Tonsillectomy Confidential: doctors ignore polio epidemics and high school biology


Seth Roberts is the author of The Shangri-La Diet and posts at Seth's Blog about personal science, self-experimentation, and the scientific method.

In 2008, Rachael Hoffman-Dachelet's eight-year-old son started having frequent sore throats. He'd run a fever, feel stiff and tired, and miss a few days of school. After six sore throats in a year, her pediatrician said This is crazy. I'm going to refer you to an ear nose and throat specialist. I think he'll recommend a tonsillectomy (tonsil removal).

Rachael and her son saw the specialist, who did recommend a tonsillectomy. Tonsils are part of the lymphatic system, a network of tiny tubes and nodes all over the body. It is mostly a drainage system. Lymph drains into the tubes, which carry it to the heart, where it reenters the blood. En route to the heart, lymph passes through nodes. How can lymph move through the system if you remove part of it? Rachael asked the specialist. If there were any bad long-term consequences we'd know because so many tonsillectomies have been done, he said. The correct answer is that lymph does not pass through the tonsils. Rachael asked about the benefits of the surgery. Your son will miss a lot less school, he said.

Rachael teaches art at a Minnesota middle school. Her experience with doctors had made her skeptical of their predictions. To decide for herself if a tonsillectomy was a good idea, she googled "pubmed tonsillectomy meta-analysis" and found a Cochrane Review about tonsillectomies and tonsillitis. There are thousands of Cochrane Reviews. Each tries to summarize the evidence about the effect of a treatment on a health problem (e.g., "Antibiotics for sore throats"). They are meant to be practical -- to help everyone, including outsiders like Rachael, make treatment decisions (such as "should my son have a tonsillectomy?"). They are produced by the Cochrane Collaboration, a British non-profit, which says its reviews are "internationally recognised as the highest standard in evidence-based health care".

The Cochrane Review that Rachael found ("Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis") was published in 2009. It describes four experiments that compared tonsillectomy to the care a sick child would otherwise receive. All four involved children like Rachael's son, and all four had similar results: Tonsillectomies had only a small benefit. (Contrary to what Rachael was told.) During the year after random assignment to treatment -- the point at which some children had their tonsils removed, other children did not -- children whose tonsils were removed had one less sore throat than children who were not operated on (two instead of three for children like Rachael's son). Because the benefits were small, the decision was easy. "The time, expense, and risk of surgery vs. one [sore throat]," Rachael wrote on my blog, "Not a tough choice."

Rachael believes "when things are going badly with your body, nutrition is a good place to start" looking for help. After she decided against tonsillectomy, Rachael and her son went to see a naturopath that a neighbor had recommended. The naturopath was especially knowledgeable about nutrition and supplements. After an hour interview, she suggested Vitamin D3 (5000 IU/day), a multivitamin, Vitamin C (500 mg/day), and powdered larch bark. Rachael searched for research about these recommendations. She found many studies that suggested Vitamin D might help. Her son is a pale redhead and used sunblock a lot. It was easy to believe he wasn't getting enough Vitamin D. Because Vitamin D won't work properly without other vitamins (called co-factors), a multivitamin was a good idea. Rachael found studies that implied that a multivitamin was very unlikely to be very harmful. She found few relevant studies about Vitamin C. Maybe extreme claims about its benefits had scared off researchers -- "Linus Pauling burned that bridge," said Rachael. But she took the Vitamin C recommendation seriously because the naturopath had made other reasonable recommendations, the recommended dose was not large, Vitamin C is easily excreted in urine (in contrast to building up in the body), and Rachael had never heard of anyone having trouble at that dose. The naturopath had said that larch bark had reduced ear infections in children with chronic ear infections. A little bit of theory supported this, Rachael found, but overall the larch-bark research was "dodgy," she said. A considerable virtue of the naturopath's recommendations was that if they didn't work or had bad effects, you could stop them (e.g., stop taking Vitamin D). A tonsillectomy is forever.

As it happened, the larch bark tasted awful and her son only took it for a few days. He took Vitamin C for a month or two. He still takes Vitamin D3 and a multivitamin. Because he took the Vitamin D3 at 7 am, maybe it improved his sleep (and better sleep = better immune function). He had no more sore throats.

Tonsillectomies are ancient and, as the ear nose and throat doctor said, very common. "For much of the twentieth century," says this book,"tonsillectomy (generally with adenoidectomy) was the most common surgical procedure in the United States." They are still very common. In 2006, half a million were done just in America.

What do tonsils do? Tonsils, like other parts of the lymphatic system, contain large numbers of lymphocytes. Lymphocytes are usually called a type of white blood cell, but that is misleading because relatively few are in the blood. Almost all your lymphocytes are in your lymphatic system, which is why they're called lymphocytes. As recently as the 1950s, their function was unknown. In 1953, for example, this ignorance was called "a disgraceful gap in medical knowledge". Failure to understand what lymphocytes do made it unclear what tonsils do. It is dangerous, to say the least, to cut off part of the body whose function you don't know. In spite of this, tonsillectomies were extremely popular from the 1920s through the 1940s. Tens of millions were done.

Around 1900, America started to have frequent polio epidemics. Starting in 1916, they happened every summer, which came to be called "polio season". Over the years, they got worse. In 1951, thousands of children died, and tens of thousands were crippled. The level of fear can be seen from a booklet called Polio Pointers for 1951. Along with practical advice ("keep [your children] away from new people"), it tried to reassure: "Remember -- at least half of polio patients get well without any crippling." As both tonsillectomies and polio increased, a horrifying correlation emerged: Children who'd had a tonsillectomy were more likely to get a certain type of polio (infection of the bulbar region of the brain stem) than children who had not had a tonsillectomy. This became common knowledge. Polio Pointers said "don't have mouth or throat operations during a polio outbreak." In 1954, the American Journal of Public Health ran an editorial summarizing the link between tonsillectomy and polio. The main evidence was that within a group of children with polio, the ones with bulbar polio were about three times more likely to have had their tonsils removed than the ones with spinal polio (infection of the spinal cord). This resembles some of the first evidence connecting smoking and lung cancer: Hospital patients with lung cancer were much more likely to be heavy smokers than hospital patients with other diseases. Although Polio Pointers implied that tonsillectomies were unsafe only "during a polio outbreak," this was false. The data implied they were always unsafe: "This higher proportion of bulbar cases in tonsillectomized persons occurs at all ages regardless of the time elapsed since operation," said the editorial. A 1957 paper about the tonsillectomy/polio association cited 19 studies that had observed it. "The association is generally regarded as an underlying causal relationship," said the paper, meaning that the usual explanation was that tonsillectomy increased risk of bulbar polio. The paper found more evidence for this explanation. Researchers considered other explanations for the polio/tonsillectomy association (for example, are tonsillectomies more common among rich children? among sickly children? ) but failed to find supporting evidence. The tonsillectomy/polio connection is probably why tonsillectomies became less popular starting in the 1950s. They declined from extremely common (the most common of any operation) to very common (the most common operation done on children).

By 1960, the tonsillectomy/polio association was firmly established, but its explanation was a mystery. If it reflected cause and effect, why would tonsils protect against infection? Around this time, work by James Gowans and others started to answer this question by figuring out that lymphocytes are the main cells of our immune system. They detect bacteria and viruses and make antibodies against them. T cells, B cells, and natural killer (NK) cells -- all lymphocytes. In one experiment, Gowans and his co-workers drained the lymphocytes from rats. The rats lost the ability to make antibodies. When the researchers put the lymphocytes back into the rats, they regained the ability to make antibodies. That's just an example. Our understanding of what lymphocytes do comes from thousands of experiments.

When the function of lymphocytes became clear, the lymphatic system made much more sense. Lymph washes germs out of tissue and into lymph nodes, where lymphocytes detect and try to kill them. The high density of lymphocytes in the nodes ensures that germs will bump into them and be detected. When lymphocytes detect more germs than usual, they multiply and the nodes enlarge. Tonsils do not filter lymph, as I said, but like lymph nodes are full of lymphocytes. Their shape and placement causes them to sample the bacteria in your mouth, so they protect you against the bacteria in your mouth. Tonsils become swollen and sore during infections because the number of lymphocytes inside has increased -- the lymphocytes are fighting off the infection. These facts about the immune system and the lymphatic system, including the function of lymphocytes, are part of high school biology. For example, this lecture.

