between innate and adaptive immunity. Research shows statistically significant decreases in cellular function after tonsillectomy, suggesting tonsillectomy also alters cellular immunity in children.

Removing the tonsils can impair the detection of the virus or germs, decrease mucosal antibody levels, decrease other protective peptides, alter the expression of host defense peptides, alter innate immunity, and increase susceptibility to viral and bacterial infections.

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