This Podcast Will Kill You - Ep 134 Tonsils: Underestimated and underappreciated

Episode Date: January 30, 2024

Raise your hand if you or someone you know has had their tonsils removed. If your hand is sky-high, there’s a pretty good chance that you (or that person you know) are from the US and were born before 1980. Of course, maybe that’s not the case, but tonsillectomies certainly fit in the category of 20th-century fads, along with Tamagotchis and the Atkins diet. While the procedure is still widely performed today (and for very good reasons), the frequency of tonsillectomies has dropped drastically from mid-20th century rates. In this episode, we explore why tonsillectomies became so popular, when they fell out of favor, and what about tonsils makes them worthy of removal. Tune in to be horrified by ancient tonsil removal techniques, shocked at how long it takes new knowledge to change policies, and appreciative of just how cool tonsils actually are. See omnystudio.com/listener for privacy information.

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Listen to the Sixth Bureau on the Iheart Radio app, Apple Podcasts, or wherever you get your podcasts. I'm Clayton Eckerd. In 2022, I was the lead of ABC's The Bachelor. But here's the thing. Bachelor fans hated him. If I could press a button and rewind it all I would. That's when his life took a disturbing turn. A one-night stand would end in a courtroom. The media is here. This case has gone viral. The dating contract. Agree to date me, but I'm also suing you.

This is unlike anything I've ever seen before. I'm Stephanie Young. Listen to Love Trapped on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts. Hello. My name is Aaron, and I'm here to talk about my tonsillectomy experience. So this happened when I was 35 years old. It started, I guess, in my early 30s. I was getting pretty consistently, I would say, two to three times a year, some sort of tonsile infection, where I would have to be on a two or three week course of antibiotics to clear it up.

And this was really doing a number on, well, my gut health, for one. And just my health in general. This was kind of taking place right after COVID had started. And with these infections came a lot of fevers and just being run down and ill, which kind of resulted to me, missing a lot of work because we weren't 100% sure if it was COVID or not. It never was. But I just had to keep going in for these infections over and over. And finally, my doctor said, this is too many antibiotics. Have you considered having your tonsils take it out? Because this is probably just going to keep happening. And I thought about it. And my coworker, her son, who I don't remember how old he was,

maybe eight or nine had just had his tonsils out, and he was fine. Two days later, he was back at school. So I thought, well, this can't be that bad. Kids do it all the time. And I asked my doctor, you know, how long would I be out of work? And he said probably two to three days. So I put in for two to three days and scheduled the procedure. So I went in. Everything, I guess, went really well. My husband was there when I woke up. I don't really remember this, but I guess when I woke up, I was trying to yell. So they actually had to come in and residate me because I was coughing so much. So I spent an extra few hours in the recovery room waking up.

And the doctor came in, you know, and he told my husband, everything went fine, gave him the prescriptions and said, unprompted. He said, she'll be back to eating hard tacos in a few days. which was kind of, you know, I wasn't awake for it. I don't remember. And so we went home and, you know, as the medications kind of wore off, my husband went and picked up, they gave me a codeine elixir. And I vividly remember for the next night and the night after that, sitting kind of propped up in bed, psyching myself up for half an hour to swallow my own spit because it hurt so badly. I this is gross I kind of decided it wasn't worth it at some point and just started spitting it out

and this as you can imagine kind of created a problem for one staying hydrated and two actually getting my pain medication down even though it was you know a syrup I just even just to swallow a sip of water was pretty agonizing so after a couple of days of this I was very very run down, and I had started coughing up this awful brown gunk. And so I don't remember, it was maybe around midnight. My husband ended up taking me to the emergency room. And I guess when I got there, they said the gunk was to be expected, which I was not warned about. But I was also severely dehydrated. So they had to give me a couple bags of fluid. And they said that codeine is not going to cut it. And I think they gave me hydrocodone, which was also a problem because those are

huge pills. So for the next couple of weeks, I did not go back to work because I couldn't really drink anything. I couldn't eat anything except jello and eventually pudding. Just a couple of bites every day. I was kind of getting by on pediolite. Just felt terrible. I obviously don't know what this feels like, but it kind of felt like swallowing razor blades. And so, you know, eventually it did get better. But I think when I looked back, Even three or four months later, I still was pretty sore. And all this is, you know, I don't want to say don't get a tonsillectomy. If you need one, you definitely should.