Removal of your tonsils is removal of part of your immune system. Our understanding of the immune system implies that removal of tonsils reduces ability to fight off infection. We cannot say exactly what tonsils do, just as we cannot say exactly what many parts of the brain do, but our general understanding of the immune system (based on thousands of experiments) implies that removal of any part of it is very dangerous, just as our general understanding of the brain (based on thousands of experiments) implies that removal of any part of it is very dangerous. When a child gets a sore throat, it suggests that his immune system is not doing a good job fighting off infections; a better-functioning system would have killed the germs sooner. Cutting off part of the body that fights infections because of too many infections makes as much sense as getting rid of fire houses because of too many fires. If your outcome measure is narrow, you may conclude that damaging a vital organ is beneficial. For example, prefrontal lobotomies were once claimed to be a a good thing (some people became less disruptive). In rare cases, the benefits of removing part of a vital organ may outweigh the risks. If I were in intractable pain, I might agree to have part of my brain removed. But not because of six sore throats.

The tonsillectomy/polio association was the first large batch of evidence that tonsillectomies do serious harm. The studies that showed what lymphocytes do was the second large batch -- so large and clear that tonsillectomies should have stopped. But they didn't, and the evidence that they do serious damage has increased. In recent years, they have been repeatedly associated with obesity. A 2011 review of nine articles found that "a large population of normal and overweight children undergoing [adeno-tonsillectomy -- removal of both adenoids and tonsils] gained a greater than expected amount of weight postoperatively." Another study concluded "risk of overweight should be mentioned as a probable undesirable outcome of adenotonsillectomy." A third study points in the same direction. To see more evidence, search "obesity tonsillectomy".

Another recent association is with heart attacks. A 2011 study found that people who had had tonsillectomies before age 20 had a much higher rate of heart attacks (about 50% higher) than matched controls over the next twenty years. The study cites other evidence that immune dysfunction increases heart attacks. The same study found that hernia operations at a young age were not associated with heart attacks. A 2010 study based on different people found that "tonsillectomy before age 7 years was associated with a 1.5-fold increase in mortality" from age 18 to 44. This supports the association of tonsillectomies with a large percentage increase in a common cause of death (heart attacks). That tonsillectomies increase heart attacks is made more plausible by the well-established association of gum disease and heart disease. Gum disease is caused by bacteria in the mouth; tonsils protect against bacteria in the mouth.

After Rachael read the Cochrane Review about tonsillectomies, she decided they're a bad idea. This is like Vladimir Putin's party getting only 49% of the vote in the recent election in spite of ballot stuffing. Cochrane Reviews are supposed to be unbiased, but this one omitted (without saying so) a great deal of anti-tonsillectomy information:

1. It does not say that tonsils are part of the immune system, nor that removing the tonsils damages the immune system. It says nothing about lymphocytes and their function. It does not say that the tonsils are full of lymphocytes. It does not say that the nodes of the lymphatic system, including the tonsils, are the main places the immune system does its work.

2. It says nothing about the tonsillectomy/polio association. It says nothing about the tonsillectomy/obesity association.

3. "Those who choose surgery for themselves or their child must be fully informed of the risks of the procedure," say the authors. I agree. Do the authors follow the advice they give to others? Here is how they answer the question "what are the risks of [tonsillectomy] surgery?": "Tonsillectomy is associated with a small but significant degree of morbidity in the form of primary and secondary haemorrhage and, even with good analgesia, is particularly uncomfortable for adults." That's their whole answer.

If you search tonsillectomy/adverse effects on PubMed, you will get more than 1000 references. There is no sign in the review that the authors did that search or any other search for bad effects of tonsillectomies. If the authors had looked at the PubMed articles published before their review (about 900), they would have learned that the risks of tonsillectomy include polio, weight gain, vomiting (many articles), taste distortion (here, here, here), Hodgkin's disease (here, here, here, here, here, but here is evidence that disputes the association), Creutzfeld-Jacob disease (e.g., here, here), inflammatory bowel disease and Crohn's disease, rheumatoid arthritis, severe spine infection, neck infection (here, here), speech problems (here, here), hearing loss, ear pain, visual loss (here, here), depression, several other serious problems, and immunological abnormalities (e.g., here, here, here). They would have learned that tonsillectomy "is associated with a relatively high risk of postoperative complications" and that "the actual post-tonsillectomy haemorrhage rate is much higher than that recorded in hospital statistics." (The Cochrane Review says this risk is "small".) They would have learned, if they didn't already know, that "the tonsils have a large immune function."

4. At the end of the review, it says, "If adeno-/tonsillectomy has an effect on aspects of an individual’s health other than sore throats - general well-being, for example - these outcomes should also be evaluated." "If"? This is misleading. By 2009, as I've shown, there was plenty of evidence of bad effects.

The Cochrane Review deserves credit for summarizing some relevant evidence. It deserves criticism for silently omitting a large amount of anti-tonsillectomy information (polio, lymphocytes, obesity, and so on) and posing as a reasonable guide to the value of tonsillectomies. (It comes with a "plain language summary" that says nothing about omitted information.) The review is by Martin Burton and Paul Glasziou, both at Oxford at the time. Both declined to comment for this post on my criticisms. Burton now heads the United Kingdom Cochrane Centre. Glasziou specializes in evidence-based medicine (which I have criticized). He has co-authored a book on systematic reviews and a consumer's guide to evidence-based medicine. He now heads the Centre for Research in Evidence-Based Practice at Bond University in Australia.

Any review must omit information. The Cochrane Review, however, omits a vast amount of anti-tonsillectomy information that could easily have been included. It does not omit a vast amount of pro-tonsillectomy information. There has been no series of devastating epidemics in which tonsillectomy was associated with less disability and death. There have not been thousands of experiments that imply tonsils reduce resistance to infection. In that sense, the review is badly biased. One reason may be conflict of interest. Burton is an ear nose and throat surgeon; he does tonsillectomies for a living. This is not disclosed in the review. I don't know if his finances depend on how many tonsillectomies he does, but I am sure he has done many of them (biasing him to think they are good) and has many tonsillectomy surgeons among his friends and colleagues. He must care what they think. Negative comments about tonsillectomies would surely displease them. Burton declined to comment on this criticism.

In its omission of anti-tonsillectomy information, the Cochrane Review reflects this area of medicine. While doing research for this post, I was unable to find a single instance in which any doctor -- including pediatricians, ear nose and throat doctors, and tonsillectomy surgeons -- or doctor-run website told any parent (or anyone else) anything like the truth about the risks of tonsillectomies. On the Mayo Clinic website, for example, a pediatrician tells parents that "the decision to remove a child's tonsils must be weighed against the risks of anesthesia and bleeding, as well as the missed school days to recover from the procedure." That's all he says about risks.

False claims about tonsillectomies are nothing new. In 1933, an American writer named Kenneth Roberts (no relation) visited England. His shoulder started to hurt. It became so painful he had trouble sleeping. He consulted a London surgeon, who recommended a tonsillectomy:

"Then you think this pain in my shoulders is due to my tonsils?" I asked him.

"My dear boy!" he expostulated. "Of course! You're poisoned! It might crop out anywhere! Arms, legs, body, head, feet, brain -- positively anywhere! Not an instant to lose, my dear boy."

Roberts encountered similar behavior by other doctors. His account of it is called "It Must Be Your Tonsils". Given this history (overstatement of the benefits of tonsillectomy), it is especially remarkable that the Cochrane Review is so biased. Professional groups are worse. The American Academy of Otolaryngology-Head and Neck Surgery currently recommends that "children who have three or more tonsillar infections a year undergo a tonsillectomy". The corresponding Canadian group has a higher threshold: six infections in a year. Those are low bars for cutting off part of a vital organ. Both groups claim that a good solution to too many infections may be removal of part of the body that fights infection.

Overtreatment -- wasteful and harmful medicine -- is an enormous problem. It is the subject of two recent books (Overtreated and Overdiagnosed) and a Newsweek article. Tonsillectomies are an example. The last sixty years have produced a mountain of anti-tonsillectomy evidence (polio, lymphocytes, obesity, heart attacks, and so on) that doctors, such as the Cochrane reviewers, seem to ignore. People like Rachael suggest a solution: help non-doctors look at evidence.



  1. It has been my experience that tonsillectomies are NOT recommended very much anymore, and have not been recommended by most doctors for a long time.  The doctor in the story doesn’t fit with my impression of what most doctors would do in the same situation in recent decades. The same goes with any optional surgery and excessive antibiotic treatment. Most doctors don’t like to do things like that.

