Nishant Reddy: Generally, as otolaryngologists, with the data that we have in front of us, we believe that taking out your tonsils probably does not have any long-term implications on your overall immune health.
Samir Undavia: Hey guys, Dr. Undavia here with NJ ENT. I’m joined by these handsome gents, Dr. Reddy, Dr. Smith. He’s less handsome, but he’s here. Anyway, today we’re going to be talking about tonsils and we had the title as soup to nuts, which both of them did not like our title, but it’s about going from the beginning of tonsils to the end of tonsils, what they’re about and what we do about them. So, our format’s going to be a little bit different today. This is going to be more of me asking them questions and I’ll chime in from time to time. It’s going to be like pop quiz, hotshot, Dr. Smith. What movie’s that from? Come on. Keanu Reeves.
Nishant Reddy: We don’t watch movies.
Greg Smith: Yeah, we don’t have time.
Samir Undavia: He’s the movie buff. Speed, “Pop quiz, hotshot.” All right. Anyways, so I’m going to be asking some questions and they hopefully will provide you with some good information. So, first I’m going to ask Dr. Reddy, what are tonsils?
Nishant Reddy: So, tonsils are these tissue in the back of your throat. There’s different types of tonsils. There’s tonsils actually in the back of your nose, called nasopharyngeal tonsils, or adenoids. And then there’s tonsils in the back of your throat called palatine tonsils. That’s the tonsils that most people think of. And then you have the tonsils by the base of your tongue, which are called lingual tonsils.
The tonsils we’re going to focus on for today, I think is just the palatine tonsils. And essentially, it’s this type of tissue called lymphoid tissue, which is part of your immune system. And the theory is for your palatine tonsils, that they may have played a critical role in your immune system, probably when you’re at birth to maybe a few years old, but after a couple years old, it’s thought that your palatine tonsils don’t really play a significant role for your immune system.
Samir Undavia: That was perfect. I actually answered all three questions. So, I wanted to ask Dr. Smith more about what Dr. Reddy talked about with lymph nodes. What do lymph nodes do? Where are the lymph nodes? Not just in the tonsils, but everywhere in your neck and elsewhere, what do they generally do?
Greg Smith: So, lymph tissue essentially is the filter for the body. It traps viruses, bacterias and other foreign materials and presents them to the body for an allergic or an immunologic reaction, which is your body’s way of seeing something, recognizing it and making a response. And so, your tonsils are lymphoid tissue, it’s an aggregate of lymph tissues responsible for presenting some of these viruses, bacterias and foreign particles, and the lymph nodes themselves again, are these aggregates of lymph tissue, that help drain and filter out for our immune system, so that we can make either a memory response, or a faster response the next time we see something.
It’s also responsible for not making a response, which is equally an important thing, making sure that we’re not making a response to things that shouldn’t be foreign. And sometimes when things go wrong, that’s when you can start making response to your own tissues, or making an overactive response to things that otherwise should be relatively inert.
Samir Undavia: Yeah. I was just going to bring up the point that we all have patients and/or friends or family that will have an outbreak of strep tonsillitis in the house, but not everybody gets it, despite being exposed to it. So, all of our tonsils behave differently. Some tonsils will behave more strongly, some will not have any response at all. And it really is patient specific about when you get sick, it’s not just being exposed to the pathogen that automatically gets you sick. So, there are some patients who will recurrently get tonsillitis or will recurrently have big tonsils, but will have the same exposure as another person who has zero of those symptoms. So, we see tonsil patients a lot. It’s probably one of our most common things we see in the office, but Dr. Reddy, can you just tell me a little bit about what most patients complain of when they come to the office? So, that brings you to the tonsil issue.
Nishant Reddy: Most people, the primary complaint that you see is sore throats. So, just trouble with pain around your back of your throat, trouble with swallowing, pain with swallowing, sometimes patients will complain of ear pain and you get this referred ear pain going from your throat into your ears. And these infections, these sore throats can be frequent. You can have these recurrent episodes, multiple episodes in a year, or they could be chronic, where patients just can complain of just this chronic, low grade kind of sore throat that’s bothering them.
Samir Undavia: And Dr. Smith, if somebody doesn’t have a sore throat, but you think they still have a tonsil issue, maybe some other symptoms that they might complain of?
