RX for readers: Tonsils were out. Now they’re in?

Experts believe tonsils are more important than they were in the past. This is one reason fewer tonsillectomies are performed today.

By JUDY SIEGEL-ITZKOVICH
tonsils_521 (photo credit: Courtesy)
tonsils_521
(photo credit: Courtesy)
I am 64 and had my tonsils out as a child (in the US). I remember that almost every child had the same. But I have noticed that my grandchildren and their peers rarely do. Has something changed in policy (I am sure tonsils have not changed) that lets children keep their tonsils?
S.J., Jerusalem
Prof. Francis Mimouni, chief of pediatrics at Jerusalem’s Shaare Zedek Medical Center, and Dr. Orna Blondheim, director-general of Afula’s Emek Medical Center and a veteran pediatrician, reply:
Although tonsillectomy is being performed today less frequently than 50 or 60 years ago, it remains one of the most common surgical procedures among children in the US and other developed countries. Yes, there is a policy change, and the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) recently issued new guidelines about surgery to remove both tonsils, which are easily seen, and the adenoids, which are hidden, lumpy clusters of spongy tissue at the back of the nasal cavity and above the roof of the mouth.
Like tonsils, adenoids promote health by trapping harmful bacteria and viruses that you inhale or swallow. Adenoids also contain cells that make antibodies to help fight infections, especially in infants and young children. But they shrink around age five, and 10 years later, they almost disappear.
While tonsils and adenoids have not changed since you were a child, there are thoughts that the tonsils have more importance than they were credited for in the past. Improved antibiotics are now widespread as treatment for infections in the throat. It is also known that many cases of tonsillitis are due to viral infections that pass by themselves, and therefore antibiotics and removing the tonsils will not help.
The surgical procedure is performed in cases of repeated acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring or abscesses. Adenoids are often removed together with the tonsils. These organs were frequently removed surgically around the world for years for economic reasons; it was profitable for doctors. If infections are manageable, it is best to wait, especially since they have been found to have a role in protecting the immune system, and removing them may be a risk factor in overweight and obesity.
Judy Siegel-Itzkovich adds:
Tonsillectomies and adenoidectomies were once so common that there was a hospital that opened in 1921 on Manhattan’s East 62nd Street that performed only these operations on poor children. Then, infections called scarlet and rheumatic fever that originated in the throat would sometimes seriously damage the heart. Otolaryngologists (ear-nose-and-throat or ENT specialists) routinely told parents that sooner or later, all tonsils and/or adenoids need to be removed in surgery because they would become infected.
Among the pioneers in recognizing that the surgery is often not mandatory was Dr. Jack Paradise, a professor emeritus of pediatrics at the University of Pittsburgh School of Medicine. In 1984, he and colleagues found in their research on tonsillectomies that those who had surgery initially had fewer infections, but those who didn’t have surgery had fewer infections as they got older. Thus Paradise encouraged “watchful waiting.” A few years later, after he examined children who suffered from fewer throat infections, he reached the conclusion that the benefit of surgery was “too modest” to apply it to everyone, due to the pain of recovery, the costs and the risks.

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The new guidelines of the AAO-HNS – which is the world’s largest and most influential organization of ENT experts – include monitoring children before deciding to do surgery. They suggest waiting for at least seven incidences of strep throat in a year before performing the surgery. But they also note that tonsillectomy and adenoidectomy may improve problems tied to poor sleep – due to obstructive sleep apnea – including bedwetting, hyperactivity, slow growth, and difficulties in schoolwork.
The AAO-HNS recommends that just before or after the operation, if it is carried out, antibiotics should not be given, because there is no evidence that they help. However, giving painkillers after the surgery is strongly recommended.

Rx for Readers welcomes queries from readers about medical problems. Experts will answer those we find most interesting. Write Rx for Readers, The Jerusalem Post, POB 81, Jerusalem 91000, fax your question to Judy Siegel-Itzkovich at (02) 538-9527, or e-mail it to jsiegel@jpost.com, giving your initials, age and place of residence.