This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age, or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.

The patient is an 18-year-old junior college student who self-refers for recurrent sore throats.

Doctor: Good morning. What can I do for you today?

Patient: I am having recurrent sore throats and they are interfering with my ability to study and to work. I would like to have my tonsils out.

Doctor: Tell me about your sore throats.

Patient: Well, they come on once a month. I usually go to the doctor. They always give me some pills. The sore throats typically go away, but I always miss a couple days work, I always feel sick, my throat hurts, and I am tired of living this way.

Doctor: Do you ever have a runny nose following the sore throat?

Patient: Rarely.

Doctor: Can you separate the sore throat episodes from the common cold?

Patient: Usually I can. Typically, the throat pain is worse. I certainly get bad breath, and they rarely cause changes to my voice or result in a runny nose.

Doctor: Has your throat ever been cultured when you were sick?

Patient: Some of the doctors do that. Sometimes it's positive, sometimes it's not. They always give me antibiotics anyway, so I'm not sure what difference that makes.

Doctor: Do you have any other medical problems related to your ears, your nose or your throat?

Patient: No.

Doctor: Well, based on the history, it sounds to me like you have recurrent tonsillitis. Tonsillitis is an illness caused by a bacterial infection in the crypts of your tonsils. Once they become infected, typically by streptococcus, then the patient, such as yourself, experiences pain, fever, malaise meaning just sort of tired and lethargic, and you will feel sick. Typically, the symptoms are bad enough that individuals stay at home, do not work, and do not study. Bad breath or halitosis is a common side effect. Antibiotics will typically kill the bacteria and eradicate the disease in a matter of 2-3 days.

Now, the other throat infection is a viral throat infection. It is known as a viral pharyngitis, also called an upper respiratory tract infection, and it is also known as a cold. It is important that we differentiate between these. The typical cold is caused by a virus and usually begins with a sore throat. It then progresses in most cases, sometimes it will affect  the voice, with voice changes called laryngitis. It ultimately goes to the nose. At first, you have a runny, stuffy nose. The nasal secretion is clear, and then as that secretion becomes infected, the nasal secretion will often turn yellow or green. The infection typically then resolves over the next several days. Sometimes people have a fever. Sometimes they feel sick. Sometimes they stay home. Sometimes they can work and study without obvious difficulty. Now, the reason I wish to differentiate these is that tonsillectomy, the operation that you have requested, cures tonsillitis. Tonsilectomy does not cure the common cold..

Patient: What exactly do the tonsils do, and why shouldn't everybody have their tonsils out? Because this infection is no fun.

Doctor: The tonsils are part of your immune system. They are lymph tissue, and particularly early in life, they are part of your surveillance system that helps you recognize disease, such as bacteria. They stimulate your immune system to develop antibodies and they help protect you against these illnesses. However, there is sufficient duplication of the immune system that even babies do well without their tonsils. Adults do just fine. You asked why everyone does not have them out. The answer is that the operation has some discomfort and it has some risk; therefore, simply removing them from everyone would subject people unnecessarily to both discomfort and risk.

Patient: Well, exactly how many infections do you think I ought to have before I should have a tonsillectomy?

Doctor: The usual recommendation is 4 or more infections per year for at least 2 years, or in patients like yourself who are developing infections literally every month, 5 or 6 months of recurrent infection with a past history of similar kinds of problems is enough to make that recommendation.

Patient: Are there other reasons to have a tonsillectomy?

Doctor: Yes there are. Some people have a low-grade infection and produce small white and yellow pustules continuously in the tonsillar crypts. This is uncomfortable and often causes horrible halitosis. Other patients simply have large tonsils. This creates a condition called sleep apnea. In children, the sleep apnea presents as snoring and as it progresses it causes children to stop breathing or to gasp for air. The snoring alone is enough to interrupt one's normal sleep, growth, and well being. The same is found in adults. Adults with sleep apnea typically present originally with snoring and then develop apneic episodes and increasing daytime sleepiness. They all require a sleep test, and while the majority are recommended for treatment with nasal CPAP, those with 3+ and 4+ tonsils may also benefit from tonsillectomy.

Patient: You said that there were risks and complications. What exactly did you mean by that?

Doctor: Well, let me tell you about the surgery and then we will talk a little bit about the alternatives, risks, and potential complications. The surgery is typically performed under general anesthesia. Your mouth is held open and the tonsils are incised and removed from your throat. The surgeon wears a headlight so that he or she can see. The bleeding is controlled at the time of the surgery using a little electric cautery. At the end of surgery you go to a recovery room, and 3 or 4 hours later you go home. We certainly provide you prescription for analgesic medicines, however, there is little question, particularly for adults, that this is an uncomfortable operation. Some people do fine with Tylenol with codeine; some people require morphine or Demerol. Whereas children typically recover from tonsillectomy in 2 or 3 days, women will usually be uncomfortable for 5-7, and for reasons I do not understand, men are typically uncomfortable for 10, 11, or 12 days. During this time you have a sore throat, and it is important that you drink fluids and maintain your hydration.

Patient: You mentioned alternatives. What alternatives are there?

Doctor: For tonsillectomy, the alternatives are medical treatment, namely antibiotics.

Patient: I have already done that.

Doctor: I understand that.

Patient: What are the risks and complications?

Doctor: The major risk from tonsillectomy is bleeding. One in 100 patients will have some bleeding necessitating return to the hospital or clinic for control. One in 1,000 patients will have sufficient bleeding that they may require transfusion, and somewhere between 1 in 10,000 and 1 in 20,000 may have such problems that they could even die from the surgery.

Patient: What do you die from?

Doctor: In some cases it is bleeding, in some cases it is problems with anesthesia. This is infrequent, but obviously when it occurs it is a disaster.

