Overview
The tonsils comprise a ring of tissue surrounding the throat, called Waldeyer’s ring. This lymphoid tissue exists in three areas: the adenoids at the back of the nose, the palatine tonsils visible on either side of the throat, and the lingual tonsils on the back third of the tongue.
Palatine tonsils
The palatine tonsils are commonly referred to as ‘your tonsils’. They sit on either side of the uvula and vary in size from barely visible to nearly filling the throat space. Various conditions affecting these tonsils can be managed either conservatively with medication or through surgery.
Conditions affecting the tonsils
Tonsillitis
Tonsillitis involves infection of the tonsils, typically caused by viruses, though bacteria can also be responsible. Affected tonsils become enlarged, red and inflamed, potentially displaying white pustules. Symptoms include soreness, fever and difficulty swallowing.
Initial treatment involves simple painkillers and mouthwashes. Antibiotics are prescribed only when bacterial infection is suspected. Patients experiencing recurrent tonsillitis may be offered surgical removal. NHS guidance follows the Scottish Intercollegiate Guidelines Network recommendations, which suggest tonsillectomy when there are seven episodes in one year, four a year for two years in a row, or three a year for three years in a row.
Obstructive sleep apnoea
Enlarged tonsils can obstruct breathing during sleep, affecting both children and adults. In children, this can impair concentration, cause behavioural problems, restrict brain development and strain the heart. Sleep studies monitoring oxygen levels may be required to confirm the diagnosis.
For children with enlarged tonsils causing sleep apnoea, tonsil and adenoid removal is recommended. Adults require formal sleep studies for assessment, and conservative treatments such as mandibular positioning devices or CPAP therapy are often preferred initially.
Quinsy
A quinsy, or peritonsillar abscess, forms behind the tonsil and throat wall. It causes severe pain (potentially radiating to the ear), prevents eating and drinking, alters the voice, causes fever, and swells the affected side of the throat. Treatment involves draining the pus and giving antibiotics. Recurrent episodes warrant tonsil removal.
Asymmetrical tonsils
Tonsils of different sizes usually pose no concern, though specialist examination is recommended. Depending on appearance and individual circumstances, removal and examination may be advised to exclude underlying problems. Asymmetrical tonsils can potentially indicate throat cancer, warranting ENT assessment.
Tonsil cancer
Tonsil cancer incidence is rising due to human papillomavirus (HPV) infection. Presentation may include a tonsil mass, a neck lump, difficulty opening the mouth, sore throat or earache. Suspected cases require ENT specialist assessment and management within a head and neck multidisciplinary team.
The procedure: tonsillectomy
A tonsillectomy removes the palatine tonsils under general anaesthesia, always removing both. Two approaches exist: intracapsular and extracapsular techniques.
Intracapsular tonsillectomy
This newer technique uses coblation technology to dissolve the tonsil tissue while preserving the outer capsule. Benefits include reduced post-operative pain, with children returning to school within a week, and minimal bleeding risk (below 1%). A small tonsil-regrowth possibility exists, occasionally requiring a second operation. This approach suits children with sleep apnoea and recurrent tonsillitis, though effectiveness decreases in adults.
Extracapsular tonsillectomy
This method removes the entire tonsil, including its capsule. It involves increased pain, requiring two weeks off work or school. Bleeding risk rises to approximately 5% over the two post-operative weeks, with roughly 1% requiring an emergency procedure. There is no regrowth risk. This technique applies for recurrent quinsy, asymmetrical tonsils, or suspected cancer.
Risks of surgery
- Pain (which increases with age).
- Post-operative bleeding, which can occur up to two weeks after surgery.
- Throat infection causing a foul smell or escalating pain, managed with antibiotics.
- A minimal risk of tooth damage (teeth are typically already loose in children, or diseased in adults).
- Temporary jaw stretching, resolving within weeks.
- Minor lip or gum cuts, healing quickly without intervention.
After the operation
Rest at home for one week (intracapsular) or two weeks (extracapsular). Take regular painkillers even without pain, as managing pain becomes harder once the throat becomes uncomfortable. Eat and drink as normally as possible, avoiding acidic or spicy items — normal eating and drinking reduces the risk of infection and bleeding.
Yellow or white colouring on the back of the throat is normal, representing wet scabbing. Increasing pain or bad breath indicates possible infection requiring antibiotics. Any spitting of blood beyond slightly pink-tinged saliva or a single clot warrants immediate A&E attendance or an ambulance call. Children may swallow rather than spit blood, so pallor, excessive swallowing, nausea or vomiting of blood requires medical attention. Contact the Practice Manager with any post-surgery questions.
Adenoids
The adenoids, located at the back of the nose, can cause snoring, sleep apnoea, nasal obstruction, glue ear, ear infections, muffled hearing and Eustachian tube dysfunction. Depending on the cause, removal via a mouth approach (leaving no scarring) may be recommended.
Enlarged adenoids
Enlarged adenoids contribute to sleep apnoea by blocking the nasal passages during sleep, causing difficulty breathing or temporary cessation of breathing. Paediatric sleep apnoea can harm concentration, behaviour and brain development; in extreme cases it strains the heart, warranting adenoidectomy with or without tonsillectomy.
Adult sleep apnoea causes cardiovascular problems, including high blood pressure and stroke risk, plus daytime sleepiness. Small cameras passed through the nose can visualise enlarged adenoids in adults. For children, sleep studies monitoring oxygen and breathing patterns help clarify whether the adenoids are enlarged, sometimes combined with a nasal camera inspection under general anaesthesia.
Risks of surgery
- Pain, requiring simple painkillers.
- Bleeding, potentially occurring up to two weeks post-operation; immediate A&E attendance is recommended.
- Infection, identified by a foul smell or escalating pain, managed with antibiotics.
- A minimal possibility of tooth damage.
- Temporary jaw stretching, resolving within weeks.
- Minor lip or gum cuts, healing quickly without treatment.
After the operation
Recovery requires one to two weeks off (two weeks if combined with an extracapsular tonsillectomy). Take regular painkillers and eat and drink normally. Increasing pain, a foul smell or bad breath suggests infection requiring antibiotics. Any spitting of blood warrants immediate A&E attendance or an ambulance call. Children may swallow blood instead of spitting it; pallor, excessive swallowing, nausea or vomiting of blood requires medical advice. Contact the Practice Manager regarding any post-surgery questions.