But, you know, I wish my doctor had been a lot more upfront with me about how terrible it was going to be. But on the plus side, I obviously haven't had a tonsill infection since because I don't have tonsils anymore. And I actually just had my first sore throat since the procedure a couple months ago, which is kind of exciting. I'm not on antibiotics all the time anymore, which is great. And one of the things that kind of stuck with me, I talked to my grandmother, who had been a nurse for decades, after I was done with a procedure about what had happened. And she said, I didn't want to tell you before you had this done. But the only thing I've heard it compared to pain-wise is like an adult circumcision. And I kind of thought, well, I wish she had told me that to be better for me.

And also, I ended up going into nursing afterwards, and I would tell nurses, you know, I had this tonsillectomy in my 30s and they would just get this look. Like, why would you do that? So, yeah, all of that to say is I wish they had been more upfront about how terrible it was, but I am also glad that I did it. Erin, great name. Great name. Great story. Also, great story, horrible story. A horrible story. I had no idea how bad adult tonsillectomies could be. I, oof, it sounds just awful. Awful. I'm so sorry. Yeah, but also thank you for sharing your story.

Thank you so much. Hi, I'm Aaron Welsh. And I'm Aaron Elman Updike. And this is, this podcast will kill you. Today we're talking all about tonsils. I mean, kind of an off-the-wall topic. A little bit. Off the pharyngeal wall.

Off the syringial wall. Oh my gosh. I don't know why. It might have been prompted. I can't remember if I got a tonsil stone before or after I suggested this. I think it was after. Which is I conjured it. You really did.

I manifested. You suggested tonsils and I was like, what? And then immediately it was like, yeah. Let's do it. I have no idea how this is going to go or what we're going to talk about. But, like, why not? Tonsels? I mean, I feel like tonsils occupy this weird space in, like, cultural history, almost.

Oh, I thought you were going to say, like, in your Oroferrings. Oh, well, that's true. I mean, I assume. It's going to be all episode. But, like, I remember as a kid wanting to have my tonsils taken out so that I could miss school and eat ice cream. Like, that's what I thought it was. Oh, my God. Okay.

So when I told my parents that we were going to be doing tonsils, Yeah. My mom, it's been hilarious to tell people that we're doing this episode. My mom was like, oh, I still have mine, but a lot of people don't. Like a lot of people my age. And then she turns to my dad and she goes, do you still have your tonsils? And he goes, yeah, I got mine. But everyone wanted to get theirs out.

And I was like, what? And he goes, well, you got ice cream. Like, where did this, where did this notion? It, like, dug in so deeply. I distinctly remember. And I don't even know if I knew anyone growing up, um, John. my fiance has his tonsils gone. Yeah.

And I think also ad nois. In Madeline, was it her tonsils or her appendix? Appendix. Yeah. So it wasn't that then? I don't know. I mean, actually, I do know because the history section will reveal all. Oh, okay.

I can't wait. Which doesn't usually happen. And maybe it doesn't reveal all. But I do feel like it answered a lot of my own personal questions about like why were tonsillectomies, why do we know them by name? Why did everyone seem to have a tonsillectomy in like most of the 20th century? Ooh, I can't wait to hear all about it. But first. But first, it's quarantini time.

It certainly is, thank goodness. What are we drinking this week? In the spirit of tonsillectomies, we're drinking the cutthroat. Not just a trout, but also a delicious. delicious cocktail recipe. What is in the cutthroat? It is a malted chocolate milk beverage. That will make sense later, I promise, with malted milk powder and vanilla ice cream,

chocolate sauce, some whiskey in there. Oh, it's just fantastic. It honestly, so perfect. Had to have the ice cream in there. Had to. Like, of course. But we will post the full recipe. for the cutthroat quarantini and the non-alcoholic placebo rita on our website,

This Podcast Will Kill You.com and all of our social media channels. Our website, this podcast will kill you.com, it's a pretty incredible website. If you haven't been there yet, check it out. We've got transcripts from all of our episodes. We've got sources from this episode and every one of our episodes. We've got links to BloodMobile for music. We've got our Goodreads account. Oh, I'm flailing here.

