Ep 134 Tonsils: Underestimated and underappreciated

While a tonsillectomy can be an effective solution for recurring tonsil infections, the recovery process can be more challenging than anticipated. Erin's experience involved multiple weeks of severe pain and difficulty swallowing, leading to dehydration and the need for hospitalization. She also wasn't warned about the post-surgery gunk or the difficulty in taking pain medication due to swallowing issues. Despite these challenges, Erin is grateful for the procedure as she no longer experiences tonsil infections and is off antibiotics. However, she wishes her doctor had been more transparent about the recovery process.

People underestimate the pain and recovery process of an adult tonsillectomy. The speaker shared her personal experience of being unprepared for the severity of the procedure and wished she had been warned beforehand. This is a common theme among people who have had the surgery later in life. The topic of tonsillectomies is an intriguing one, with a history deeply rooted in cultural history. Many people believe that having their tonsils removed was a rite of passage, especially in the 20th century. Tonsillectomies were a common procedure, and ice cream was often used as a reward for recovering patients. In the spirit of this discussion, the hosts served a "cutthroat" cocktail, a malted chocolate milk beverage with whiskey, ice cream, and chocolate sauce. The episode also explored the history and reasons behind tonsillectomies, answering many personal questions the hosts had about the procedure. Overall, the takeaway is to be aware of the potential challenges of an adult tonsillectomy and appreciate the historical significance of this common medical procedure.

Tonsils are a type of mucosal associated lymphoid tissue (MALT) that form a ring at the back of our throat, protecting us against infection. While all tonsils are MALT, not all MALT is tonsils. Mucosal surfaces throughout our bodies, including our guts, are covered in this immune-related tissue. For example, our guts have Peyer's patches and isolated lymphoid follicles. Our appendix is also lymphoid tissue. Tonsils, specifically our palatine and pharyngeal tonsils, are the ones most people think of when they hear the term. They are the ones that get swollen and painful when infected. But all tonsils, regardless of their location, serve the same purpose: to protect us from infection.

Our immune system is a complex network of organs and cells working together to identify and eliminate foreign substances, or antigens, from our bodies. One important aspect of this system is the mucosa-associated lymphoid tissue (MALT), which acts as a first line of defense. MALT, including structures like tonsils, has cells called m cells that directly sample antigens from the mucosa and transport them to the inner parts of the tissue where B and T cells reside. These cells produce IgA antibodies, which are important for defending against infections on mucosal surfaces. MALT is histologically similar to lymph nodes but is not connected to the lymphatic system. The crypts in tonsils and other MALT structures provide housing for B and T cells, and the epithelial tissue covering these structures is home to m cells. Overall, MALT plays a crucial role in the immune response by identifying and neutralizing antigens at the site of entry into the body.

Tonsils are crucial components of our immune system, acting as gatekeepers to our digestive and respiratory systems by constantly sampling and filtering out viruses and bacteria. However, their constant exposure makes them susceptible to inflammation and infection, leading to conditions like tonsillitis. Despite their importance, tonsils can sometimes need to be removed due to severe or recurring infections. It's important to note that not all sore throats result in tonsillitis, but when it occurs, it can be painful due to inflammation and the presence of open nerve endings in the affected area. Additionally, many respiratory pathogens are well-adapted to the cells of our tonsils, making them particularly susceptible to infection.

Tonsils, especially in young children, are prone to infections due to their size and location in the upper airways. These infections can lead to recurrent issues such as missed school, pain, and exposure to antibiotics. Enlarged tonsils can also increase the risk of ear infections and breathing problems, including obstructive sleep apnea. Severe infections can even cause airway compromise and require medical attention. Tonsil stones, which are collections of debris in the tonsils, can also cause problems. Bacterial infections, such as strep throat, are more likely to cause complications than viral infections. It's important for parents and caregivers to be aware of the signs and symptoms of tonsil infections and seek medical attention when necessary.

Tonsils, while serving important functions such as protecting against infections and producing antibodies, can become problematic and require removal through tonsillectomy and adenoidectomy. Complications from surgery include bleeding and infection, but long-term negative effects are not well-documented. The removal of tonsils shows the body's built-in redundancies, as we still have other mucosal lymphoid tissue and our entire immune system. Tonsillectomies have been performed for thousands of years, even before anesthesia and antibiotics, and references to them can be found in ancient texts. Despite the risks, the benefits of tonsillectomy include reducing recurrent infections and improving sleep in certain cases. Overall, tonsils are fascinating structures with essential roles but also the potential for issues that may necessitate surgical intervention.

Tonsillectomies, a common surgical procedure today, have a long and painful history. Roman aristocrat Celsus described the process as painful and required the use of hooks, scalpels, and even sunlight to perform. Galen, a 2nd century CE physician, suggested using a snare to amputate the tonsil, while Paul of Agena advocated for waiting until the inflammation subsided before performing the surgery. During the Middle Ages, tonsillectomies declined in popularity, but by the 16th century, they became fashionable again, despite the discomfort and controversy surrounding their removal. Some believed that the tonsils absorbed secretions from the brain and filtered them before sending them back, and without them, these secretions would linger and cause hoarseness. One surgeon even warned that the procedure could turn into a physical fight between the surgeon and the patient. The history of tonsillectomies is a testament to the resilience and determination of medical professionals to improve surgical techniques and alleviate suffering, despite the challenges and controversies.