    1. I live in Spain, it used to be a very common procedure 30 years ago ( almost all of my friends got it), but I don’t  know any children who has undergone a tonsillectomy in recent times. Doctors say there are no visible benefits to it.

    2. Many doctors still overuse antibiotics, new strategies are used, but abuse continues. Recent reviews:
      This article talks about disagreement in the field between specialists and GP’s, ENT’s tend to like tonsillectomies more than GP’s for common issues.
      I’m glad your mileage has varied, but it may only be your mileage.

  2. I 100% agree with this – but would also point out that there are cases where tonsillectomies are a good idea. For example, as a child my tonsils became so infected that they swelled to the size of golf balls. When they were removed, the surgeon showed them to me and my mother and told us that he could actually smell the decay when they came out – that they were the worst he’d ever seen. My pediatrician did not want me to get a tonsillectomy one bit, and insisted on exhausting every other method first – including excessive antibiotic treatment which has left me allergic to many antibiotics to this day.

    Obviously, anecdata is useless as far as making good decisions, but my point is: doctors have a great deal of specialized knowledge which is a huge part of making medical decisions for oneself, but educating oneself is extremely important as well, and the right medical choice for one person and one situation may not be the right choice for another!

    1. >>Obviously, anecdata is useless as far as making good decisions…

      No, Ms. Klink, that is NOT obvious. Anecdotes are completely relevant to making good decisions. It is up to each of us to weigh the claim — its costs, benefits, and applicability to our own situation.

  3. I know this is just one example… but my 7 yr-old (at the time) son was having ear infections and strep throat about every 12 weeks for more than 1.5 years, and when we finally got him a tonsillectomy, they stopped entirely, and he hasn’t had either strep or an ear infection in the five years since.

    The doc told us that the antibiotics we were using (and we’d tried a bunch… some of which gave him some pretty severe other symptoms) couldn’t get into his tonsils because the blood flow there was so poor. So the infection would die down elsewhere, lie dormant in the tonsils, and then flare up again within a few weeks. When he took the tonsils out, he said they looked like those of an old man who’d been smoking for 30 years.

    So… I hadn’t heard this other stuff, and I’m sure it’s good to know. But the tonsillectomy really seemed to help my boy out.

    1. One of the things I wonder about is what is going on with our environment, diet or breeding that so many humans have these sore throats, infected tonsils issues. Do other countries with different diet, environments, breeding have the same problems?

      1. What’s going on is that we now live in a time where 1/4 or 1/5 children doesn’t die before the age of 2. What’s going on with our environment, diet, and breeding is that we’re rescuing children that would have otherwise died – instead they’re merely getting sore throats, earaches, and so forth.

        They’re mostly not even growing up to be deaf in one or both ears from those ear infections, which is amazing.

        What might have been a serious crippling illness that leaves the child weakened enough to be killed by the next one, or might have killed them outright, has now been reduced to “inconvenient”.

    2. One thing that often gets missed by most people is that most of the common signs of infection – irritation, mucus discharge, fever, swelling of tissues, etc – are actions of the immune system, not the disease agent. 

      Could it be possible that removing the main garrison of the immune system in the throat has only appeared to reduce the infections because the action has moved elsewhere in the body? Is this why the risks of other health issues go up if the tonsils are removed, because the infectious agents are not stopped at the gate?

      Removing the tonsils could make sense if it could be demonstrated that the immune system was “overactive” and needed to be curbed somehow (reducing the overall suffering is worth the other risks) – but this is another area where I think modern medicine is failing us, as so many autoimmune ailments are on the rise these days (asthma, MS, Crohn’s, etc.)

      Why are our immune systems attacking us?

  4. Unless there is overwhelming need, always start with the non-invasive options first. As the article well points out, you can stop the vitamins, but you can’t put our tonsils back in. Vitamins and nutrition are good to adjust, as long as you’re not doing it completely in lieu of treatment. For instance, antibiotics are great and revolutionized medicine – but we need to be judicious with their use and not jump to them when the problem may be viral. Each of the tools we have has its place.

    If non-invasive measures don’t work, you can’t write off the invasive ones because you don’t like them. For severe medical cases – cancer springs to mind – you may not have the luxury of trying out simpler therapies. Sadly, that’s what Steve Jobs did – he delayed surgery for his pancreatic cancer for months while he tried to find alternative remedies, and by the time he went through with the surgery the cancer had spread.

  5. Fascinating essay.  It’s content like that which keeps Boing Boing on my Google Reader even if some of the more politically motivated pieces rub me the wrong way.   

    I also had constant sore throats as a child, but so did my parents so they weren’t overly concerned with them.  (I always got tested for strep, but once that came back negative they just let me stay home from school for a day and rest up.)

  6. When your car flashes the symbol for “More Oil Needed”, what do you do? Buy a can of black spraypaint and cover it up!… problem solved, right? It’s about as sensible as a tonsillectomy for “curing” sore throats.

  7. Seth, I think you seriously misunderstand what Cochrane reviews are, and you give waaaay too much credit to case-control studies. 

    Cochrane Reviews are systematic reviews of randomized trials (or sometimes quasi-randomized or controlled trials). They take every single study that has ever been done to try to address causation and try to put them together in a meta-analysis to answer a clinical question. They do not include every single paper that has ever been done about a procedure (Does tonsillectomy reduce the risk of being a habitual or severe snorer?)

    Only randomized, double-blind controlled studies can truly suggest causation, any other study can only suggest correlation. There are certainly some areas of medicine where it would be unethical to randomize people, and so we occasionally use these other studies in their stead (like the ones you’ve linked to) to suggest causation. However, this is primarily in studies with very, very high ratios of correlation. Smoking, and lung cancer, for instance: 40 times more likely to get lung cancer if you’re a smoker. In most of the studies I briefly looked through, the correlation is 1.3 times. That’s barely an increased risk at all.

    There are plenty of things to criticize about medicine — including physicians not discussing risk and benefit and over-treatment — but doctors trying to have more data to make evidence-based decisions about what we should and shouldn’t be doing for patients is not one of them.

    1. Ubergraham made a very important point – Cochrane reviews only look at one topic and only count RCTs.  Perhaps Seth could author a review in a good medical journal to cover these points rather than expect the Cochrane collaboration to revise their methodology.

      Also, I was very surprised how this post could swing between sensible, rational approaches and then swing over to wild speculation.  For example, a fair-skinned child using lots of sunscreen might need more vitamin D from a supplement – very rational.  In the next sentence, the mother uses larch bark on her kid – for which there is no evidence of reducing sore throats.  How you end up on larch bark after looking at multiple, high-powered RCTs to make your decision about tonsilectomy is really hard for me to see.

      Seth makes these broad swings as well.  His pulling up an older reference of an association between polio and tonsiectomy is quite interesting (but, as ubergraham said, Seth could perhaps use a refresher in correlation does not equal causation). But then there is a discussion (purely speculation) about what the tonsils do plus a laundry list of illnesses associated with tonsiectomies that so expansive, I half-expected an association with autism too.

      As a scientist, I get a bit dissapointed when reading these kinds of discussions.  There is always a nugget of scientific fact that attracts my attention followed up by a lot of sciency-sounding speculation held together with duct tape.

      I’ve said it before, and I’ll say it again: Boing Boing should label these pieces something like “Science Dissenters Series:…” so that readers can appreciate the piece for what it is – concepts and speculation.  Maggie’s pieces don’t generally have this broad speculation angle, so I would hope BB can find a way to differentiate between the two.

      1. Was going to ignore you, but since you’re pulling the “well, I’M a scientist…” BS…

        The larch bark wasn’t Rachael’s idea, it was the idea of the naturopath that Rachael consulted.  Rachael was even quite skeptical of the idea.  This is all spelled out very clearly in the article.

        At no point does Seth suggest that tonsillectomies CAUSED polio.  It was very clear that Seth was talking about correlations the whole time.  Such correlations are good grounds for caution regarding the safety of a procedure regardless of whether causality has actually been established, especially since it’s so difficult and frequently downright unethical to do the studies to establish causality.

        And I’m very curious what you think was off about the account of the role of tonsils in the body.  Here is the only passage I’ve found in the OP that I can even imagine you to be talking about:

        Tonsils do not filter lymph, as I said, but like lymph nodes are full of lymphocytes. Their shape and placement causes them to sample the bacteria in your mouth, so they protect you against the bacteria in your mouth. Tonsils become swollen and sore during infections because the number of lymphocytes inside has increased — the lymphocytes are fighting off the infection.

        So what’s wrong or speculative about it?  Have you checked out the handy source links Seth included in the article on the way to your conclusion?