Patient: Not that that isn't enough, but are there other complications?

Doctor: There are, but they are infrequent. Some people experience some changes in taste. This is typically short-lived, meaning 2-3 months, but it theoretically could be permanent. It is also possible to develop some scarring in the back of your throat A tonsillectomy will rarely cause problems with nasal regurgitation, but this, too, can be a complication.

Patient: What is nasal regurgitation?

Doctor: Well, in its mildest form, it means simply that you kind of talk in a hypernasal voice. In a more severe case, you may actually find that fluids or even foods reflux through your nose. While it is not uncommon to have some nasal regurgitation in the early postoperative period, it is very uncommon to have it as a prolonged complication.

Patient: What happens to me if I don't have a tonsillectomy?

Doctor: Based on your history, it seems that you are at risk for continued repeat infections. Antibiotics certainly can be used to ameliorate these infections.

Patient: I have had enough of this tonsillitis stuff. I want a tonsillectomy.

Doctor: I believe that is a reasonable recommendation. I will support that and make application for approval from your insurance company. Once approved, you will need to return for a History and Physical and we will go over the preoperative instructions at that time.

Two weeks later, the insurance company approves the tonsillectomy.  The patient is scheduled for surgery. One week prior to surgery, the patient returns for a preoperative evaluation.

Doctor: Well, it looks like your insurance company has approved the surgery.

Patient: I am looking forward to getting this done.

Doctor: I need to ask, is there any family history of bleeding problems? By bleeding problems I mean hemophilia or excessive bleeding after cuts or difficulties with surgery?

Patient: No.

Doctor: Same question regarding yourself. Any problems with bleeding or any known bleeding problem?

Patient: No.

Doctor: Do you take aspirin or Motrin or any blood thinners?

Patient: I take an occasional aspirin for a headache.

Doctor: It is very important that you not take any aspirin, any aspirin-containing compound, or any nonsteroidal anti-inflamatory agent such as Motrin, Ibuprofen, Advil, or any of those medications for a minimum of 2 weeks before surgery. All of these compounds interfere with platelet function. They will interfere with your ability to form a blood clot, and will increase the chances that you would have a postoperative bleed.

Patient: Anything else I should know?

Doctor: You can have a normal day, normal food, and normal beverage the day before surgery. I encourage you to have an extra glass of water or two before you go to bed. The morning of surgery you should not have any food or drink. Even when you brush your teeth, spit the water and the toothpaste out. If you do drink or eat, the anesthesiologist will cancel your surgery and postpone it to another day.

On the day of surgery:

Doctor: Are you ready for your tonsillectomy?

Patient: I'm nervous, but ready. Let's get these infected, bad breath tonsils out.

Doctor: It will be just a minute before the anesthesiologist will be coming.

The tonsillectomy went well. Three hours later, the patient is in the recovery room with a friend who will be driving the patient home. The doctor makes one last visit and checks the patient's mouth. The throat is dry.

Doctor: It is very important that our patient drink fluids. My favorite is flat 7-Up. Carbonated beverages or acidic beverages such as orange juice, tomato juice, and other juices will burn the open wounds. For this first day, clear fluids with a little sugar are recommended. If you have a little discomfort , you can certainly take some Tylenol or one of the other prescribed pain medicines. Gum chewing is to be encouraged, for as soon as you begin to move the muscles of your throat, the discomfort begins to dissipate. Beginning tomorrow, full liquids are encouraged. Our favorite food is ice cream; chocolate and vanilla are the preferred flavors. Yogurt, sherbet and the more healthful ice creams are all acidic, and would be uncomfortable. You can have as much to drink and as much ice cream as you want. As soon as you feel ready, foods are encouraged, whether these are soft foods such as scrambled eggs or mashed potatoes, or things such as toast or a toasted cheese sandwich, is personal preference. Typically, hot foods may be uncomfortable, and cold foods are more soothing. It is also important that you not engage in any exercise for a period of 10 to 14 days, for this increases the chance of bleeding. Once we cross the 14-day line, gentle exercise working up to full exercise by 3 weeks is recommended. Now, this does not mean that you are stuck at home. You can go for a walk in the park. You can go shopping. You can go to the movies. Nothing is to be pushed, but there is no use sitting at home restless. Bending over and lifting are also discouraged, for these raise blood pressure and predispose to bleeding. And remember, no aspirin, and no nonsteroidals, for this is the quickest way to develop postoperative bleeding.

One week later, the patient presents for the postoperative check. The doctor walks in.

Doctor: How are you doing?

Patient: The sore throat is worse than I thought it was going to be; however, I have been able to drink fluids, I have eaten tons of ice cream, and just today I had some scrambled eggs and toast. I have lost 5 pounds, but with the pain medicine, things were quite tolerable.

Doctor: Let me examine your throat.

The doctor performs the examination.
 
Doctor: It looks fine to me.

Patient: It looks terrible to me.

Doctor: I know it does, but this is the normal healing period and it looks to me like you are healing just fine.

Patient: Do I need to see you again?

Doctor: Yes, I would like you to stop by in 5 or 6 weeks just to know that you have fully healed and that all is well.

Patient: Fine. I will see you then.

Six weeks later, the patient returns.

Doctor: How are you doing?

Patient: I am doing spectacularly. I only wish I had had this surgery several years earlier. I could have saved myself many, many days of discomfort and many, many sore throats. I have not been sick. I have not had any sore throats. I do not have bad breath. I feel good, and most important, I do not have any more tonsils and I do not have to go through this operation again.

Doctor: Do you have any questions?

Patient: No, not really.

Doctor: Well, it was my pleasure to take care of you. I am glad that you are better.

Patient: I remain eternally grateful.