We've got Patreon. on. We've got us. There's, check it out. You're good. You're good. We got it. Merch. Okay. Are we ready for the biology? Let's do it right after this break. Okay. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients so there's no meal planning and no extra grocery trip. Their assemble and bake meals take about five minutes of hands-on prep. Just spread the pre-chopped ingredients on a sheet pan, put it in the oven,

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British establishment of this is wrong. Listen to Doubt, the case of Lucy Lettby on the Iheart radio app, Apple Podcasts, or wherever you get your podcasts. Tonsils. Tonsils. Now I wish that I had written something really clever to start this off with, but I didn't. I mean, tonsils don't rhyme with like anything. I know. You sent me that screenshot of all the things they 92% rhyme with. Right. It's terrible. Consul was the closest. It's not even good. So first of all, what most of us think of when we think of our tonsils are in fact only one of four different tonsils in our bods. Yeah. That was like one of the first things I learned and I felt like I had been lied to. to my whole life. But really, I just didn't seek the knowledge. So the set of two tonsils, it's a

paired set of tonsils that sit at the back of our throat, the ones that get swollen when we get strep throat or any other infection, those are called our palatine tonsils. But we have three more. We have tonsils at the very base of our tongue, like where our tongue connects back in the base, that are appropriately named are lingual tonsils. We have a set that's like in the wall of our nasopharynx way back up near the opening to our eustachian tubes. That's our ear tubes. And those are called our tubal tonsils. They're little.

And then we have another one that sits at the top rear of our palate in our nasopherinks, like above and behind our soft palate, right in the midline. where our nose kind of connects to the back of our throat. And this particular tonsil, which is called our pharyngeal tonsil, is also called our adenoid. Ah, okay. So when you hear adenoids and tonsils, those are the same things. They're just talking about two different sets of tonsils. Yeah.

And everyone always says adenoids, but it's just one. Like, it's one structure. It's not a paired set. It's a one. I mean, it's like J.C. Pennies or Meyer. or... Sorry, you say J.C. Pennings, plural? I have heard people say that.

I do say Myers. What is Myers? Remember Meyer, the grocery store chain? Oh, yeah, yeah, yeah. I forgot about that. Yeah. Showing our Midwest roots. Anyways, anyways.

Our adenoids and our tonsils, meaning our pharyngeal tonsil and our palatine tonsils are the two that we all think of the most. when we think of our tonsils, because these are the ones that get big and swollen and oftentimes painful when we get an infection. So these are the two that we'll focus on, kind of, but really, when I'm talking about tonsils, it means all of these different things. So what are these things anyway? Like, what the heck are tonsils? And what do they have in common with one another? Well, let me tell you. All of these tonsils,

are a type of tissue that are called mucosal-associated lymphoid tissue or malt. Oh, yeah. Okay. All of these tonsils together form a ring at the back of our throat, which is essentially at the opening of both our digestive and our respiratory systems, right? And this ring is sometimes called Waldier's ring. Probably named after a guy, I don't know. But I'm sure. Uh-huh.

But the function of all of these tissues, all of this ring of tonsular tissue, essentially, is, in short, to protect us against infection. The end. Our tonsils are part of our immune system. But it's like the type of tissue. So that type of tissue is like only found in these tonsils? Oh, great question. No. Toncils are by no mean the only forms of malt mucosal.

associated lymphoid tissue that exist. In fact, they are a small part of a large network of malt throughout our bodies. Basically, all of malt are these immune-related tissues that exist specifically on our mucosal surfaces. In our guts, we often call this galt, gut-associated lymphoid tissue. So we have gut tonsils? Yeah, pretty much. They're called pyers patches.

Oh. In our guts, we. also have like isolated lymphoid follicles that just kind of scatter throughout our guts. And we have, wait for it, an appendix. Uh-huh. Of course. Also lymphoid tissue. There's also bronchial malt, which is sometimes called bolt, huh? Although not all humans have this. I don't know. It's probably really interesting. I didn't get into it. What? Rodents don't have tonsils, but they do have Nalt, which is nasopharyngeal associated lymphoid tissue. This is why, spoilers, I didn't get into the evolutionary history of tonsils,

is because I got really overwhelmed by nalt and malt and disseminated malt and, like, organized or something malt and nalt, and I was just like, I, it's too much. This sounds very cool. Yeah. This is over my head, and I'm going to focus on other things. Well, let me bring it under your head again because. Is that appropriate? Sure.

I love it. So the question that we want to understand is like these globs of tissue that are associated with our immune system. Like what does that actually mean? Like what does it even mean to be a part of our immune system? What are they doing? What are they composed of? If we remember way, way, way back to our vaccines episode. No.