The history of tonsillectomy, or the removal of tonsils, is marked by controversy, ordeal, and debate. This medical procedure, which involves removing the tonsils to alleviate various health issues, has been practiced for over two millennia. Early methods, such as using a tonsil guillotine or even a simple fingernail, were crude and often resulted in complications. However, as medical knowledge advanced, surgeons began to realize that partial removal was not always effective, leading to the development of more sophisticated tools and techniques for complete removal. The popularity of tonsillectomy reached its peak in the first half of the 20th century, but its use declined in the mid-20th century due to advancements in germ theory, hospital practices, and the shifting perspective of evolution. In essence, the history of tonsillectomy is a reflection of the evolving understanding of human health and the medical practices that emerged from it.

The belief among surgeons in the early 20th century that tonsils were a major source of systemic infections and should be removed was driven by the common experience of seeing the positive effects of tonsillectomy in patients with recurring throat infections. This belief was fueled by the assumption that tonsils were an incubator of infection, harboring bacteria that could enter the bloodstream and cause widespread illness. This belief was not based on solid evidence or extensive investigation, but rather on anecdotal evidence and personal experience. The idea that tonsils were vestigial structures, remnants of evolution that no longer served a purpose, may have also contributed to this belief. However, it's important to note that not all surgeons shared this view, and the decision to remove tonsils was not a universal practice. The belief that tonsils were not necessary gained traction during the mid-19th century with the introduction of the theory of evolution and the concept of vestigial structures. Despite this, tonsils were not listed as a vestigial structure by Robert Wiedersheim in his influential work "The Structure of Man."

The popularity of tonsillectomies during the first half of the 20th century was driven by a combination of factors, including the theory of evolution by natural selection and the belief in vestigial organs, as well as advancements in surgery and anesthesia that made the procedure more common and profitable. However, as statistical and controlled clinical studies emerged, doubts about the necessity and effectiveness of tonsillectomies grew, and it was found that many of the procedures had been incomplete, leaving residual tonsil tissue in many patients. Despite this, tonsillectomies continued to be hailed as essential for child health by some, while others questioned their value. This history serves as a reminder of the importance of rigorous scientific inquiry and the potential consequences of accepting medical practices without sufficient evidence.

The acceptance and application of new scientific research in the medical field, and ultimately in the general public, can take decades. The example of tonsillectomy illustrates this well. Despite evidence emerging in the 1920s that the procedure may not be necessary in all cases, it continued to be widely recommended and performed for several decades. The shift in attitude and decline in tonsillectomies did not begin until the 1960s and 1970s, and even then, it was a gradual process. The gap between primary research and its dissemination to the medical community and beyond is significant, and it can take a long time for new knowledge to reach and influence practice. This is due in part to the time it takes for researchers to test and confirm new findings, as well as the challenge of unlearning previously accepted knowledge. Additionally, factors such as the availability of alternative treatments and changes in medical training and practice can contribute to the decline of a procedure like tonsillectomy.

Despite the historical significance of tonsillectomies, there is a significant discrepancy between the number of tonsillectomies performed and those that meet evidence-based criteria. A study from the UK found that only 4 in 1,000 children met the paradise criteria for tonsillectomy, yet over 32,000 tonsillectomies were performed each year, with less than 1 in 8 of those having an evidence-based indication. This highlights the persistence of outdated practices and the importance of reevaluating the necessity of tonsillectomies. The study also emphasizes the need for more careful consideration and adherence to evidence-based guidelines in medical procedures.

The guidelines for tonsillectomy, a common surgical procedure for children, can vary greatly depending on the location and the specific indication. A study from the UK found that a significant number of children underwent tonsillectomy for recurrent tonsillitis that did not meet the evidence-based criteria. However, the number of children recommended for tonsillectomy due to obstructive sleep disordered breathing or obstructive sleep apnea increased over time, even though it was not considered an evidence-based indication in the UK. The study also noted that the rates of tonsillectomy vary widely across the globe, with rates in some countries being twice as high as in the UK, and in others being significantly lower. In the US, about 289,000 tonsillectomies are performed each year on children under age 15. The most recent guidelines from the American Academy of Otolaryngology and Head and Neck Surgery Foundation recommend watchful waiting for recurrent infections, but strongly recommend tonsillectomy for obstructive sleep disordered breathing. The evidence for this indication is not as strong as for other indications, but the numbers may be increasing as more evidence becomes available.

Researchers have discovered a new way to study the human immune response using organoids grown from tonsil tissue. This method, which was first demonstrated in a 2021 study published in Nature Medicine, allows scientists to observe the immune response to vaccines and infections in a more realistic human model than animal models. This could lead to advancements in vaccine development and a better understanding of the immune system. Additionally, there is evidence suggesting short-term improvements in sleep outcomes and behavioral parameters for those who undergo tonsillectomies. Despite the controversy surrounding tonsillectomies throughout history, it's clear that tonsils play an important role in our immune system, particularly in responding to respiratory infections. For more information on the history and significance of tonsils, check out the recommended sources.

Proper hygiene, specifically hand washing, is essential to maintain good health. The discussion emphasized the importance of hand washing in preventing the spread of diseases and viruses. It's a simple yet effective measure that can help protect individuals and those around them. The reminder to wash hands was delivered with a lighthearted tone, but the message remains serious. Staying clean is a crucial habit that can make a significant impact on overall health and wellbeing. So, remember to wash your hands regularly, especially during times when the risk of infection is higher. It's a small action that can lead to big benefits.