18 and Under: A Tonsil Remedy Is Fitted for a New Century

It opened on East 62nd Street in February 1921, its mission to remove the tonsils and adenoids of poor children on the East Side of Manhattan, thereby preventing sore throats and streptococcal infections and all their serious consequences in an era without antibiotics. Parents saw scarlet fever, named for its red, sandpapery rash, as a frightening and dangerous childhood illness; rheumatic fever, which sometimes followed strep, could seriously damage the heart.

But times have changed. Built on studies of throat infections and tonsillectomies, new guidelines from the American Academy of Otolaryngology, issued in January, suggest tonsillectomy for recurrent sore throats only if frequent or severe.

At the same time, the academy now recommends that the operation be considered for children who have trouble breathing while they sleep.

The new guidelines reflect changes in clinical practice, and attempt to bring scientific evidence to bear on an operation at times popular to the point of ubiquity.

In the era of the Tonsil Hospital, pretty much all children got tonsillectomies. Consider “Cheaper by the Dozen”: The 1948 memoir about two efficiency experts and their 12 children happens to contain the single funniest tonsillectomy chapter in literature (granted, competition is limited).

Six of the children undergo tonsillectomies, performed by a doctor in an operating room rigged in the family home in Montclair, N.J. The father of the family still has his tonsils, and the doctor is “rewarded” for his cooperation by being allowed to remove them, too.

Leaving aside all the family dynamics, the chapter is notable for the matter-of-fact assumption that sooner or later, all tonsils need to be removed. And even after antibiotics were available, many if not most tonsils continued to be removed, through the 1950s and ’60s.

“It was the single most common operation in the United States,” said Dr. Ellen Wald, a specialist in pediatric infectious disease who is chairwoman of the pediatrics department at the University of Wisconsin School of Medicine and Public Health.

But which children really benefited from these operations, and which did not? “When I was in practice and first began to question this issue and was faced with the question of ‘Should my child have a tonsillectomy or not?,’ I never knew the right answer,” said Dr. Jack L. Paradise, professor emeritus of pediatrics at the University of Pittsburgh School of Medicine.

Dr. Paradise and his colleagues tried to provide an answer in a study, published in 1984, that looked at children with many well-documented episodes of throat infection (seven or more in the preceding year, for example). Those who got tonsillectomies had fewer infections in the first couple of years after surgery than those who didn’t, the researchers found. But the children who didn’t have surgery also had fewer and fewer infections as they got older.

Tonsillectomies were a reasonable option for children with severe, recurrent throat infections, Dr. Paradise concluded. But so was watchful waiting.

Later, Dr. Paradise studied children with fewer infections and concluded that the benefit of tonsillectomy was too “modest” to justify the risk, the pain and the cost of surgery in those children.

These days, many doctors are less likely to move to tonsillectomy for a smaller series of run-of-the-mill sore throats. I try to explain to parents that their children will grow out of these infections, and taking out their tonsils won’t necessarily do very much to expedite that process.

Yet at the same time, doctors are more willing to consider that children may need the operation if their tonsils obstruct the throat enough to affect breathing while they sleep.

Dr. Richard M. Rosenfeld, one of the authors of the new tonsillectomy guidelines and a professor of otolaryngology at SUNY Downstate Medical Center in Brooklyn, suggests that back when most children had their tonsils out, it was perhaps less common to see these sleep problems — what with all the tonsillectomies, there was “nobody breathing with a golf ball in the mouth.”

Now that more children are growing up with their tonsils intact, he said, “we created this new disease, sleep-disordered breathing.”

Some behavioral issues, including some attention problems, can be traced to a lack of deep, restful sleep. A child suffering from obstructive sleep apnea will not simply grow out of it, said Dr. Kasey Li, a surgeon at Stanford University. Even if the tonsils do become less problematic at puberty, as sometimes happens, the child’s development will have been affected.

For problems short of obstructive sleep apnea, “the advice to parents is, if you’re even the least bit unsure, don’t do it — it’s an elective surgery, don’t worry about it, you can always re-address it,” Dr. Rosenfeld said. “There’s very little harm to some watchful waiting till things sort themselves out.”

Parents should also know that in a significant number of children, the breathing problems — and everything that follows from disordered sleep — may persist even after the operation and need further treatment.

So the tonsillectomy, once routine, now requires a nuanced diagnosis. It may improve quality of life for some children, but there are limits to what it can accomplish — with sleep issues and behavior problems, and with recurrent infections.

It’s a far cry from where we were in the first half of the 20th century, when philanthropists provided poor children with a dedicated facility for tonsil removal. The Tonsil Hospital closed in 1946.

“I’m on the Upper East Side at Cornell New York hospital, 10 blocks from where the original hospital was," said Dr. Edward McCoul, an otolaryngologist who wrote about the hospital last year in a medical journal. “I ask around, and basically no one I’ve mentioned it to has ever heard of it.”