Are Tonsils Low-Hanging Fruit?
I was 6 when I had my tonsils and adenoids taken out. I have two distinct memories of the event. The first was the odor of ether. I had been instructed to count down to 1 from 10 but never made it past 5. The second memory was waking in the middle of my first night home from the hospital and vomiting a volume of blood so great that I was in my fourth year of medical school before I saw its equal. My near-exsanguination was managed at home with a phone call.
What I don’t remember is why I had my tonsils removed. I am told I was a fairly healthy kid. Most of my colds ended with a prolonged nocturnal cough, not surprising since both of my parents smoked, and we lived in a small house. I remember fondly the taste of cherry-flavored, codeine-laced cough medicine.
I asked my parents many times what had prompted my tonsillectomy. They always said they couldn’t remember, although I often wondered if there was some dark family secret I was never to learn. I always suspected that my maternal grandmother may have had a hand in the decision. She frequently boasted about having her tonsils removed on the kitchen table by her uncle — who is the only medical doctor in my lineage. Apparently, it was a family affair, as he operated on her two siblings on the same afternoon.
It may have been that in the late 1800s, tonsillectomy was a sort of rite of passage, like today’s precollege trip to the oral surgeon for wisdom teeth extraction among families in affluent suburbs. Tonsils of good size are easily viewed and can be accessed without an abdominal incision. They are the proverbial low-hanging fruit.
In the early 1970s, investigations by Jack Wennberg, MD, MPH, and Alan Gittleson, MD, revealed that there were factors beyond boasting grandmothers that were influencing the frequency of tonsillectomies. By comparing the number of tonsillectomies across a broad geographic area, researchers found wide variations between communities. For example, in one Vermont town, 20% of the population had had their tonsils removed before age 15. In the next town over, that number was 60%.
These studies of geographic variations eventually included other surgeries and medical diagnoses and in 1996 culminated in the publication of the first Dartmouth Atlas by Wennberg. Although the results of the initial study may have been one of the factors in the gradual decline of tonsillectomies nationwide, more than a half million procedures are still performed annually and wide variations persist. An updated version of the Dartmouth Atlas covering 2007-2010 in three New England states found a frequency of 2.7 tonsillectomies per 1000 persons in Bangor, Maine, and a fourfold difference in Littleton, Vermont, at 10.9 per 1000.
One would expect, or at least hope, that several decades after the initiation of these epidemiologic revelations, some standard would have evolved and the variations in tonsillectomy rates would have narrowed. The explanation may in part reside in the fact that studies regarding the efficacy of tonsil and adenoid removal have at times yielded conflicting results.
For example, in March of this year, a multicenter study of 459 children with mild sleep-disordered breathing found that compared with a control group managed with watchful waiting, children who had undergone adenotonsillectomy experienced a 32% reduction in total healthcare encounters and a nearly 50% reduction in prescriptions.
On the other hand, 7 years ago, a study in Denmark looking at the records of 1.2 million children found that children who had their tonsils and adenoids removed had an increased risk of later experiencing respiratory, allergic, and infectious diseases. The authors of that study concluded that these “risks were considerably larger than changes in risk for the disorder these surgeries aimed to treat.”
One could argue we shouldn’t be comparing apples (sleep disturbances) and oranges (respiratory disease, allergy, and infection). However, a study from Epic Research published in 2024 that compared 7590 patients who had their tonsils removed with the same number of patients with tonsillitis but without the surgery found that those who had undergone tonsillectomy had “lower rates of influenza, otitis media, strep throat, and sinusitis.” It is interesting that during this study, which ran between 2018 and 2021, the investigators could “not find a significant difference in the frequency of COVID-19 between patients who had undergone tonsillectomy and those who had not.”
. So where does this leave us primary care pediatricians? We are often the folks initiating or at least signing off on a parent-requested referral to the ear, nose, and throat (ENT) specialist. Although adenotonsillectomies have a low mortality risk, it is not zero and is certainly higher in patients with multiple and complex problems. We in primary care must keep abreast of the literature as best we can and make our referrals based on our own judgement while leaning heavily on the experience of the ENT, who will make the final decision. I suspect, like me, many of you may target your referrals to the surgeons who share your biases. If parental anxiety and not my professional concern is the primary driver of the referral, I may intentionally select an ENT who leans toward watchful waiting.
Despite the lack of standardization, we must congratulate ourselves that we have moved on beyond an era when tonsils were removed because they were easy to get at.
