For decades, the removal of the tonsils (tonsillectomy) was one of the most common surgical procedures performed on children, often considered routine. This practice was widespread, becoming a cultural expectation in many parts of the world. However, the medical community’s approach has changed dramatically, leading to a significant decrease in these surgeries. This shift raises the question of what medical and scientific developments caused the move away from routine removal and why the tonsils are now generally preserved.
The Role of Tonsils in Immune Defense
The tonsils are specialized collections of lymphoid tissue that function as a first line of defense for the body’s immune system, forming part of a ring of protective tissue called Waldeyer’s ring. This allows them to sample pathogens, such as viruses and bacteria, that are inhaled or ingested.
These tissues are classified as mucosa-associated lymphoid tissue (MALT) and contain numerous immune cells, including T cells, B cells, and macrophages. Specialized cells on the tonsil surface, known as M cells, capture microbial antigens and present them to the underlying immune cells. This process initiates a localized immune response and helps educate the developing immune system, particularly in early childhood.
Activated B cells within the tonsil’s germinal centers proliferate and mature, producing memory B cells for future defense. The tonsils are particularly known for their role in producing Immunoglobulin A (IgA), an antibody that provides mucosal immunity. While the tonsils play a less significant role in immunity as a person ages, their function in initial immunological development provides a foundational reason for their preservation.
The Shift Away From Routine Surgery
The high rate of routine tonsillectomies in the early to mid-20th century was largely influenced by the prevailing “focal theory of infection”. This theory posited that localized, chronic infections in areas like the tonsils could serve as a “portal of infection,” leading to systemic diseases throughout the body, such as rheumatism or kidney issues. As a result, tonsillectomy was often recommended to prevent a wide array of seemingly unrelated health problems.
This practice was especially common in the pre-antibiotic era, where recurrent or severe tonsillitis presented a serious health concern without reliable medical management. By the 1930s, tonsillectomy was the most frequently performed surgery in the United States. The operation had become a common medical ritual, despite a lack of robust evidence supporting its long-term benefits for non-severe cases.
The medical paradigm began to shift significantly starting in the 1950s and 1960s, driven by two major developments. First, the widespread availability of effective antibiotics offered a straightforward and low-risk method to treat acute bacterial tonsillitis, meaning the infection could be managed without surgery. Second, medical researchers began conducting rigorous studies that questioned the efficacy of routine tonsillectomy.
These mid-century studies demonstrated that the benefits of removal for mild to moderate recurrent infections often did not outweigh the risks and costs of the surgery. The improved understanding of immunology showed that removing a functioning component of Waldeyer’s ring was unnecessary if the tonsils were not causing significant problems. This combination of better medical treatments and evidence-based practice led to a progressive and dramatic decline in tonsillectomy rates.
When Tonsil Removal Is Still Necessary
Despite the overall decline, tonsillectomy remains a common procedure today, but it is reserved for specific, medically documented conditions. The indications for surgery have shifted significantly from recurrent infections to issues related to breathing. The primary reason for tonsil removal in children today is Obstructive Sleep-Disordered Breathing (OSDB), which includes Obstructive Sleep Apnea (OSA).
When the tonsils are severely enlarged, they can obstruct the upper airway during sleep, leading to snoring, gasping, and brief pauses in breathing. This obstruction can cause daytime fatigue, behavioral issues, and other health consequences, making tonsillectomy a highly effective treatment for most children with this condition. The removal of the enlarged tissue alleviates the crowding in the throat, often curing the sleep-disordered breathing.
The second major indication is recurrent, severe tonsillitis, defined by strict frequency guidelines known as the Paradise criteria. Surgery may be recommended if the patient has documented infections meeting one of the following patterns:
- Seven or more episodes in the preceding year.
- Five or more episodes per year for two consecutive years.
- Three or more episodes per year for three consecutive years.
These criteria require careful medical documentation of each episode, often including a high fever, tonsillar exudate, or a positive test for Group A beta-hemolytic streptococcus. Other, less common indications include a peritonsillar abscess resistant to drainage, or the presence of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis (PFAPA) syndrome. In all cases, the decision for surgery is a careful balance between the risks of the procedure and the significant impact of the chronic symptoms on a patient’s quality of life.