Season two. I know. 2018. Maybe. Maybe. Yeah. In that episode, we talked about the very specifics of the ways that our immune system responds to antigens. Basically, responds to the stuff, viruses, bacteria, dust, proteins, the crud that we're exposed to all the time.

And I won't make you go back and listen to that, but if anyone wants to, it's a great episode. But I'll summarize what we talked about really briefly so that we can understand tonsils. In that episode, I split the immune system into a four-act play, focusing specifically on our adaptive immune system. The summary is basically that our bodies, mostly via things like our nose and our mouth, but also our guts and our skin and our eyes, are constantly exposed to hundreds of thousands of stuff every day. And we call this stuff antigens. And our immune system's job is to identify all of this stuff and decide what belongs and what doesn't, what's a part of us, and what is not supposed to be there, and how to deal with it. And one of the major ways that we do this is that we have cells in our body called macrophages. These cells go along in either our bloodstream or our lymphatics, and they gobble up this crud, these antigens, wherever they're exposed to them.

and bring them to our T cells, who then bring that crud to our lymph nodes, which we also touched on in our lymphatic filariasis episode. And lymph nodes are where our B cells hang out, and our B cells are what make antibodies. Right. That will then be very specific to be able to find, neutralize, and destroy the crud, the antigens.

It turns out that that part is accurate but leaves out part of the story of our immune system, and that story is malt. So malt. It sounds like you're talking about a person. It just makes me think of malted milk shakes. I mean, appropriate. Appropriate. Okay, so malt.

The composition of malt tissue is very similar to our lymph nodes themselves, except that. it is not connected to our lymphatic system. That is so bizarre and cool. It gets cooler because the stuff that malt is sampling, the stuff that it's going to decide whether or not for our B cells to mount a response to is being sampled directly from the mucosa itself, rather than going through macrophages, traveling through the lymphatics and the making its way to the lymph nodes. So it's like first line. Exactly. It is first line.

That is what malt is. It is first line immune system. Okay, now I kind of wish I had read more about the evolutionary history because I wonder how basal that is compared to like other parts of our immune system anyway. It would be really interesting. Histologically, malt is very similar to lymph nodes, except that it doesn't tend to have a capsule. And again, they don't have any lymphatic drainage. But the outer cells of malt tissue, including our tonsils, have these cells called M cells, which are depending on the source called membrane cells or microfold cells. But these are cells that are essentially just really good at uptaking the stuff that our mucosa, our nose, our mouth, our guts are constantly exposed to floating across our mucosa.

These M cells take them up and then shuttle them into the core of. of these tonsils or other malt tissue, but we'll focus on tonsils for this episode. Our tonsils have these crypts, these like deep crypts. And so these structures are covered with this epithelial tissue, and then these M cells just like swoop stuff into the inner bits where are housed B cells and T cells. And these B and T cells do exactly what they do everywhere else in our body.

They sample antigens and then they make antibodies. And it gets even cooler because I can see your face being like, what? My mind is totally. Yeah, absolutely. Our malt tissues, especially our tonsils and our pyres patches in our gut, they make and secrete a kind of specialized type of antibody called IGA, which is different than other antibodies like IGM and IGG. And it's probably beyond the scope of this episode to get into the nitty-gritty on all these different types of antibodies.

But IGA is a really important type of antibody that really does function as a first-line defense on these mucosal surfaces. And it's being secreted from things like our tonsils and adenoids and in our guts and things like that. This, okay, I don't even know where to begin. I'm fascinated. I don't even know if I have a question. at the end of this. I mostly just want to say how, yes, we should definitely do an episode on all the IGs. How I know. And secondly, it's just beautiful. It really is. It really is. Wow. Okay. And so what's the purpose of the Crips? They essentially are what are like funneling and

shuttling things in, if that makes sense. And kind of grabbing, grabbing onto them a little bit. It's increasing surface area for stuff to get slooped in. Yeah. Yeah. And our tonsils, especially our palatine tonsils and our adenoid or pharyngeal tonsils and the other ones as well, they are especially important in this role because they form this ring around the entrance to two of our most important systems that interact with the outside world are. digestive system and our respiratory system. Yeah. So our tonsils are being constantly exposed to everything all the time. So that's what they do. That's what they're for. They are a hugely important part of the development of our antibody mediated immune response, especially for things like respiratory

viruses and bacteria. You may have already said this, but which tonsils are the biggest? Great question. The ones that you think of as tonsils, your palatine tonsils, the two that sit in the back of your throat are the biggest. Okay. Like physically, they're the big honkers that you see. The tubular tonsils near you station tubes are really quite small. Your adenoid up in your nasopharynx can get large, and we'll talk about it, but is just a single tonsil and is a little smaller than the others. and then your lingual tonsils back in the back of your tongue

are actually a whole series of a bunch of really little things. Okay. Like little, little cell areas and nuggets. I'm doing things with my hands that people can't see. Yeah, yeah. Patchy bits. Patchy bits. Okay.