Greg Smith: Yeah, a lot of people complain of foul breath or a foul odor within their mouth, or halitosis would be the medical term for that. And they may complain of tonsillar stones, which are these little chalk like debris that exude from the tonsils from time to time. And within the tonsils, there’s these cryptic kind of caves, that these little food particles and debris can get in the bacteria that allow within these crypts can make these little debris stones that come out from time to time. I’m not sure if that’s exactly what you’re alluding to, but a lot of patients complain not just of infections, but these tonsil stones as well. And they can be pretty pesky. They can be pretty painful when they start to come out of the tonsils as well. And so, people try to do all sorts of things, like use long cotton tips, or Q-tips, use a Waterpik to try to flush them out. A lot of times we recommend gargling with just something, water or salt water after anything, any meal or anything sugary, to try to wash out all of that sugar debris that might cause these tonsil stones. But really, there’s not a whole lot that you can do to prevent tonsil stones. Chronic infections and recurrent infections often triggers these because of these crypts and caves that form within the tonsils.
Samir Undavia: Yeah. The last symptom that I wanted to allude to was sleeping issues. So, Dr. Reddy, tell me about what somebody might complain about with regards to that and what might bring you to the tonsil issue?
Nishant Reddy: Yeah, so if you have larger tonsils and the tonsils have overgrown, then you can have issues with snoring, mouth breathing, and sometimes even sleep apnea, where your snoring is so severe and the resistance in the back of your throat is so severe, that you’re actually having pauses or cessations of in your breathing while you’re sleeping, which results in decreasing oxygenation levels. So, if you have snoring, sleep apnea issues, and you have large tonsils as a primary cause, removing the tonsils, or reducing the size of the tonsils can significantly improve your sleep quality.
Greg Smith: And this is especially true in children, when the caliber of their airway and the size of the back of their mouth, what’s called their oropharynx, where the mouth meets the throat, that area’s really spine and constricted already. And if they have these big nuggets back there causing obstruction of their airway, removing those tonsils significantly improves that air flow and decreases that resistance, that upper airway resistance. Adults can also have that problem, but because their airways are so much larger, sleep apnea is often more multifactorial when it comes to adults. It’s more rare for an adult to have tonsils so large that it causes major obstruction, but it does happen.
Samir Undavia: So, let’s talk about that, between the kids and the adults. So, the adults, it’s pretty easy to have somebody tell you that either they snore a lot, or their spouse or partner says that they’re snoring a lot. Snoring by itself doesn’t necessarily mean that you have sleep apnea. It just means that there’s a vibration inside the back of the throat and the back of the nose, possibly. But if like Dr. Reddy alluded to, if that happens where you have pauses in breathing, that can truly cause a stress on your heart and lungs, increases your risk for certain heart disease, stroke. And that is a significant risk factor for heart and stroke in patients that don’t have any other risk factors for those two diseases.
But Dr. Smith, if a child … if the parents say that they have snoring, but they aren’t really sure if they’re having pauses or gaps, maybe what are some other symptoms that the parents might notice during the day, or other symptoms that they could complain about, that would allude you to this sleeping issue?
Greg Smith: Sure. So, I mean, often in adults, they complain of daytime sleepiness or needing to take naps and that can often happen in children too. Children can have issues staying awake. So, if you have a three or four year old who’s typically starting to outgrow naps, they may need still frequent naps. So, often I’ll ask parents, “All right, if you’re not sure, the first thing we can do is maybe start recording the child for a little bit. Go in there, take a look at them while they’re sleeping, record their breathing for a little bit, see if they’re having gasping, choking, pauses.” But other behaviors that you can look for, if you can’t kind of get that out, bedwetting is one thing that can happen with chronic sleep apnea, even mood instability. So, kids that are having hyperactivity, sometimes that can be linked to sleep apnea as well.
So, if you think about mood changes, bedwetting. And so those behavioral changes, anything that really changes with the child’s behavior can be a sign of sleep apnea. But certainly, I’ve had parents who have brought kids in who, even during my exam in the office chair which is typically a stressful thing for kids, they’re so tired, they’ve been asleep almost the entire time and aren’t really arousable, and that’s typically a sign of some pretty significant sleep apnea.
Samir Undavia: Correct, correct. All right, so then we’ve figured out that the tonsils are part of their problem, whether it’s for infections or for sleeping issues. Is there any other less common reason that a tonsil might be a problem, Dr. Reddy?
Nishant Reddy: So, there are rare reasons for why a tonsil might be a problem, especially if you … The thing that comes to mind is if there’s a growth within the tonsil and there’s many different kinds of growths that can occur within the tonsil, the most common growth in a child would be a type of cancer called lymphoma, where you can actually have a cancer growing within the tonsil. And so, if we ever see a child with one tonsil that’s significantly larger than the other, that’s one of the first things that we worry about.