        1. “The larch bark wasn’t Rachael’s idea, it was the idea of the naturopath that Rachael consulted.”Well, exactly. Naturopathy is simply quackery. i.e. Wild-speculation. Yes, there is a point that you can stop taking Vitamins, but the ‘doctor’ who recommends a glass of water for every ailment ‘because you can always stop the treatment’ is not doing any good either.

        2. Thank you for taking a moment to reply and share your thoughts, and I am happy to return the courtesy.

          It was not my intent to mention that I am a scientist to project some faux superiority. I mentioned it to show why I am attracted to articles like this but then find them dissapointing.

          Rachel gave her child the larch bark and only discontinued it because of the bitter flavor. Evidently, the lack of evidence for larch bark (“dodgy”) did not deter her from using it anyway.

          I agree with you that correlations can be cautionary tales until causation can be established. Seth takes it a bit beyond that step with statements like, “The tonsillectomy/polio association was the first large batch of evidence that tonsillectomies do serious harm.” This and other statements sound like correlation interpreted as causation.

          Seth stated that “…removing the tonsils damages the immune system” without providing clinical evidence other than correlations. It is a straightforward experiment to test an immune response pre- and post-tonsillectomy. Seth citing the importance of lymphocytes in general is not a substitute.

          I hope that helps with the points you raised.

          1. “Seth stated that “…removing the tonsils damages the immune system” without providing clinical evidence other than correlations. ”

            The work by James Gowans and others establishing what lymphocytes do is far more than correlations.

          2. Seth –

            Sir James Gowans made many remarkable contributions to immunology that established some of its most basic principles.  To the best of my knowledge he did not identify an immune function impaired by the removal of the tonsils – neither have you.

            Citing Gowans work to support your theory is like citing Einstein to prove that aliens have visited Earth.  It is not a 100% unrelated factoid, but it has nothing to do with proving your point.  In fact, it is a method of distracting less informed people from the fact you have no support for your statement.

      2. Cochrane pioneered the use of systematic reviews for data from clinical trials, but that’s by no means the only area in which they’re applicable. There’s a growing consensus that systematic reviews are essential in any field of study in which an abundance of data on overlapping topics has accumulated (i.e., this is a useful concept anywhere).

        Case in point, in my field (regulatory toxicology) an agreement was reached at a 2011 conference that systematic reviews need to come to the forefront of research priorities as a way to both condense available information while also reducing or eliminating the duplicative use of animals in experimentation. The Montreal Declaration can be read in summary here: (.pdf alert).

        Systematic reviews are incredibly powerful. Look at Sena’s systematic review data regarding animal modeling for stroke interventions (for example: ).

  8. This was really fascinating; I had no idea of the tonsils / immune connection.  While I really appreciated the article and the writing, I think it went off the rails a bit with the bias claims towards the end.  I suspect you’re right, but it made the general tone read a bit too fringe when you’re really making a mainstream claim.  But that’s my stance – I would say stick to educating and not to trying to expose vast shadow conspiracies.

    1. Indeed. You read it and start to look over your shoulder in case Big Tonsillectomy is coming to get you with their cover-ups and puppets in the publishing industry.

  9. I had my tonsils out as an adult – and they looked like Freddy Kruger’s balls once they came out. Prior to the surgery, I missed at least a week out of every month due to illness for at least 6 years. I haven’t been sick since I’ve had my tonsils out and my allergies are less severe. 

    But I had 30 years of being sick and having tonsils the size of racquet balls to deal with before a specialist decided I should have a tonsillectomy. Up until then, I was treated with antibiotics, supplements, acupuncture, massage, etc., and doctors never recommended surgery. I probably would have benefited from having my tonsils out earlier in life, but it just wasn’t done when I was growing up. Just like I hardly know anyone my age without an appendix, most of my peers still have their tonsils. I’ve been told by friends that are MDs, and some parents, that this trend is reversing… but not why this reversal is happening. 

    I’m reminded of my dad’s story about the polio ward being next to the tonsillectomy ward when he went in to have his tonsils out in the 50s. Crazy!

    1. The reason the reversal is happening is because the treatment is not usually justified. However, there are times when the treatment *is* justified. You are one of those cases. This is why we have doctors and studies. 

    2. I was in the same boat, but nowhere near to the same extent. I missed one out of every five weeks – extremely high fever, hallucinations, sore throat – but only for about a year and a half. I could look in my mouth and see that my tonsils were pitted and scarred from frequent reinfection. My doctor was hesitant at first, but ultimately ordered the procedure. I’ve been healthy ever since.

      1. I always thought that it was just me.  When I count up my sick days, I went to slightly less than nine years of school, out of twelve.

  10. The “tonsillectomy as cure-all” of the 50’s and 60’s seems to have been replaced by the near ubiquity of ear-canal tubes. It seems like half the parents I know have had tubes put in the ears of their infants. Is that as common outside the Midwest?

    1. It’s everywhere, but it’s mostly boys, who get the majority of ear infections. And who apparently get far more ear infections than we used to.

  11. Side note: I’m a practicing internal medicine physician now doing a fellowship in pulmonary and critical care medicine—I decided to get my tonsils removed last year at the age of 32. It was, in retrospect, a fantastic decision.

    Main point: Agreed with ubergraham. The Cochrane reviews aren’t really designed to provide a plain-english overview of the subtleties of a medical intervention…for that I’d recommend Elsevier’s Clinics series. Cochrane also trends towards the unambiguous, and medicine is full of ambiguities and individual variations.
    Which doesn’t mean there’s not a lot of room for improvement…only that in this case it’s hardly cut-and-dried. Some people will benefit from having their tonsils out. Some won’t. A lot of medicine is predicting who will benefit from Procedure X. The fact that some organizations choose to try to predict doesn’t indicate bias.

  12. Great article.  From a young age, my son had loud breathing (with snoring at night), frequent sore throats, and nasal problems also. For a while, we called him Portly Snortly it was so bad. My MIL and my husband, who had his tonsils out, kept suggesting removal of tonsils as a cure all.  My pediatrician responded with a firm, “No.”  He continued to insist that my son shouldn’t have his tonsils out unless it became absolutely necessary, and only at a older age then.  With time we discovered my son is sensitive to milk which causes his nasal congestion after meals.  We discovered an extreme allergy to dust mites, and lesser seasonal allergies aggravated by chicken waste routinely dumped on the fields here in Oglethorpe County, GA (aka the stinky sewer pit from millions of chickens).  Like the article’s mother, we changed his diet, added Vitamin D to substitute for milk, and also use antihistamines daily (to counter dust mites and airborne farm filth). In addition, salt water gargles keep his tonsils cleansed and 500 MG of Vitamin C is a daily addition.  He no longer snores, seldom has those +4 size tonsils, seldom has any sore throats that can’t be warded off with salt water gargles and extra Vit C. and breathes regularly.  I’m glad our pediatrician didn’t default to old school thinking and kept pushing for to discover the causes of sore throats and giant tonsils.  It was worth the journey.

  13. Studying the benefits & risks of therapies is complicated by the fact that patients who are prescribed one therapy may differ in many ways from those who receive another. These differences may, in turn, explain any apparent discrepancy between the two therapies in terms of how well they work & how safe they appear. As a result, the best way to test in an experiment if two approaches differ (here the comparison of tonsillectomy with no tonsillectomy) is to make the 2 groups of patients receiving these therapies as similar as possible. This is done by effectively removing the subjective element & randomly allocating the therapy to the patients:- a so called randomized controlled trial.Appropriately conducted randomized trials provide the current best method for assessing medical therapies. It is for this good reason that the Cochrane Review Seth refers to focusses its attention solely on randomized trials & not the other studies Seth cites.I did not check every link he posted, but the first dozen or so were not randomized trials, & therefore do not provide as robust evidence. Such studies are, by definition, prone to biases of such severity that they have been shown many times over (in other situations) to completely invalidate any apparent findings.   This is not to say, of course, that the only type of informative study is a randomized trial. But I wanted to balance Seth’s inappropriate conclusion that the Cochrane Review “omits a vast amount of anti-tonsillectomy information that could easily have been included”.Thanks,x

  14. Evaluating medical treatments to verify their efficacy?

    Isn’t that what Republicans started calling “DEATH PANELS”?

  15. In Roald Dahl’s biography Boy, he relates how he was taken to the doctor one day, sat in a chair and told to open his mouth.The doctor produced a instrument with a hook at one end which he inserted into young Roald’s mouth. He hooked one tonsil, twisted around, then cut it loose with a scalpel. Then he did the same to the other tonsil. All without warning nor anesthetic.

