Dr. Jack Paradise, of the University of Pittsburgh, reports that surgically removing tonsils and adenoids has little, if any, effect in preventing recurrences of ear infections (1). Incredibly, doctors remove more than 400,000 tonsils each year. Tonsils and adenoids are lymphatic tissue. Tonsils should never be removed before age 4, because prior to age 4, they are a major supplier of the cells and proteins that help to protect you from being infected with viruses and bacteria. However after that, the tonsils and adenoids are less important in protecting you from infections and removing them does not appear to cause harm. Dr. Paradise followed 461 children who had recurrent ear infections. Those who had had their tonsils and adenoids removed were just as likely to suffer recurrences.
The accompanying editorial in the Journal of the American Medical Association recommends preventing recurrent ear infections with environmental control from filth, mold and dust mites, episodic antibiotics, childhood immunizations, ear tubes and "selected removal of adenoids" when all else fails (2). Fluid produced in the middle ear flows down the Eustachian tube into the mouth, where the child swallows it without even knowing about it. Children have such small Eustachian tubes that they are blocked, causing fluid to accumulate in their ears. Taking the antibiotic, erythromycin, may help clear fluid from a child's ear just by stimulating the cilia to sweep out the accumulated fluid (3,4).
Since the eustachian tube enlarges as a child grows, the tube usually opens by itself in time and it is rarely necessary to perform surgery. However, if the doctor feels that fluid in the drum can interfere with a child's hearing or school work or that permanent damage in possible, it is reasonable to relieve this pressure by punching a hole in the ear drum and inserting a tube to keep it open.
The main reasons to remove tonsils are blockage of the flow of air to a child's lungs and when an abscess forms. Even then, doctors can often avoid surgery because tonsils reach their maximum size at ages 8 to 10 and then become smaller with each passing year. However, tonsils are usually removed when a child has sleep apnea, a condition in which he stops breathing intermittently during sleep, severe snoring or significant difficulty swallowing.
It is now time to correct current recommendations of The American Academy of Otolaryngology- the surgeons- who recommend removing tonsils when a child has more than three sore throats a year. The American Academy of Pediatrics- who do not perform surgery- recommends removing tonsils after seven episodes in a year, even though there is no evidence that surgery prevents further infections. Doctors now have a rapid strep test to help them diagnose and treat strep throat infections while the child is still in their offices. The surgery is now safer than ever with newer equipment such as electrocauteries that can remove tonsils without causing bleeding.
1) Paradise JL et al. Limited benefit of tonsil and adenoid surgery for children with recurrent ear infections. JAMASeptember 7, 1999.
2) editorial JAMA 9/7/99.
3) Y Sugiura, Y Ohashi, Y Nakai. Roxythromycin stimulates the mucociliary activity of the eustachian tube and modulates neutrophil activity in the healthy guinea pig. Acta Oto - Laryngologica : Suppl. 531 (1997):34-38.
4) Y Sugiura, Y Ohashi, Y Nakai. Roxythromycin prevents endotoxin-induced otitis media with effusion in the guinea pig. Acta Oto - Laryngologica: Suppl. 531 (1997):39-51.
5) Xylitol chewing gum in prevention of acute otitis media: Double blind randomized trial. British Medical Journal 313: 7066 (NOV 9 1996):1180-1183. Conclusion-Xylitol seems to have a preventive effect against acute otitis media.
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