Is now the time to say, well, what the heck, if they're so, like, they seem pretty dang cool and important, how can we take them out with seemingly few negative consequences? Are there negative consequences? Why do they get so bad that they have to be taken out all of that? I know. Yeah, there's a lot of stuff. There was a lot where I was like, I don't know where to go from here. Like, that's what a tonsil is. Right. Now what? So let's start with where can things go wrong? If these are something that is so great, then why don't we talk about when things are less great, i.e. tonsil shall we? Yeah. So tonsillitis literally just means inflammationitis in your tonsils. And again,

at this point when I'm talking about tonsils, I am primarily now only talking about the two big ones, the pharyngeal tonsil that is your adenoids and primarily the palatine tonsils that are commonly referred to as tonsils, right? So tonsillitis, turns out is not actually like a very specific thing because sore throat in general is really common. It's one of the most common symptoms. It's associated with so many viral infections. The flu, the common cold, COVID, mono, so many bacterial infections, strep throat, many more. Not all sore throats will necessarily cause inflammation in the tonsils themselves. And sometimes a sore throat is just, just called like acute pharyngitis, which just means sore throat in medical terms, inflammation in the pharynx or whatever. But often there is some degree of tonsillitis, especially depending on the age of the person and the infectious agent, that happens when there is sore throat. there's a few different reasons why our palatine tonsils, the two in the back of your throat,

are so very prone to this. Partly, it's because, like I already said, they are constantly being exposed to and sampling all of the viruses and bacteria that we're exposed to and that just like live and hang out in our throats. So you're just like walking around Costco trying every single sample and blocking the entrance to the aisles. Yes. That's what it is, because that's what happens. The crypts just get trapped sometimes. Stuff gets stuck in the aisles of Costco in our tonsils. I don't know if this metaphor is like, I love it. I love it. But then they can begin to proliferate before we've managed to mount a sufficient immune response, right? And that's going to cause some degree of

blood flow, inflammation to the area, pain receptors, cytokines are going to be sent out, which are going to tell us that there's pain. There's also, I have a really interesting paper on, like, the actual pathophysiology of the pain of a sore throat that's, like, really fascinating and interesting. But there's, like, a lot of open nerve endings that exist in that region, which is part of it. Like, why? It's so painful. It's so painful. I know. But anyways, on top of that, a lot of the respite. pathogens that cause sore throat, especially like all of the millions of rhinovirus seravars, are really well adapted to the cells of our tonsils. So they are actually really good at not just

being sampled by, but getting into and replicating within the cells of our tonsils. So our tonsils cells, while there's like this tradeoff, right, they're really good at sampling all of this material, but they're also really prone to infection because of the tonsill cells. they sit at some of the most commonly infected sites in our upper airways. Right. On top of that, the people who get the most infections in their tonsils and the most severe infections in their tonsils are kids, especially school-age kids. And part of that is because our tonsils, which are present from birth, actually grow during early childhood. and they reach their peak in size in kids ages like four to eight,

and then they start to regress as we get older. Interesting. On top of that, comparative to body size, the tonsils are the largest in very young kids. So rather than like school age and like teenage years, when the tonsils are still kind of growing, when they're very young, like three, four, compared to the size of their throat, tonsils are really big,

even though they're going to continue to grow. Does that make sense? Yeah. And then like the swelling then is exactly so much more pronounced. Yes. So that is where this type of inflammation can cause real problems. This infection and inflammation can either just be very recurrent, especially in like school-aged kids from like five to 15. It can cause really recurrent infections, which can end up with a lot of miss school or just a lot of pain, a lot of exposure to antibiotics, as we heard in our first-hand account, which was not even during school age. This kind of hypertrophy can also put kids at increased risk of things like recurrent ear infections because hypertrophy of various tonsill or tissue can also then compress the eustachian tubes where our ears are supposed to drain, which is what can increase the risk of ear infections.