    My dear late grandmother decided one day when  my dad was six (1940) that it was time to get his tonsils and adenoids out. He wasn’t sick; she had just decided it was time to get it out of the way. She also told the doctor, that while he was knocked out, they might  as well circumcise him, too. She was always a practical woman.

    I had my tonsils out at the age of 20. I am told that the older you are the harder the surgery is on you. I was expecting to wake up and eat ice cream. It kicked my ass for two weeks afterwards as I recovered, plus I had a hemorrhage in the middle of the night about 10 days after the surgery. I woke up with a mouth full of blood. As Count Floyd says, pretty scary. Fortunately, I am one of the folks who clearly benefited from the tonsillectomy. I stopped snoring, my breath got much better, and the 6-12 times a year I got throat infections has fallen to 3 or 4 in total over the last 25 years.

    1. Wow – your story of getting a tonsillectomy as an adult sounds almost like mine, down to the clots dissolving during recovery. In my case I had to have emergency surgery to re-cauterize the blood vessel in my throat.

      I still remember my first normal meal 3 weeks after recovery – it was the best food I’d ever had.

      I can’t say enough positive things about getting a tonsillectomy. I went from getting sick/sore throat on a constant basis to, and I am not exaggerating, not having a sore throat in the 16 years since I had the tonsils removed.

      1. I had to get re-cauterized and then even after that one day I began vomiting up blood clots. My roommate took me to the emergency room where I waited, vomiting, in the waiting room. Other patients families asked them to take me back first.

        The trick post-tonsillectomy is dehydration, but I found that out too late.

        However, the surgery did stop months of vicious colds/sore throats/etc.

    2. I was expecting to wake up and eat ice cream.

      When you have your tonsils out, it really hurts the first time that you eat, but not much afterward. It doesn’t matter if you eat right away or wait for three days, it still hurts the first time.

    3. Your comment reminds me that the most common operation in the US is actually circumcision, not tonsillectomy, and truth be told the public is largely ignorant about both surgeries and the lack of evidence that they should be performed.

  16. Cochrane Review doesn’t omit trials out of malice.  It will omit a trial if there is no meta-analysis or systematic review for it.

    The bigger problem is conflict of interest.  Publication bias means that negative or non-effect trials make it into publication far less than positive trials.  Therefore, the literature become skewed toward treatments having a significant effect.  Which is sad, because many treatments are worthless, and have severe side effects, yet are “regarded” as effective.  

    :((((   very sad face about this.  I’m an epidemiologist.

  17. When I was 6, I had my adenoids taken out, but as far as I know, I still have my tonsils.  The adenoids were taken out after at least a year of chronic infections, which stopped right after the operation.

    Around the time I was 20, I got a series of throat infections, which probably included tonsilitis, pharyngitis and laryngitis.  This lasted for 2-3 years, with 2-3 flare-ups per year (I was ok the rest of the time.)  Then, at one point, I started a new job where my employer offered free flu shots (this was a few years before the bird flu scare, so vaccines weren’t as hard to come by) and I have to say that, apart from a mild flu that lasted only a few days, I didn’t any other infections for the next year or so.

    Then, at the height of pig flu scare, I got the relevant shots, and I didn’t get any serious flu-like illnesses in the next year or so.  Actually, I haven’t had any really bad infections since then, except for one: about a year ago, I had my appendix removed, after a bout of appendicitis.

    Which brings me to my question for those of you who’ve done the same kind of research about the appendix as what is being discussed here about tonsils: is there any downside to the removal of the appendix?

    I did some research of my own (before and after the operation.)  What I read told me that, for a very long time, the appendix was thought to be a useless evolutionary remnant, but that recent research had found that the human body had found a new secondary use for it: apparently, during bouts of diarrhea, the “good” bacteria in your intestines can take refuge in the appendix while all the bad shit (literally and figuratively) gets expulsed from the body.  This is also an immune system link (like the tonsil situation being discussed) but apparently to a lesser degree.

    Regardless, the removal of my appendix proved to be necessary, as the surgeon who took it out told me afterwards that it was ready to burst at any time (and peritonitis is much less desirable.)

    So, does anyone else here have more info about the function of the appendix, and what the consequences of its removal might be?

    1. Like you, I had my appendix out on an emergency basis (10 years ago). My fever spiked so high in a 4 hour period that my slow-cooking brain didn’t believe I had a fever or was even sick – I thought it was just monthly cramps from hell and would have fought being dragged to Emergency except I was too sick to fight effectively.

      I do wonder what the long-term consequences of the surgery will be, and there’s bowel and colon cancer in the family so messing with my guts seems like a bad idea… but I’d rather live to be 50 or 60 with bowel cancer than have died at 20, or lived but had a few feet of my bowel (including the appendix) removed from the infection after it burst :P

  18. Observation and question: Sometimes, an important organ or part of one develops chronic inflammation or susceptibility to inflammation. The appendix (not important) does this; tonsils do, as well. The spleen can become so engorged in some infections that it must be removed. The gall bladder, as a result of natural processes, may become so inflamed because of blockage that removal is the only recourse. The same is done to treat chronic/intractable liver disease, some lung disease, some instances of autoimmune colitis. In each of these cases, with the exception of the appendix, the tissue or organ involved serves a function, yet cost-benefit analyses point to removal as the best way to cure the acute or chronic condition. Should they not be removed simply based on the argument that they have a purpose, sometimes directly related to what necessitates their removal?

    I’d argue that given the treatment tools currently in the arsenal, even if the removal results in an increased risk of certain conditions later, as may be the case with appendix removal and myocardial infarction, for example, removal is the best recourse, as with appendicitis given that a burst appendix is not a desirable outcome. Chronic tonsillitis can carry with it debilitating effects that powerfully influence quality of life, including repeated high fevers, persistent vomiting, significant absence from work or school, and other sequelae. These experiences no doubt have their own long-term negative effects. I’m curious about a comparison between people who had chronic tonsillar inflammation who had and didn’t have tonsillectomies and long-term outcomes. The studies in question covered a general population of people who had tonsillectomies. Are there longitudinal studies comparing the specific population of people with chronically inflamed tonsils who did and did not have tonsillectomies?

  19. Cochrane Reviews sift out the crap, perhaps that why they “ignored” the vast amount of anti-tonsillectomy research. The Cochrane system is very simple, it seeks to select and review the good quality studies on a particular health topic. Most of them end up with the boring conclusion: “there are few good quality studies in this area, no firm recommendations can be made, more research is needed”.

    1. I wouldn’t say they sort out the crap, but more that they isolate the gems.  The gem quality studies are often built on a scaffolding of previous “crap” studies. 

  20. To add to all the comments already here – Polio has been eradicated from America and most of the world now for a very long time. That cannot be considered at all as a deterrent.

    A further aside – I benefited a lot from the operation. I used to snore and suffer from absolutely chronic sore throat and once the surgery was done all this improved.

  21. I was initially delighted to find an article scolding those old fashioned doctors who are still promoting tonsillectomy for tonsillitis despite the evidence base against it.  I was even more impressed that you cited the Cochrane review, and was anticipating a well argued case for persuading people to avoid surgery.  An argument I would tend to agree with.

    Then the article went a bit… odd.  As others have said, you seem to have not fully understood the purpose of the Cochrane Review at all, and having failed to understand, have attacked it.  This despite the fact it had illustrated your original point rather nicely.  Still, I read on with some interest, and when it got to the section detailing other problems associated with tonsillectomy I was once again intrigued.

    Some I knew already – I’m based in the UK so the issue regarding CJD is well established (there was a shift to using disposable plastic scalpels to combat this, although these created problems of their own.)

    The association with Hodgkins lymphoma was news to me so I clicked through to the links. Sadly many of them provided only a title, and as I’m some way away from a medical library, I popped onto Pub Med myself.  Oddly the very first entry under “Hodgkins Disease Tonsillitis” (and similarly under “tonsillectomy risk hodgkins disease” in Google) was a study from August 2010 which concludes that it is in fact tonsillitis that is a risk factor for Hodgkins, irrespective of whether you subsequently have your tonsils removed.

    It seems odd that you have chosen to omit such a recent, readily identified study.

    I confess I pretty much gave up at that point.  Perhaps Cochrane has its place after all?

    1. “It seems odd that you have chosen to omit such a recent, readily identified study.”

      I omitted studies published after 2009 because the authors of the Cochrane review could not have seen them.