In adults, a thing that we really worry about with asymmetric tonsils or one tonsil that looks different completely different than another tonsil is a tonsil cancer. And the most common tonsil cancer in adults is squamous cell carcinoma. And now, the leading leading cause for this type of cancer is HPV.
Samir Undavia: Dr. Reddy, what does HPV stand for?
Nishant Reddy: So, HPV is human papilloma virus. In the past, actually just very recent past, the most common cause of tonsil cancer was excessive smoking and drinking. But now the most common cause is actually just exposure to this virus called HPV, which almost the majority of the population has actually been exposed to at some point in their lives. But you’re more likely to have had exposure to this particular virus via sexually transmitted diseases.
Samir Undavia: Dr. Reddy, do you remember the different subtypes and the numbers associated with the benign growths and the malignant growths?
Nishant Reddy: Yeah, so HPV six and 11 are usually associated with the low risk types of papillomas and other growths like that, which aren’t usually typically cancers, but the tonsil cancers, the squamous cell carcinomas that we worry about, are usually associated with HPV subtypes 16 and 18.
Samir Undavia: Bonus. Also, for all of you guys watching, me and Dr. Reddy have the same shirt on for all of our podcasts, but Dr. Smith has changed one of his shirts. He was worried that all of you were going to judge him.
Nishant Reddy: Make sure you judge Dr. Smith.
Greg Smith: One thing to mention, a little bit of a soapbox thing is that HPV cancers are very preventable. It’s one of the only cancers that we do have a vaccine for. So, it’s something that I would say, absolutely talk to your primary care, your pediatrician, your medical providers, about vaccination with the HPV vaccine and whether it’s the right choice for you. Because that is one thing that hopefully, as we all continue to practice, we will see less and less and less of, as the vaccine becomes more and more prevalent and active in society.
Samir Undavia: I don’t know how young you can be and still get the vaccine. Do you know?
Nishant Reddy: I believe it’s around age 12. The Gardasil vaccine is widely, widely used and given to females, but now has been FDA approved for males as well. It’s important for all males to be vaccinated for this as well.
Samir Undavia: Okay, so now we’ve figured out the tonsil’s a problem. We got to do something about it. Dr. Red, you want to talk about the medical things that we can do about them? And then Dr. Smith, you talk about the surgical things you can do about them.
Nishant Reddy: Sure. So, if you have a tonsil infection, you typically treat it with antibiotics. And sometimes we also add some steroids if you’re having a lot of swelling, or a lot of pain and discomfort. If we’re talking about tonsil stones, the medical management is things like a Waterpik which Dr. Smith alluded to before, to try to clean out your tonsillar crypts. You can also do frequent salt water gargles, especially after eating sugary foods. And then after that, if all of that fails, then usually surgery is warranted.
Samir Undavia: Do you have a rule for how often you’ll give antibiotics before you jump to something surgical?
Nishant Reddy: Yeah, there’s different criteria that people use. One of the most widely used criteria, if you have seven or more sore throats or tonsil infections in a year, in one given year, or if you have five or more in two consecutive years, or three or more in three consecutive years.
Samir Undavia: But that also has a lot of play because there might be somebody who just keeps missing school, but they haven’t had all seven infections in one year and you just need to pull the trigger, or if they have other complications like a peritonsil abscess, which we’ll have another podcast about, but Dr. Smith, you want to talk about the surgical stuff?
Greg Smith: Sure. So, surgery, tonsillectomy, is certainly not one of the most fun things to undergo, but it’s often very necessary to help reduce the amount of infections that can occur. Or for sleep apnea, as we mentioned before, more and more now are probably doing more tonsillectomies in children for sleep apnea, sleep disorder breathing, than chronic tonsillitis. And we’ve gotten much better at treating strep infections. And so, strep is becoming less and less of a chronic issue, but certainly that still does exist, that kids are getting seven strep infections in a year, and five for two, and three for three. But certainly surgery is the mainstay of treatment for tonsillectomy.
Historically, tonsils removed with curettes, or a wired dissector, or a guillotine. There’s a million different ways to take tonsils out. However, the most common way of taking them out is a traditional tonsillectomy using electric cautery dissection to go around the tonsil, between the muscle and the back of the tonsil pillar, and removing the tonsil tissue from within that little muscle pouch on both sides, basically from the top of the palate, down to the top of the tongue base, or the bottom of the back of the tongue there. The tonsils can be removed in a newer matter, in which we do what’s called an intracapsular tonsillectomy. That often is done in children, to try to decrease bleeding and the pain as well after tonsillectomy.
