New guidelines on treating strep throats and on tonsillectomy for recurrent strep throat

There are some important new recommendations both about strep throats in general and about tonsillectomy — taking out the tonsils — as a treatment for recurrent strep throats.

Some of us can recall a time when getting your tonsils out was one of the rites of passage of childhood. Usually a related procedure is added — an adenoidectomy, removing the adenoids as well. It’s called a T&A in the medical world, and it’s one of the most common surgical procedures done on children.

Where are the tonsils, what do they do, and why would we take them out? The tonsils are at the back of the throat, one on either side. If they haven’t been removed, you can see them peeking at you when you open your mouth wide and look in the mirror. Both are part of your immune system, similar to lymph nodes (the “glands” you can feel at the front of your neck). As part of the immune system, the tonsils fight infection; they are first line of defense in the throat, and when they are doing their job fighting infections, you get a sore throat. The tonsils usually swell a bit and get red when that’s happening. Here’s a picture of them:

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The connection between tonsils doing their job and strep throats is that a common cause of tonsillitis in children is a strep infection. Before we had antibiotics, removing the tonsils was one way to combat recurrent strep infections. As soon as penicillin, one of the first antibiotics, came along, though, we instantly had an effective nonsurgical treatment for strep tonsillitis. Nearly all of the time it works, primarily because the strep bacteria has maintained its sensitivity to penicillin — we haven’t seen the antibiotic resistance that bedevils our ability to treat other bacterial infections.

Nearly all strep throats happen in children older than two years of age. Strep infection is very unlikely in a younger child with an inflamed throat; in toddlers they are nearly all caused by viruses, which antibiotics don’t help. Children beyond that age do get a lot of strep infections, and some children have recurrent strep, sometimes multiple times each winter. For those children, doctors often recommended taking the tonsils out. Before I went into critical care, I first trained and practiced as a pediatric infectious disease specialist, and I was consulted many times about such children. My bias was nearly always against tonsillectomy. My reason, shared by most infectious disease experts, was that we have effective antibiotics to treat strep. Why risk the surgery?

A key point is that recurrent strep tonsillitis nearly always gets better with age no matter what we do. This makes tonsillectomy look good, because the natural history of the illness is to improve. I’ve met dozens of parents who say their child (or themselves as children) had constant strep infections until the tonsils came out. Often these same parents (and especially their grandparents) had had their tonsils out as children and more or less regarded tonsillectomy as something children need, like vaccinations. But frequent courses of penicillin, one of the safest medications on the planet (if your child is not allergic to it, of course), nearly always ultimately lead to the same favorable result as the tonsillectomy. (If your child is allergic to penicillin, we have other safe options.) This is why the Infectious Diseases Society of America, the professional group of specialists in infectious diseases, has made these new recommendations.

The important thing to remember is that tonsillectomy, like any surgery, is not without risk. It’s not just a routine thing like getting a vaccine shot. Compared with other surgical procedures the risk is low, but it is not zero. There are risks of bleeding afterward, sometimes life-threatening, and there are other risks associated with the anesthesia needed. Every year I see at least one child in the PICU who has suffered a complication from a tonsillectomy.

There still is a place for tonsillectomy for some cases of strep. Abscesses around the tonsils are one example. Tonsillectomy can also be very helpful for persons whose tonsils are so large that they block the airway, especially when they sleep (a condition called sleep apnea). But for the bulk of children with recurrent strep throats, it’s generally best to wait it out, treating each infection with antibiotics.

With everything we do in medicine, it’s important to weigh the benefit of the treatment against its risks: for recurrent strep tonsillitis, most of the time the calculus favors antibiotics. The importance of these new guidelines is that such a viewpoint is now the standard one.