  22. Or you could be me: I contracted a staph infection in my throat in June of 1997, when I was 18.  I was in constant, excruciating pain for almost a year, as I was then suffering from chronic tonsillitis, until I had my tonsils removed in June of 1998.  I’ve never looked back.  (They also took my uvula out, too, which is kind of weird but also kind of awesome.)

  23. So THAT’s why I started putting on weight from about age 7 onwards, and have spent the rest of my life dieting to keep it at bay. I always knew having my tonsils out when I was 6 was a bad idea – yes, even when I was 6 I felt it was the wrong thing to do – I went through my childhood and teens with all sorts of chest infections, and often wondered whether tonsils would have stopped the infection from reaching my lungs. I guess I’m lucky I’ve managed to stay pretty healthy really, but it’s been hard work at times. I look after my immune system, and I’ve managed not to have a heart attack at an early age.

    This essay explains a lot, so thank you. I’m surprised to hear that some doctors still recommend this treatment. I thought it was pretty universally known by now that it’s a bad idea.

  24. “After she decided against tonsillectomy, Rachael and her son went to see a naturopath that a neighbor had recommended. The naturopath was especially knowledgeable about nutrition and supplements.”

    While i’m neutral on whether a tonsillectomy is required, placebo isn’t necessarily a “treatment” either.

    1. This “naturopath” thing had me concerned as well.

      “Naturopathy, or Naturopathic Medicine, is a form of alternative medicine based on a belief in vitalism, which posits that a special energy called vital energy or vital force guides bodily processes…”

      Now I know why it concerned me.

  25. As someone who’s both had a lot of strep throat and has degrees in biochemistry and epidemiology, I have to say that this article is based on emotion and not science.  1.  Doctors do not recommend tonsilectomies anymore unless it’s a last resort.  I grew up in the late 80’s early 90’s and had strep throat 6-8 times a school year.  I was perpetually on penicillin and missed almost enough school to be held back each year and my doctors still refused to take my tonsils out.  2.  The Cochrane review probably does not mention all of the studies you mention because they probably were not convinced that there was a strong enough causal relationship in those studies.  I haven’t looked into this particular area much, but with these types of studies it is important to look at the control group.  A lot of theses studies (especially the older ones from the age of polio) probably look at tonsilectomy vs. no tonsilectomy.  The problem is that if you need a tonsilectomy, you are already more prone to getting sick.  The appropriate control group should consist exclusively of people who get just as many sore throats like the one you mention in the beginning of the article.  3.  Why would Cochrane mention polio as a side effect when there is no chance that someone could get polio now?  4.  Coming back to my experience, and this is purely anecdotal I know and slightly hypocritical for me to site, but I strongly believe that being on antibiotics for most of my childhood has irreparably damaged or stunted the development of my immune system.  Being on antibiotics when your immune system is developing cannot be any less damaging than having tonsils removed, I’m sure there is just as much research in that area as there is on tonsilectomies.  Oddly enough for me, I ended up having to have my tonsils removed in my 20’s after getting mono and having swelling that never went down.  Personally, I wish they had done it sooner.

    1. I’d argue with the “no chance of polio” statement. Granted, we haven’t had a polio case in the U.S. for a while, but with waning vaccination rates and increasing polio cases in some developing countries, the next U.S. case of polio is just waiting to happen.

      Of course, the reasonable way to avoid polio infection is to get vaccinated, not to avoid tonsillectomies.

    2. I too, had recurrent strep infections as a child but didn’t have my tonsils out even though they were permanently swollen.  After a college bout of mono, they permanently swelled larger still.  I toughed it out until I was in my early 30’s (I didn’t realize that it wasn’t supposed to be so difficult to breathe, as it had crept up on me)  when I saw a doctor who realized that I had a problem and advised me to have them removed.  It literally changed my life for the better overnight.  I can eat without choking, breathe effectively enough to run more than short distances, I no longer snore loud enough to wake people in other rooms and sleep better, I have more energy, no longer get constant illnesses with store throats, even my complexion is better.  I wish it had been done much earlier.

  26. I am a physician.  Presently, the vast majority of tonsillectomies that are performed are for obstructive sleep apnea, not for chronic infection.  Obstructive sleep apnea is caused by upper airway obstruction causing snoring, hypopneas, and apneas while sleeping.  There is a vast array of research showing that obstructive sleep apnea causes strain on the right side of the heart, increases the risk of pulmonary hypertension, increases the risk of systemic hypertension, increases inflammatory mediators, and causes decreased ability to concentrate with a negative effect on school performance.     
    In  addition, when tonsils are removed for infection it is for a certain number of documented episodes of Group A strep tonsillitis, not for run of the mill sore throats.  Systemic Group A strep infections are serious because they can damage the mitral valve of the heart and cause damage to the kidneys (glomerulonephritis).

    A third, and less common, indication for tonsillectomy is in the case of tonsils that are different in size, which are removed for pathologic diagnosis to rule out lymphoma.

    The fact that children who have a tonsillectomy before the age of seven have more heart disease is more likely related to the fact that children who had severe enough complications from their tonsils, either from obstructive sleep apnea or from recurrent infections with Group A strep, to have a tonsillectomy at such a young age may have already had a negative affect on their heart from early childhood.
    While I am very conservative about recommending surgery for children, this is one surgery that has a large amount of data to prove its necessity in most cases. 

    I appreciate the fact that a meta analysis tool was used to look into a subject instead of blindly accepting something as a common truth, but I’m afraid that this article missed its mark.

    1. One of my sons had a series of Strep A infx (about eight) that included high fevers, vomiting, and substantial days of missed school. His tonsils were enormous, and after the end of each round of antibiotics, he’d start the cycle again. After a tonsillectomy three years ago, he’s not had a single sore throat, and obviously no Strep A infx. He also happens to be only one of two children I know who have had a tonsillectomy.

      I appreciate this specific comment. It addresses several questions I had.

    2. Apnea is exactly why we had the tonsils and adenoids of our son removed. He had night terrors, and sleep walking and was having trouble in school. Since the operation, all of these symptoms went away. 

      I was surprised that this reason seemed to be absent from the article.

  27. As a periodontology resident, I’m unfamiliar with any link between periodontitis (“gum disease”) and tonsillectomy. In fact the tonsils can harbor periodontal pathogens and could be considered a reservoir for the disease, but much like many of the statements toward the end of this column, that’s pure speculation.

    1. The tonsils do provide one more surface at the back of the throat to get tonsilloliths on… but removing the tonsils will provide a nice scarred surface to get tonsilloliths on instead. I get them on my tonsils, but also behind my tonsils on the back of my throat. They’re balls of crud heavily colonized by sulfur loving bacteria, but I don’t know if they’re actually related to plaque or not.

      Of course if you mean “harbor” internally, I don’t know squat about it :)

    2. As a periodontology resident, I’m unfamiliar with any link between periodontitis (“gum disease”) and tonsillectomy.

      Perhaps you know about the association of gum disease and heart disease? As I point out, there’s also an association of heart disease and tonsillectomy.

      1. You mean the *correlation* between gum disease and heart disease and the *correlation* between heart disease and tonsillectomy?

  28. I grew up with sorta-hippie parents who came to the same conclusion as Rachel did in the article.  Even after 9 bouts of strep throat in one year, they still opted me out of the surgery.  I finally had a tonsillectomy at age 25 and my recovery was long and incredibly painful. But I haven’t regretted it once – after years of bronchitis, tonsilitis, and terrible colds, I now spend the winter healthy (for the most part). 

  29. I have two points, lets start with the second and minor:
    Who but an ear and nose-specialist are fit to write medical reviews about ear and nose medicine? Seems odd to call that a conflict of interrest.

    The other thing is, I am interested to know if any of the landslide of studies you site are controlled against not the general populace but against other heavy throat-infection sufferers who have not had tonsillectomy.
    Since clearly there would seem to be something (perhaps unconnected with tonsills, as you eloquently argue) causing those patients to suffer more sore throats it is easy to imagine this same thing to be the cause of, for instance, the higher rate of heart diseases…

    1. “Who but an ear and nose-specialist are fit to write medical reviews about ear and nose medicine?”
      PhD’s with a relevant background (bacteriology,  epidemiology, etc), MD’s in related fields.  The MDs who figured out the bacterial etiology for peptic ulcer weren’t gastroenterologists.  Props to specialist MDs who write studies, but to suggest that only ones who are fit to do seems unscientific to me. 

