When is a tonsillectomy necessary? A guide for parents.

The tonsils (palatine tonsils) are two structures of lymphatic tissue located on either side of the throat, forming part of what is known as Waldeyer's protective ring. They play an important role in the immune system, particularly during the first years of life, helping to filter bacteria and viruses that enter through the mouth and nose and teaching the body to recognise infectious agents. In some cases, however, the tonsils themselves become a chronic focus of infection or a mechanical obstacle to breathing – in other words, more of a problem than a protection.

What do the tonsils actually do?

The tonsils are most active between the ages of 2 and 8, the period in which a child first encounters a wide range of microorganisms. As the years pass, their immunological role diminishes considerably, because the maturing immune system takes over this defence through other structures. This is why removing the tonsils, when there is a clear medical indication, does not represent any loss to the body's defences.

When do the tonsils become a problem?

In clinical practice, we distinguish three main scenarios in which the tonsils harm health rather than protect it:

• Recurrent acute tonsillitis: Frequent infections, often caused by group A beta-haemolytic streptococcus, with high fever, severe sore throat, difficulty swallowing and repeated absences from school or work.
• Chronic tonsillitis: Persistent inflammation presenting as mild but constant throat discomfort, bad breath and tender lymph nodes in the neck.
• Tonsillar hypertrophy (enlargement): Enlarged tonsils narrow the airway, especially during sleep, causing snoring and pauses in breathing.

What are the indications for tonsil removal?

In our clinical practice we follow European guidelines and standards, which are based on internationally recognised criteria (the Paradise criteria). Tonsil removal (tonsillectomy) is recommended if the patient meets one of the following key criteria:

• Recurrent, documented infections: At least 7 episodes of acute tonsillitis in the past year, 5 episodes per year over the past two years, or 3 episodes per year over the past three years.
• Breathing problems and sleep apnea: Enlarged tonsils can obstruct the airway at night, causing heavy snoring and pauses in breathing (obstructive sleep apnea). This is an absolute indication for surgery, as it directly affects a child's physical growth, cognitive development and school performance.
• Peritonsillar abscess: A collection of pus around the tonsil that requires urgent drainage. After an abscess, particularly a recurrent one, tonsillectomy is recommended to prevent future episodes.
• Other indications: Chronic tonsillitis that does not respond to antibiotic therapy, persistent bad breath caused by tonsil stones (tonsilloliths), or marked one-sided enlargement of a tonsil, which always warrants specialist evaluation.

Does removing the tonsils weaken immunity?

This is the most frequent concern among parents, and the scientific answer is clear: No. The immune system has many other protective mechanisms – the lymph nodes, the spleen, the bone marrow and the lymphatic tissue of the mucous membranes – which fully take over this defensive role. Long-term studies have shown no decline in overall immunity after tonsillectomy. On the contrary, many children fall ill noticeably less often after the operation, because the chronic focus of infection that was constantly exhausting them has been removed.

How is the operation performed?

Tonsillectomy is performed under safe general anaesthesia and takes around 30-45 minutes. Modern techniques are used today – classic dissection, electrocautery or radiofrequency methods – which minimise bleeding and postoperative pain. In most cases, the patient stays at the clinic for only a few hours or one night for observation and returns home the next day.

What is the recovery like?

Full recovery usually takes 7-14 days. Throat pain is most pronounced in the first days and may radiate to the ears – this is normal and does not indicate an ear infection. For the smoothest possible healing, we recommend:

• Plenty of fluids: Drinking cool liquids regularly is the single most important factor in easing pain and preventing complications.
• A soft, cool diet: Yoghurt, purées, lukewarm soups and ice cream. Avoid hard, hot, spicy or highly acidic foods.
• Pain control: Regular pain relief as advised by your doctor (paracetamol or ibuprofen; aspirin must not be used in children).
• Rest: Around 7-10 days away from school or work and avoidance of strenuous physical activity for at least two weeks.

One important detail: between days 5 and 10, the protective scabs covering the wound begin to detach and there is a small risk of bleeding. Any fresh bleeding from the mouth, however minor, must be assessed by a doctor immediately.

When should you consult a specialist?

If your child (or you yourself) is approaching the criteria described above – frequent throat infections, snoring with pauses in breathing at night, or recurrent abscesses – do not postpone the visit. The decision to operate is always made individually, after a full ENT examination and an open discussion of the benefits and risks. In the great majority of correctly indicated cases, tonsillectomy brings a marked and lasting improvement in quality of life.