And so, the difference with this is that instead of going all the way around the tonsil capsule and taking all the tonsil out along the muscle bed, you’re leaving a little fine rind of tonsil tissue in that pouch and in heat sealing or cauterizing all that residual tonsil tissue that’s left there, which decreases the bleeding rate and also the pain. The big concern is tonsil regrowth, depending on how much tonsil you leave behind, there is a rate of regrowth that can occur if you do an intracapsular or partial tonsillectomy versus if you do a traditional tonsillectomy, where you’re removing all the tonsil tissue. It’s pretty rare to get regrowth in a traditional tonsillectomy.
And certainly, over the years, all sorts of devices have been generated and developed to try to reduce pain, which is always our biggest concern after tonsillectomy, and bleeding rate, which probably should be our biggest concern after tonsillectomy. But these devices, whether they use radio frequency, or electric cautery, or laser, all of them have very similar outcomes as far as pain, discomfort and bleeding rates afterwards. And so, really it’s making sure that your physician is comfortable using whatever device they’re most comfortable using and taking these out.
Samir Undavia: That’s right, we all have different ways of doing things, but the outcomes-
Greg Smith: Yeah, absolutely.
Samir Undavia: … ought to be the same. And each individual surgeon will have, in their hands, the better way of doing things. Dr. Reddy, can you talk to me, Dr. Smith already alluded to a little bit, but about complications of tonsillectomy?
Nishant Reddy: Yeah. The biggest worry we have with tonsil surgery is bleeding. And the reason for that is that the tonsils are situated very close to branches of the external carotid artery. And it’s a very vascular area. Especially if the tonsils have been through a lot of chronic inflammation and recurrent infections, you’re much more likely to have an extensive blood supply there. So, the bleeding rate is probably around 2% to 3% nationally and a postoperative bleed can typically happen anywhere between day zero and day 14. Most likely to occur days one through three, right after the surgery, but sometimes can also occur most commonly in about day seven through 10, when whatever scab may fall off and cause another bleed.
Now, most bleeds can actually just be treated probably just conservatively would just soft diet and maybe even an in-office cauterization. But sometimes, the thing that we dread the most, is having to have to go back to the operating room and cauterize the surgical bed. That’s really the biggest risk.
There’s other more rare risks that we worry about. Sometimes you can get small scrapes or injuries to your lips, teeth, or gums. There’s the small amount of the anesthesia risk with tonsil surgery. In some patients, this can happen a little bit more in children and it’s usually a temporary phenomenon, there’s this entity called VPI, or velopharyngeal insufficiency, where you can potentially have, temporarily usually, where you’re swallowing liquids, it can come out of the mouth. And that’s just usually a temporary problem.
And then the other thing you worry about in kids especially, especially young kids that have severe sleep apnea and very large tonsils, is the potential for postoperative pulmonary edema, or fluid buildup in the lungs. And for these kids that we worry about that possible complication, we typically watch them overnight in the hospital on the pediatric service to make sure that we aren’t dealing with that rare issue.
Samir Undavia: The other thing I wanted to bring up, and that is also a real risk, and it has to do with one of the things about a tonsillectomy that both Dr red and Smith alluded to, which is that it is an incredibly painful surgery. And it is what it is. It’s much more painful the older you get. Kids, obviously it’s painful, but not as bad. And so, what you don’t realize is that you probably swallow a thousand times a day, but after you get your tonsils out for that first 10 days, you’ll notice every time you swallow. It hurts every time you swallow. And because of that, you have the risk of getting dehydrated, because you don’t want to drink anything.
So, rarely, not very commonly, but rarely we can have, especially kids, pop back into the hospital just for some IV fluids just to get rehydrated. And that might be one of the risks too, is just needing IV fluids. I think we all three alluded to the worst part about tonsillectomy is either the bleeding or the pain. Can you guys think of any long-term complications of having the tonsils out there? There aren’t many.
Nishant Reddy: Yeah, I think there’s been some people that looked at the potential long-term immune issues that can happen after tonsillectomies and it’s pretty controversial, but generally as otolaryngologists, with the data that we have in front of us, we believe that taking out your tonsils probably does not have any long-term implications on your overall immune health.
Samir Undavia: Yeah. And he’s not talking about getting more infections. He’s talking about other things that have to do with asthma and stuff. People get less infections after you take your tonsils out, which is … that has been very definitively proven. So, that’s all I have for the tonsils. Do you guys have any … I think we went … we really did go from soup to nuts with these tonsils, please like, and follow us again. If you haven’t checked out our website, it’s njent.com. Make sure you rate us five stars. All three of us are relatively handsome.
Greg Smith: Here in the front.
Samir Undavia: And check out our Instagram page, New Jersey ENT. And we’ll see you next time.