  30. My 3 year old son is scheduled for a tonsillectomy at the end of February, my wife and I are worried sick about it.  He doesn’t suffer from throat or ear infections, but his tonsils are very big  and he has a hard time sleeping at night.  He snores, gets up in the middle of the night and he often quits breathing for seconds at a time.  You can tell hes not getting any sleep just by looking at his eyes,  and like any 3 year old he gets pretty wound up when he’s over tired.  I read somewhere they can do tonsillectomies that leave some of the tissue intact and the healing time is quicker.  I’m going to have to talk to our doctor about this and ask if there is any treatment to reduce the size of the tonsils without surgery.  Its not a decision to take lightly but we hope he will be able to sleep soundly when this over.

    1. For the record, if my son had had sleep apnea I would have had his tonsils out in a flash.  I have UARS myself, and have used a CPAP for years.  But he just had strep, and not even inflamed tonsils.  I am here to tell you: if you can improve your child’s sleep, do it. Though, I would see if he will tolerate CPAP first, I have no idea how well it works with kids that young, but might as well try first, no?

  31. Can I make another suggestion as to why tonsils get inflamed, how this can be prevented/reduced and why tonsillectomies are probably not ever warranted except in the most extreme cases.

    We humans are designed to breathe through our noses. The nose and sinuses have many features to prove this: the air will be warmed, humidified, filtered and cleaned even before it gets to the adenoids, then finally it will go past the tonsils.

    But what if you breathe through your mouth? You don’t have any of these features and cold (potentially also hot), dry, “dirty” air hits your tonsils full on before moving into your lungs.
    What it that’s the reason they’re inflamed, because they’re having to do all the work and they’re having to act like garbage cans which can’t be emptied quickly enough?

    If someone is a mouthbreather, they may find that becoming a nose breather fixes a lot of problems.

    You may argue that the person can’t breathe through their nose because of inflammation, but there are ways around this.

    1. You may argue that the person can’t breathe through their nose because of inflammation, but there are ways around this.

      Such as?

      1. There is probably a degree of nasal congestion due to lowered CO2 levels. By doing some carefully controlled hypoventilation you can raise Co2 levels again, which will decrease this congestion.  May work quickly or may take some practice, best done with a health professional who knows what they’re doing with this – there aren’t many around and they’re usually not doctors.

        A lot of people, “learned” and otherwise will diss these ideas because they seem to simple, or it means if you accept them you may have to admit that a lot of other stuff is a waste of time, money and potentially people’s quality of life.

  32.  Seth, you had me on your side until you disparaged “evidence based medicine”.

    This implies you support “woo based medicine”, such as homeopathy. Could you please elucidate?

    1. A) Every time you turn the world into a dichotomy, we are all poorer.  I’m neither for you nor against you.
      B) Evidence Based Medicine is a specific ideology, not a generic idea that we look at all the evidence. They totally won people over by picking that name.

      Looking at all the evidence leads us to have arguments about what constitutes evidence. Two fully rational bayesian agents with equivalent priors aren’t able to disagree on that subject, but reasonable human beings definitely are.

      So, I am an opponent of the ideology of Evidence Based Medicine because it deliberately de-values some evidence[1] in favor of other evidence. The evidence it generally values is largely evidence that is profitable to someone, and the evidence it ignores is that which isn’t profitable.

      1 Some of the evidence it ignores are:
         – Evidence which seems “weird” or low-status. Does Seth Roberts’ idea of looking at faces in the morning improving mood work? We don’t know, and are unlikely to know because it’s weird enough sounding that the likelihood of it being studied by RCT, the only acceptable standard of evidence for EBM’ers, is significantly lower. Any one lower-likelihood “weird” thing may be studied, but many fewer of them are.
         – anecdotes, also known as case reports, which are a good stepping stone to gathering better information. In other words, if we don’t know anything about the health effects of eating lemon peel, and we don’t, anecdotes saying that it’s effective are evidence. If we have many good trials of homeopathy, and we do, then anecdotes don’t tell us much anymore. EBM lumps those anecdotes together.
        – evidence which doesn’t profit anyone, since no one is there to pay to create new RCTs, which are incredibly expensive.

    2. I agree with j freyley. The problem with “evidence based medicine” is that a lot of evidence is ignored. 

      1. it’s called exclusion criteria and how can you be against ‘evidence based medicine’ surly you (like everyone hopefully) is against poorly designed studies and biased meta analysis, not against ‘evidence based medicine’. Evidence based medicine is far more to do with audit cycles where a change in practice is evaluated for positive outcomes as awell as adverse effects – the fact that tonsillectomies are more rare is because pooled data shows that it is not very effective for the majority of children – i.e the change in practice came as part of EBM!

      2. I sent this article to my sister, who is a doctor and she replied as follows:
        “Sorry but the author clearly doesn’t understand what the Cochrane Database is about. “The Cochrane Review, however, omits a vast amount of anti-tonsillectomy information that could easily have been included”. There may be lots of anti-tonsillectomy information out there, and I clicked on a couple of the links included in the article, but none of them seemed to be randomised controlled trials (RCTs). Cochrane reviews deal ONLY with RCTs and the implication that the information she found could easily be included is nonsense. All medical research is based on a hierarchy of study design, of which RCTs are the second highest. Cochrane reviews are systematic reviews, the highest level, which pool the results of RCTs so that from the cumulative numbers conclusions can be drawn that have statistical significance. Case-control studies, cohort studies etc. do have merit but are no where near as scientifically robust and can not by definition be included in a Cochrane review. I think the reviewers quite rightly declined to comment – all Cochrane reviews are subject to rigorous standards that have to hold up internationally and I don’t see why they should take time to explain scientific methodology, statistics etc. to someone who is clearly trying to imply that they are trying to subdue evidence for monetary gain – in fact they could sue her for defamation!”

  33. When I read articles that give me the options to hack out part of my child’s immune system on the one hand, or else dose with multivitamins and hope, I recognize how far we still have to go, and how much is still left to discover. Often, “We don’t know, yet, let’s work more to try to figure it out,” is actually the wisest and safest response. If I ever find a doctor who would be honest enough to tell me that, for example, in the event of recurrent febrile seizures that I had as a child which led them to hack out my tonsils, I would rejoice in the name of Carl Sagan. Patience and gathering data, in an effort to learn more about what might be going on until a clearly indicated course of action is found which matches the specific details of a given complex human state is what I always seek, not blanket answers. I would only say not to let any practitioner pressure you into a certain treatment without solid evidence that it generally works, combined with a compelling case that it has good odds of working in your specific situation.

  34. Great article.  Thanks for all of the well referenced information. I found it thourougly enjoyable to read and very informative!

    1. Try tracking down the references – they are low-quality studies published in low-quality journals, which is why the Cochrane Review didn’t include them.

      1. “They are low-quality studies.”

        The work by James Gowans and others establishing what lymphocytes do is very high quality research.

        1. yes, but you can’t just pile a load of references to interesting things into a clinical meta analysis of patient outcomes. ‘what lymphocytes’ do may actually have little bearing on clincal outcome

  35. I can’t speak to the tonsillectomy issue other than to say that my brother had one as an adult after his became inflamed and scarred and probably were not functioning well any more. It did reduce the amount of throat/sinus infections he had, which were chronic. 

    That said, I would say that from my personal experience, most of the doctors I have encountered have been generally incompetent. They lack basic information about the procedures they practice and recommendations they make. They have almost no understanding of statistics and risk. As such, in my experience, they aren’t much better than quack naturopaths. I have friends who are doctors and their approach to their personal care is bizarre.

    I have know doctors that were excellent. They had a passion for medicine, immersed themselves in constantly learning new things. They tended to be skeptics at heart and knew the limitations of medicine and medical understanding. Unfortunately, these people are few and far between.

    I think the best one can do is try your best to understand the issue, be skeptical of intervention until you know what the risk/rewards are and do your best to focus on the things we know are helpful, like eating well, reducing stress and exercising.

  36. I have three children, now adults, none of whom was ever recommended for a tonsillectomy. In fact, among all my siblings’ children I cannot think of one who ever had a tonsillectomy. I remember asking a pediatrician about it maybe 20 years ago and he said that tonsillectomies were not recommended and no longer routinely done, at least in the mid-Atlantic region of the U.S. On the other hand, I still have a picture of myself with 3 of my siblings, taken just before we were all brought to a hospital in Massachusetts for a “routine” tonsillectomy despite the fact that only my brother was having problems with sore throats and ear infections. We were between the ages of 3 and 7 and it was about 1963. After the surgery we were all put in the same room and left alone overnight. One of my sisters started bleeding and choking on blood and the nurses never answered the call button. My other sister urged me to get out of my bed to help the one who was bleeding, which I did, because our older brother could not leave his bed due to being hooked up to an IV. I somehow helped my sister, perhaps by getting the bedclothes untangled and getting her to turn on her side to breathe. The memory is dim – I was just 6 – but it was actually one of the great traumas and shared experiences for my siblings and me in our early childhood. I rather doubt that the hospital shared much information with our parents about just how complicated the “routine” surgery and followup and had been.