And, of course, if tonsils and especially adenoids, which sit at the top back of our nose, nasofarinks become severely enlarged and hypertrophied, it can cause problems with breathing. Yeah. Both in the acute form where an acute infection can be a real risk of, like, respiratory distress, or just over time it can cause obstructive sleep apnea in kids. There is also a phenomenon that you may have heard of called peritonsular abscess. Did you come across that? I did not, but abscess in tonsils.

Abscess in tonsils. And it's not really in tonsils, really. This is a complication that happens when an infection kind of spreads beyond the tonsils. It can also happen in absence of tonsils, even after a tonsillectomy, for example. But it's essentially just a group of deep space neck infections. So abscesses either right next to the tonsils or in the back of the tonsils or in the retroferengial or parapherential space. Essentially, our neck is very complicated with a whole bunch of things in it in a really small amount of space. So we have a lot of like fascial layers separating these all.

And if infection spreads beyond some of those fascial planes, it can become very severe and lead to airway compromise really easily. That makes sense. So these type of infections can be really serious because they can, you know, cause a lot of swelling and, make it so that people can't breathe. And is this associated with certain pathogens, or is it just like anything can do it? Anything can do it. Bacterial infections are going to be much more likely to cause an abscess than anything like a viral infection. And streptocockeye, like your group A strep, strip throat is a really common one, but by no means the only pathogen that can cause these types of infections. Okay. Yeah. And then there are tonsil.

Stones. Yay. I'm so glad you're talking about these. I've had two in my life. Yeah, and one just recently. One recently, and the other one was I was like a freshman in college or a sophomore in college. Tonsil stones are just collections of schmuts, really. It's unsatisfying, I feel. I know. It's just schmuts that get stuck in those little crypts in the tonsils. And what our body tends to do to schmuts anywhere in our body is kind of calcify it to be like let's wall this off and package it up so that it doesn't cause any more problems and in so doing it can sometimes cause problems it's like cask of a monteado style have you had that joke on this podcast before i don't know because i don't know what it means because i'm probably not smart enough no it's like some edgar allen poe

story, I think, where somebody, like, bricks in somebody else into a wall. I thought, isn't that the telltale heart thing? I thought that was just someone who killed someone. Well, clearly we need to refresh our poe knowledge. We're not getting it. No. Anyways, tonsils stones, schmuts in your tonsils. These can also happen in your salivary glands.

Like, they can happen in a lot of other places. That's not, that's all I really have for that. It's not all that exciting. But those are the kind of ways in which tonsils can become a problem and why someone might need to undergo a tonsillectomy and or an adenoidectomy. Are stones enough for that? No, no, no, no. Okay. So there are reasons to remove tonsils, but maybe not as much as people used to lean into in historical times.

Yeah. But what happens when those tonsils are gone? Because it seems like from what my. growing up interpretation or like what, you know, my ingrained knowledge and also reading about this is that there aren't many negative consequences. Yeah. So there's risks associated with surgery, right? Yeah. So most of the complications that we see are in that acute phase where you have risk of things like bleeding. You have risk of infection as a result of surgery. Bleeding is really the big one. And in really severe cases, people can end up dying as a result of complications

from surgery. Very rare, but surgery is surgery, and so complications can happen. Beyond that surgical complication time frame, we don't really have a lot of data to say that there are negative effects in the long term from not having tonsils. And when it's indicated, like in the case of really recurrent infections, or even in the case of obstructive sleep apnea in young kids, there is some data that there is benefit to tonsil removal in those cases because it can significantly reduce the rate of recurrent infection. And in kids with obstructive sleep, it can improve their sleep, even if it's only in the short term. And we'll get more into that later. But it's fascinating that something that would appear as integral

as a major source of antibodies and a major source of sampling of our environment to protect against infection can be removed with relatively little consequence. To me, what I think makes that so fascinating is it kind of shows how many redundancies we have in our bodies. I was just about to say it's like built-in redundancy.

Exactly. And it is, right? Because whenever tonsils are being removed, it's not all of them. You still have your lingual tonsils. You still have those tubal tonsils. Nobody's removing those. It's just the palatine tonsils and sometimes the adenoids. Sometimes both, but sometimes just like one or the other, right?

So first of all, we have redundancy just within that. There's also additional, like, malt-like tissue throughout other parts of our mucosa that just isn't as well organized as the actual tonsils themselves. And then, of course, there's the rest of our entire immune system, which is doing all the same stuff. It's just doing it in a slightly different way than this mucosal lymphoid tissue is doing. So cool. It is. And there's a lot more that we could do in talking about malt and galt, because, yeah, like celiac, for example, is associated with discrepancies in Galt and IGA secretion and things like that. Like, it's really cool.

