Tonsillectomy was once performed almost routinely for recurrent sore throats. It is now reserved for clearer indications, because most children outgrow recurrent tonsillitis and surgery carries real if uncommon risks.
The criteria are specific, and knowing them helps parents judge whether surgery is genuinely warranted.
What Tonsils Do
Tonsils are lymphoid tissue at the back of the throat, part of the immune system's first line of defence. They are most active in early childhood, enlarge naturally between around three and seven years, and gradually shrink afterwards.
Removing them does not meaningfully impair immunity, since other lymphoid tissue takes over. But the natural shrinkage is one reason waiting is often reasonable, as many children improve without surgery.
Viral Versus Bacterial Sore Throat
Most sore throats are viral and need no antibiotics. Distinguishing them prevents a great deal of unnecessary prescribing.
Suggesting viral: cough, runny nose, hoarseness, conjunctivitis, mouth ulcers, gradual onset.
Suggesting streptococcal: sudden onset, fever, pus on the tonsils, tender neck glands, absence of cough, headache and abdominal pain in children.
A throat swab or rapid antigen test confirms streptococcus where the picture is unclear. Treating streptococcal tonsillitis with antibiotics matters, since untreated it can rarely lead to rheumatic fever, which remains a concern in India.
The Criteria for Surgery
Recurrent tonsillitis justifies tonsillectomy when episodes are frequent and genuinely disabling, using established thresholds.
- Seven or more well documented episodes in one year
- Five or more per year for two consecutive years
- Three or more per year for three consecutive years
Episodes should be documented with fever, tonsillar exudate, tender neck glands or positive streptococcal testing, not simply reported sore throats.
Keeping a diary of episodes with dates and treatments is genuinely useful, since decisions rest on documented frequency and memory tends to overestimate.
Obstructive Sleep Apnoea Changes Everything
This is now the most common reason for tonsil and adenoid surgery in children, and it carries a much lower threshold than recurrent infection.
Enlarged tonsils and adenoids can obstruct breathing during sleep, causing repeated drops in oxygen and disrupted sleep architecture.
- Snoring most nights, often loud
- Observed pauses in breathing, followed by a gasp
- Restless sleep and unusual sleeping positions with the neck extended
- Mouth breathing during the day
- Bedwetting that restarts after being dry
- Hyperactivity, poor concentration and behavioural problems, rather than sleepiness
- Poor school performance
- Failure to thrive in severe cases
Children with sleep apnoea present as hyperactive rather than sleepy, which is why it is frequently mistaken for a behavioural problem. Surgery, often combined with adenoidectomy, is highly effective and the change in a child's behaviour and sleep can be dramatic.
Other Indications
Several other situations warrant removal regardless of episode counts.
- A peritonsillar abscess, particularly a second one
- Marked asymmetry of the tonsils, to exclude malignancy
- Difficulty swallowing or persistent throat obstruction
- Chronic tonsillitis with persistent bad breath and tonsil stones not responding to treatment
- PFAPA syndrome, a periodic fever condition in children
Tonsil stones alone rarely justify surgery, since they usually respond to gargling and improved oral hygiene.
The Operation and Recovery
Tonsillectomy is done under general anaesthetic through the mouth, with no external incision, taking around thirty to forty five minutes.
Recovery is more uncomfortable than parents expect, and being prepared for that helps considerably.
- Throat pain for seven to ten days, often worse around days three to five rather than immediately
- Referred ear pain, which is normal and not an ear infection
- White or yellow patches at the operation site, which is healing tissue rather than infection
- Bad breath for a week or so
- Reduced appetite
Regular painkillers on a schedule work far better than waiting for pain. Adequate pain control matters because a child who will not swallow becomes dehydrated, which is the main reason for readmission.
Eating and Drinking Afterwards
Advice here is often wrong. The old guidance to eat only ice cream and soft food is not ideal.
- Encourage normal eating as soon as tolerated, since chewing helps clean the healing area
- Drinking is more important than eating. Aim for frequent small amounts
- Cold drinks and ice cream in the first day or two help with pain
- Avoid very hot, very spicy and sharp crunchy foods for a week
- Avoid acidic juices, which sting
- Keep the child at home for around ten to fourteen days, away from anyone with an infection
Watch urine output. Fewer wet nappies or reduced urination means inadequate fluid intake and needs medical review.
The Bleeding Risk
This is the main complication and parents must know what to watch for.
Bleeding occurs in a small percentage of patients, most commonly between days five and ten when the healing scab separates. It can also occur in the first twenty four hours.
Any bleeding after tonsillectomy requires immediate hospital attendance, even if it appears to stop. A small bleed can precede a larger one. Do not wait to see whether it settles.
Spitting out old brown blood once is less concerning than fresh red bleeding, but both warrant contacting the hospital. Avoid aspirin and ibuprofen unless specifically advised, as they increase bleeding risk. Our emergency department handles post tonsillectomy bleeding around the clock.
Recurrent sore throats alone rarely justify tonsillectomy now, and most children improve as they grow. Snoring with pauses in breathing is a different matter and has a much lower threshold for surgery, with results that often transform a child's sleep and behaviour.
Our ENT department at T. Nagar assesses children for tonsil and adenoid surgery, and Dr. Niraj Kumar Joshi sees paediatric ENT referrals.
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