Tonsillectomies: No Longer a Routine Solution

sore throat2
Desperately seeking a cure: how treatments for chronic sore throats have shifted with medical developments. Image credit: Malcom

 

By Judith Lavelle
BU News Service

At the start of her college career in 2009, Mimi Raver’s tonsils swelled so severely that she struggled to swallow and even to breathe. “At that point,” she says, “I wanted them out right then.”

But it would take three years, two consulting surgeons and several cases of tonsillitis before the University of Miami voice major and her troublesome tonsils would finally part ways. Mimi recalls that her surgeon was hesitant at first. “[He] didn’t recommend it,” she says, “and I literally begged him. I told him, ‘No. You have to take them out.’”

As recently as a generation ago, Mimi’s story could have been much different. Tonsillectomy—the removal of the lymph glands at the back of the throat—was the most common surgical procedure in the United States for a good chunk of the twentieth century. By their heyday in 1965, over 1.2 million tonsillectomies were performed in the United States.

Tonsillectomies gained popularity just after the turn of the century, when surgery in general—prompted by better sterilization techniques and improved methods to induce anesthesia—became increasingly accepted as a legitimate medical practice. Removing the tonsils particularly appealed to surgeons because the organs were relatively easy to access and seemed to serve no other purpose than offering bacteria a place to colonize and cause infection.

But when antibiotics entered the public sphere in the 1940s, physicians could turn to a relatively cheaper, more immediate and essentially more effective solution to sore throats. But tonsillectomies did not immediately decline; their reputation as a useful, relatively low-risk and almost rite-of-passage procedure managed to stick. From the 40s to the early 80s, elite physicians challenged the wisdom of tonsillectomies in medical journals while parents requested the treatment in exam rooms. As a result, the likelihood of a child having his tonsils removed frequently depended more on his doctor’s preference for the procedure and his parents’ insistence than on his medical history.

In this way, the procedure’s history fits into a much larger revolution in medical practice in the United States. Tonsillectomies performed on the basis of infection didn’t start fading out until physicians began to embrace “evidence-based medicine”—the idea of using the results of peer-reviewed research to support medical decisions at the patient level. By the mid-1980s, physicians used clinical data to set national guidelines and standardize the indication for a tonsillectomy: three cases of tonsillitis per year for three years, five infections per year for two years, or seven infections in a single year.

It didn’t take long for the procedure to decline. By 1986, surgeons removed tonsils only 281,000 times, less than a quarter of the number in the mid-1960s. But that doesn’t mean that, even now, tonsillectomies have shed their reputation among parents. “I’ve definitely had patients’ families where parents have had their tonsils out,” says Dr. Jessica Levi, a pediatric surgeon at Boston Medical Center. “They’ll come with their child and want their child’s tonsils out, but they don’t have a great indication for it.”

Like Mimi, patients who may not fit the criteria to receive a tonsillectomy are often frustrated to be denied a once-common procedure. “There are real symptoms for people who suffer from chronic tonsillitis,” says Dennis Scanlon, professor of health policy and administration at Penn State University, “so lots of people want the surgical intervention or some magic bullet that’s going to make them feel better.”

Scanlon observes that this scenario is an opportunity for shared decision making between the physician and her patient. Dr. Nina Shapiro, the director of pediatric otolaryngology at UCLA, explains that many questions can be considered before performing a tonsillectomy. “What’s the evidence?” she says. “What’s the benefit of doing tonsillectomies in otherwise healthy children? Versus the risk?”

While physicians no longer recommend tonsillectomies lightly, many believe that the removal of the tonsils does cause far more benefits than risks for children with a condition called sleep apnea. A growing problem among children in the United States, sleep apnea is a nighttime breathing disorder in which obstruction of the airway (often because of enlarged tonsils) leads to snoring, oxygen deprivation and eventually, daytime exhaustion. According to Dr. Levi, the disorder affects about 90% of her tonsillectomy patients.

Adults get sleep apnea too, but the disease is usually relieved by wearing a CPAP mask to ensure a steady flow of oxygen. Young children, however, will pull the device off and eventually sleep just as restlessly. This is a big problem, as studies have shown that children with sleep apnea may struggle in school because of their fatigue. According to Levi, tonsillectomy is then the first line of treatment—allowing surgeons to reduce the risk of obstruction by removing the bulky organs from a child’s airway.

Dr. Shapiro agrees that sleep apnea is by far a more common reason to remove the tonsils, citing that only about 5% of her tonsillectomy patients come in after multiple cases of sore throat. But for the few who do have the procedure done for the old-fashioned reasons, the relief can be palpable. “It’s been so much better,” says Mimi Raver, now a studio singer based in Los Angeles. “I’m so happy that I had it done.”

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