Sunday, October 1, 2000

Daniel Richmond has been to the operating room before. The Burtonsville boy has had three sets of fluid-draining tubes placed surgically in his ears. He has been on a host of antibiotics and allergy medications. He has had CT scans and chronic sinus infections.

On this day, Daniel, 9, is having his tonsils removed.

“I don’t think Daniel knows what it is like to feel normal,” says his mother, Bernice Richmond. “He has headaches. He has trouble sleeping. It is hard for him to breathe. The doctor seems to think this will make him feel so much better.”

A generation or two ago, taking out a child’s tonsils often was the first line of defense against chronic throat infections and breathing problems. Today, as doctors have studied the tonsils’ purpose and have developed stronger antibiotics, it often is the last.

In the 1930s, tonsillectomies were performed as preventive measures. By the 1960s and ‘70s, close to 2 million were performed in the United States each year. The American Academy of Otolaryngology estimates that now fewer than 600,000 tonsillectomies are performed annually.

“Years ago, I think it was a matter that guidelines were not so structured,” says Dr. Scott McNamara, an otolaryngologist in Northwest and a member of the American Academy of Otolaryngology’s board of governors. “Today, there are certain criteria for removal.”

Those criteria include more than six throat infections (tonsillitis) a year or episodes of sleep apnea, in which swollen tonsil tissue constricts breathing while sleeping. Other, less common, tonsil-related problems include chronic ear infections and dental mal-formations.

Just because tonsils look large is no longer reason enough to remove them, Dr. McNamara says.

Dr. McNamara says extended-spectrum antibiotics have improved to the point where drug therapy, rather than surgery, often is the first treatment.

“A candidate for surgery might be a patient who has three or more episodes of tonsillitis a year despite adequate drug therapy,” he says. “As good as antibiotics are, there is nothing that is going to remedy recurrent tonsillitis.”

Tonsils 101

To understand why doctors are becoming more hesitant to remove tonsils, it helps to understand what the tonsils do.

Tonsils are masses of lymphatic tissue similar to the lymph glands located in the neck, groin and armpit. Adenoids, which often are removed along with the tonsils, are smaller masses made up of the same tissue and located behind the roof of the mouth.

Located behind the soft palate, tonsils function as the first outpost of the body’s immune system at the point of easiest entry the mouth. The tonsils work by filtering germs that attempt to invade the body, and they help the body develop antibodies to germs.

Sometimes the bacteria become trapped there, and the tonsils themselves become infected.

“Every piece of us is supposed to have a purpose,” says Dr. David Bianchi, a Silver Spring otolaryngologist. “The tonsils act as a processor to the immune system. They trap incoming particles, which feed to the immune chain and set up our immune response. However, this seems to be functional for only the first two or three years of life. After that, 95 percent of our immune system is patterned.”

For a child who is suffering recurrent infections, removing the tonsils will not cause any immune impairment, Dr. Bianchi says.

“Long-term studies have not shown that people who have had their tonsils out have any more propensity to immune infections than people who have kept their tonsils,” he says.

No tonsils equal better grades?

For children whose swollen tonsils have caused sleep apnea, removal of the tonsils may improve school performance, medical stud-ies suggest.

Sleep apnea, which is characterized by severe snoring, may prevent a child from going into a deep sleep at night. He may wake up often, leaving him tired the next day. In children, signs of apnea include hyperactivity, a short attention span and aggressive behavior, all of which can be mistaken for disorders such as attention deficit hyperactivity disorder.

The connection between tonsils and children’s abilities is not a new one. Back in 1889, the British Medical Journal published a study titled “The Awkwardness and Stupidity of Children With Large Tonsils.”

More recently, Dr. David Gozal of the Tulane University School of Medicine in New Orleans looked at 300 first-graders whose perfor-mance put them near the bottom of their classes. He then screened the children for sleep apnea, the nighttime breathing disorder that leads to daytime fatigue. Dr. Gozal found that 54 children (18 percent) had apnea symptoms.

Of those children, 24 underwent surgery to remove their tonsils and adenoids. A year later, the children who had had surgery had improved their school performance an average of half a letter grade, while there was no difference in the grades of the children with apnea who had not had the surgery.

“The significant improvement in school performance in the treat-ment group demonstrates that some component of the learning diff-iculties exhibited by these children is attributable to sleep-disordered breathing,” Dr. Gozal wrote in the 1998 study. “It is therefore rec-ommended that sleep-related symp-toms should be actively sought in children with developmental or learning problems and that referral for evaluation of sleep-disordered breathing should occur early rather than late.”

However, another study looking at the effects of tonsil and adenoid removal on recurrent ear infections is neither as dramatic nor long-term.

The 1999 study followed 410 children, ages 3 to 15. Two hundred and sixty-six of the children had middle ear problems but not recurrent throat infections or enlarged tonsils. They were divided into three groups: those who underwent tonsil surgery, those who had adenoid and tonsil surgery, and those who had no surgery.

Those who had throat infections and recurrent tonsillitis were divided into two groups: They either had tonsils and adenoids removed, or they had no surgery.

The study found that the children who had ear infections and surgery had an average of 1.4 episodes of ear inflammation, which was not that much fewer than the children who did not have surgery (2.1 episodes).

“The children in the surgery group did not do much better than the children who did not have surgery,” says Dr. Jack Paradise, a pediatrician at Children’s Hospital of Pittsburgh and the study’s lead author. “If they did do better, the benefits only lasted for about a year. The benefits of the surgery were small and had a lot of variability. I am more in favor of treating [recurrent ear infections] with antibiotics. If we are dealing with apnea or throat infections, though, they might need to have surgery.”

Dr. Paradise’s study also showed that nearly 15 percent of the children who had surgery had complications such as fever, bleeding or pneumonia.

However, Dr. McNamara main-tains that tonsillectomy is generally a safe procedure performed on an outpatient basis.

“The procedure is a common one,” he says. “There is a low incidence of problems, and tech-nology is evolving, so we are getting to quicker, less painful ways of removing the tonsils.”

While children usually undergo a tonsillectomy under general anesthesia and with a traditional scalpel removal, the newer tech-niques are being tried on adult patients, Dr. McNamara says.

Those techniques include shrink-ing the tonsils with radio frequency or lasers. This would be an option only for those who suffer from apnea, snoring or other breathing problems, and not for those who suffer recurrent infections, Dr. McNamara says.

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