  37. I agree with the main point of the article; that tonsilectomies are too easily promoted as a cure-all.

    The part that discusses the Cochrane review seems totally off-base.
    The review looked at using tonsilectomies to cure recurring tonsilitis (which it will, by definition) and the effect on the related condition of sore throats. It is theoretically possible that a tonsilectomy could make sore throats worse, since it is hypothesised that the tonsils help the immune system fight colds. The conclusions of the review are valid, and suggest that a tonsilectomy actually causes a small reduction in colds.

    The Cochrane review could not look at all the side effects, because that wasn’t its objective. Medical evidence is tricky and uncertain, so Cochrane reviews focus on a limited set of well-examined effects that provide a sufficient database for a meta-analysis. If you start down the road of “we weren’t going to look at this, but we also found this side effect” then you get into some serious statistical problems in any meta-analysis (erm, ).

    Criticising the Cochrane review for not examining unexpected/unusual side effects is stupid. Cochrane reviews are absolutely not designed to provide comprehesive advice on medical treatments for the layman. They are designed to examine a specific question and provide the most accurate answer currently possible.
    (This is not to say that layman won’t find useful data in them, just that it won’t provide comprehensive information on the pros/cons of a treatment)

    1. “Cochrane reviews are absolutely not designed to provide comprehesive advice on medical treatments for the layman.”

      The tonsillectomy review provided a “plain language summary” obviously intended for the layman.

  38. What an awful piece of writing. It sounds like it was penned by a child.Uk Nice guidelines for tonsillectomy:”Sore throats are due to tonsillitis.The person has 5 or more episodes of sore throat per year.Symptoms have been occurring for at least a year.The episodes of sore throat are disabling and prevent normal functioning.”
    In the UK interpretation, this boy would qualify for a tonsillectomy. i.e the current evidence suggests that the cost/benefit comes in favour of a tonsillectomy as a viable therapy for reduction of recurrence. However, expectations should be appropriately set.
    The question of tonsillectomy If there are breathing/swallowing difficulties or sleep apnoea is a separate issue covered under emergency medicine.

    As usual, Seth always provides piss poor anecdotes that no one can verify, never seems to contact the doctor in question for view on the subject or even to ask if they were following local guidelines etc.
    I’m sure some family doctors are guilty of oversimplifying, not explaining the risk and benefits effectively and to be frank have pretty rusty anatomy and physiology knowledge, and this has to change. Saying ‘I can find out’ seems much harder for the older generation of physician to say, and it’s understandable given the expectation of them as keepers of the knowledge in the old days but no longer acceptable – ok we get it.

    Meta analysis is not without flaws, but simply referencing papers like your shot gun approach does not make you a ‘researcher’, just another idiot who mistakes complex problems for conspiracy.
    How about balancing the stuff about vitamins with the fact that most tonsilar problems resolve as a child grows. In fact the tonsils continue to shrink and reduce function through adolescence and old age.

    Lymphocytes originate from bone marrow and T-lymphocytes are matured in the thymus (which atrophies after childhood). Lymphocytes rapidly cycle between the blood and lymphatics and are found in HUGE numbers in the plasma as well as in peripheral tissues. MALT tissue such as the tonsils provides a germinal centre to allow for monoclonal expansion of T and B cells that show affinity for a particular bacterial, viral or other foreign body. At this level, the immune system is incredibly complex with 100s of messenger molecules co-ordinating the cells. I don’t understand it and I think an immunology professor would be considered arrogant for saying that he/she understood what the tonsils do. Thanks for your awful explanation though.

    Cochrane reviews are international with over 100 different countries contributing. They can only realistically work by measuring specific outcomes in papers which are methodologically acceptable. There are other meta analysis that look at whether immune response is affected by tonsillectomy, I’ll leave that to seth to quote his extensive review of the literature. Honestly, Seth -read up on Archie Cochrane and understand how a master agitator of the medical establishment works.

  39. I was going to post a long, detailed response to most of Mr. Robert’s ridiculous claims (most of which are based on a single weak association in a small group of subjects in a single paper from a decade or more ago, and which may or may not have been subsequently disproven – here’s looking at you, “ZOMG it causes teh Hodgkin’s Lymphoma” sentence), but the wonderful blog Science-based Medicine went and did it for me.

    Seriously BoingBoing, I expect better from you in the Science/Health department (mostly thanks to Maggie’s excellent work!).

  40. It finally occurred to me that Seth Roberts is the same person who wrote the BB piece on alternative therapies for Crohn’s disease.  I looked into his website and began to gain some insight.

    But first, I have the impression that Mark F. (and perhaps other BB editors) like to put the alternative viewpoint on BB – like this blog post.  I have a bit of this happy mutant bent too so I can appreciate that it is actually kind of fun to throw a mind-blowing insight into a tame conversation to see the reaction.  Mix it up a bit to see what comes out.  Good fun, really!

    And, I also need to consider that scientists and physicians can come across all dour and conservative about fun/interesting posts like this.  Any disapproval from these stiff shirts must mean there is fire among this smoke.  Right?

    Throw in concerned parents worried about any surgical procedure on their child.  Multiply that concern if it is a parent who turned down a tonsillectomy option and still worries if it was the best decision.  Throw in older folk who remember silly reasons for too many tonsillectomies.  Throw in anti-establishment views too.

    Throw in Seth, who comforts you to know that you are right.  He is full of information and scientific papers telling you how right you are.  He assures you that your point of view is right, and your choices were the best decision.

    But, science is hard.  It rains or it doesn’t rain as predicted, why is that?  A drug cures one person’s cancer and doesn’t work for another, why is that?  They can put a man on the moon but they can’t do anything about these mosquitoes around here (to paraphrase my Uncle).

    So, how does Seth answer so many questions about such a difficult topic with ease?  Does he have Maggie’s acumen as a science journalist?  No.  Seth is a conspiracy theorist.  Hear me out…

    Conspiracy theorists are exceptionally good at gathering information.  I once had a fellow showing me photos of CCCP tanks on US freight cars proving that there is a conspiracy between the US and the Soviet Union (history disagreed).  How did he get those photos in the pre-internet days?  I am guessing he was amazing at gathering information!  Seth gathered a lot of information that looks impressive.  It takes a lot of training and education to analyze that information (similar to asking you to look at a home electrical wiring diagram and make big repairs without killing yourself).  But Seth accuses the people who can read his “diagram” of being in on the conspiracy.

    Conspiracy theorists assume there is a cover up.  Even if they were given a tour of Area 51, they would find a way to explain it away.  Birthers are still around.  An ENT doc tried to cover up the truth about tonsillectomies, apparently.  A tried and true method of reviewing medical questions (Cochrane collaboration) covered up the terrible injuries of tonsillectomies.

    Conspiracy theorists implore the public to ask the hard questions and expose the conspiracy.  Challenging the status quo appeals to many happy mutants on BB (e.g. security theater).  But, when it comes down to asking the government to explain why the CIA killed JFK or demanding they release the truth about aliens visiting Earth, I think we can suspect foregone conclusions as much as we suspect government cover-ups.

    I am not going to change the mind of people who strongly identify with Seth’s comments.  Your belief is more powerful than the evidence, and your personal experience is more true to you than anything from outside your belief.

    I am not sure if anyone is still reading this stale thread.  I hope that BB can give a little less credence to conspiracy theorists like Seth, or open the doors to Area 51, JFK, Birthists, et al believers to see what fun ensues!  Then again, I AM a scientist, so perhaps I am “in on” it (evil laugh). ;)

    1. I agree. It’s hard to non appear dour face and conservative when what a lot of Seth says either reinforces some people’s own conspiracy theories about their medical care end even encouraging vulnerable people with horrid disease to believe in untested therapies then it starts becoming an ethical issue. 

    2. You may be right about bb’s intentions on this (I hope so). But I still have to throw in a thumbs down to the editors for letting this misleading drivel onto the site. Boourns, boingboing. Boourns.

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