More Tonsillectomies Need to Be Done

In 2009 President Obama revealed his view of physicians as motivated more by profit than the health of their patients. Using the unfortunate (for him) example of tonsillectomy for sore throat, he revealed his (or his speech writer’s) thorough lack of understanding of the problems tonsils cause and the reasons they are removed. He made the common mistake that just because tonsillectomy and adenoidectomy (T&A) it is the most common operation performed in children in the US today, making a decision to proceed is a simple one. Nothing could be further from the truth.

I have spent more than 30 years studying the tonsils and adenoids, have written dozens of papers, articles and book chapters and have given talks on the subject on 4 continents. I have also witnessed a profound change in how tonsils behave and how the interact with the soft tissues of the throat, an important, but often overlooked relationship.

Whereas infection was responsible for tonsillectomy more often 50 years ago, today about 85-90% of tonsillectomies are done for obstruction. Sleep apnea is a serious and increasing problem in both adults and children. Tonsils are removed because they block breathing, disrupt sleep, impair intellect, negatively affect behavior, cause growth failure, and lead to cardiac problems such as heart failure and stroke.

How many adults do you know have sleep apnea? At least half of the children who come to me for sleep apnea (about 50% of my practice, about 500-750 new patients a year), have parents many of whom are on CPAP–continuous positive airway pressure–a form of mechanical ventilation for night use. Many of them are very nasal and sound as if they have a throat full of cotton.

“Have you had your tonsils out?” I often ask, already knowing the answer to the question.

Ninety per cent of the time the answer is, “No. I had a sleep study and they told me I needed the CPAP machine.”

Most of them tell me they hate their machine. I can understand why. Who wants to sleep to the sound of a machine anymore than the sounds of snoring and snorting?

I have taken on several of these parents as my patients. And they have undergone tonsillectomy. Many are now off their machines. And they are much happier.

Surgery is not always an answer. Surgery is not always successful. Surgery has risks. There is a lot to think about. Each patient presents with different needs and different contributing factors such as weight, variations in soft tissue and bony anatomy, and many other contributing factors. Each person deserves a thorough evaluation and the right to make an informed decision.

Sleep apnea is a seriously under treated disease. I believe that more tonsillectomies need to be done. Many adults and some children are tied to these expensive machines, the safety of which is not proven. Injury to the upper airways, such as the nose, and making acid reflux worse, with its long term consequences, have to be considered.

And the size of the tonsils as seen through the mouth, even by a trained eye, such as mine, might not matter. Several years ago I found myself in the embarrassing situation of putting off a tonsillectomy in an 18 year old young woman with sleep apnea causing unremitting headaches and depression. Finally, I was persuaded by her sleep medicine doctor to perform the operation. I found very deep, very dense tonsils. Her sleep apnea and headaches and depression went away.

I started to think differently and to look at the tonsils more critically, particularly how their “size” is measured. In 1986 I described the classification system for describing the size of the tonsils, which in many other countries is known as the “Brodsky Classification,” so I think I can legitimately and without rancor, criticize what I now recognize as an inadequate classification.