Well, that's on our list for sure. It is. So that's tonsils, Aaron. They're amazing. They're so cool, except when they're a problem. And then it's cool that you can take them out. So tell me, Aaron, where did we get to hear from? Is that? Why don't I just share what I brought with me to share right after this break, please?

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Listen to Love Trapped on the Iheart radio app, Apple Podcasts, or wherever you get your podcasts. So it turns out that people have been irritated about tonsils or found them to be like troublesome enough to get rid of them for millennia. Stop it. Oh, yeah. I don't want a millennia ago anyone cutting anything out of me. I've got to be honest with you.

I've listened to enough episodes of this podcast. I think that given some of the quotes that I'm going to toss and sprinkle in throughout here, that opinion will be even more reinforced. Yeah, okay. Yeah, because this was like pre-anesthesia, pre-anibiotics. Nope. Mm-mm. But I was honestly really taken aback by the number of references to tonsillectomies over the centuries.

Huh. They're everywhere. Hmm. All right. So from 1,000 BCE in a Hindu medicine textbook, quote, when the phlegm and blood are deranged in the soft palate and tonsils, they become large. and like a full bladder, accompanied with thirst, cough, and difficulty in breathing. When troublesome, they are to be seized between the blades of a forceps, drawn forward, and with a semicircular knife,

the third of the swelled part is removed. If all be removed, so much blood may be discharged as will destroy the individual. If too little is removed, it will produce an increase in the swelling with fainting and swimming of head, end quote. Oh my goodness. Yeah. I can picture every piece of that that you just described, like very clearly, and I don't like it. Oh, okay. If you didn't like this one, you're really not going to like this next one. Give it to me. Okay, so this is from Selsus, a Roman aristocrat who lived from like 25 BCE to 50 CE. Quote, quote, They ought to be disengaged all round by the finger and removed. What?

If they are not separated by this method, it is necessary to take them up with a blunt hook and separate them with a scalpel, then to wash them with vinegar and anoint the wound with a stiptic application. Can you just imagine how much that would hurt? Because you're talking about an acutely inflamed, angry organ. And using a fingernail. I really feel like this quote, as the kids say, has lived like rent-free in my head since reading it. I just keep, I have this intrusive thought of like a fingernail and the tonsils. I'm sorry.

I know. I know. But the way that both of these descriptions are written kind of sounds like this is a relatively common procedure. Yeah. And that's supported by the many, many more quotes that I'm going to toss in here. So for instance, in the second century CE, Galen wrote about using a snare to amputate the tonsile. And this method increased in popularity over the centuries with a few authors advocating for like, hey, let's remove just part of it and not all of it so that we don't cause hemorrhage. Yeah, good call.

Yeah. The next quote, I think, provides an excellent glimpse into the world of pre-modern day surgery. From the 4th century CE, Greek physician Paul of Agina wrote, quote, When therefore they are inflamed, we must not meddle with them. But when the inflammation is considerably abated, we may operate, more especially upon such as our white, contracted, and have a narrow base. but those which are spongy, red, and have a broad base are apt to bleed. Therefore, seating the person in the light of the sun and directing him to open his mouth while one assistant holds his hand and another presses down the tongue with a wooden spatula,

we take a hook and perforate the tonsil with it and drag it outwards as much as we can without drawing its membranes along with it. And then we cut it out by the root with a scounder. scalpel suited to that hand. After ligation, the patient must gargle with cold water or oxycrate, which is a mixture of water and vinegar, or if hemorrhage occurs, he may use a tepid decoction of brambles, roses, or myrtle leaves, end quote. That was very detailed. I think the thing that stuck out to me the most with that was that make sure that they're, like it's the noon day sun and that the light is penetrating the back of their throat. I just

didn't think of that. Also, someone is holding their hand. Yeah. So during the middle ages, tonsillectomies went through a decline in popularity, like many other surgeries. And swollen or abscess tonsils were mostly dealt with through just like lancing the tonsil rather than straight up removal. But you know how trends come and go. Yeah. I'm thinking about buying flare jeans, which I never thought I would do again after high school. But, you know, You know, got to be cool. And by the 16th century or so, people were starting to get back into removal. Ambrose Paray, a very famous French surgeon and anatomist.

He was one of the major ones to kickstart surgery and also work on like surgical improvements during this period. He was a big proponent of gradually strangling the tonsil with a ligature until circulation was cut off, which just like sounds deeply unpleasant. I mean, at least you'd bleed a lot less. I mean, yeah. Yeah. But I think that this, like, this next quote speaks to some of the discomfort.

Oh, okay. So someone from this era wrote that this method of tonsillectomy, quote, is liable to resolve itself into physical combat between the surgeon and his patient. End quote. Oh, dear. I mean, yeah. Yeah. I feel like it's not even like you're not, you just, it's like instinctive. Like you're just, you're going to fight it.

Get out of my mouth. Exactly. Yeah. Other surgeons of the time objected to the procedure because of what was thought about the purpose and physiology of tonsils, which was that essentially they absorbed the secretions that came from the brain and then exited through the nasal cavity and then the tonsils like sent them back to the brain after filtering, something like that. Wow, that is complicated, isn't it?

I know, right? And so with the tonsils gone, those secretions would just linger and cause hoarseness. So it turns out that the controversy around removing tonsils is nearly as old as the procedure itself. So, for instance, take this quote by Deonis from 1672, quote, Some of our ancestors proposed the separation and evulsion of these glands, which operation they very easily performed. I refer you the methods which they proposed to do it, which I think very cruel. For the function these glands being to separate and infiltrate the sacroities, which serve

to moisten the tongue, larynx, and esophagus, these parts must find themselves deprived of that dew, which is of great use in tempering of the air in the lungs and slithes. the nourishment into the stomach. Okay. Yeah. And so on this theme of controversy, I found this quote in many of the other quotes that I've mentioned so far in a paper titled, quote,

A History of Tonsilectomy, two millennia of trauma, hemorrhage, and controversy. Oh, end quote. So I wonder which side the author fell on. And yeah, so, you know, of course, for there to be a debate, there has to be at least two sides. So on the other side was a physician

from Philadelphia named Philip Singh Physic, who in 1828 modified an instrument that was normally used to remove the uvula and used it as a tonsil guillotine. He wrote, quote, it is easy to cut

off the hole or any portion that may be necessary of the enlarged tonsil. The operation can be fulfilled in a moment of time. The pain, the pain, is very little and the hemorrhage so moderate that it has not required any alteration in four cases in which the doctor has recently performed it. Sorry, I'm also really wondering why they were taking out people's uvulas. I don't know.

That part, yeah, that's like the sneaky, scary, terrifying part. Yeah. I don't know. Okay. Mm-hmm. We should do an episode on the uvula. We should, I guess. Now we have to.

We'll learn about the uvula guillac. And this tool that he developed, the tonsillotome, was a popular choice for partial tonsillectomies for about 80 years. But some people still use the good old fingernail. Seriously. Seriously. I cannot. They're actual fingers? Yes.

It's gruesome. I... Yeah. I also just like, I'm thinking about tonsils. Doesn't seem easy. No. Nothing ever worth doing was easy, I think, is their mentality. Or something like that.

But up until the early 20th century, the removal of tonsils via surgery, or fingernail, was only partial. And physicians had noticed that partial removal didn't necessarily alleviate all of the symptoms that it was supposed to. Some people had regrowth of tissue, others had persistent infections, and so they began to try to take more of the tonsils out. And they realized that, frankly, the tonsil guillotine, or tonsillotome, was not up to the task. After a series of close but no cigar attempts at full removal by surgeons throughout the 1890s, English otolaryngologist George Waugh succeeded in publishing about the dissection method he used to completely remove the tonsils.

And with this, tonsillectomies, the word first used in 1904, took over modern surgery. Hmm. Not an exaggeration, not an overstatement. During the first half of the 20th century, from 1915 to 1960, tonsillectomy, along with adenoidectomy, were the most frequently performed surgeries in the U.S. Wow. Yeah. But, like, why? Yeah, just because they could?

Just because they could. It's like Everest. What about tonsils just made people want to rip them out of you? And what happened in the mid-20th century to change everyone's mind? Why was this trend reversed? I can't wait to find out. And if you were hoping for like a one-line answer, you've come to the wrong podcast. No one wants a one-liner, Aaron.

No, they don't. So to really get at the heart of that question, we have to consider not only what people thought tonsils did or didn't do, but also how surgery was changing, how hospitals were changing, how germ theory was driving concepts of infection and disease, and how the theory of evolution was shifting the way we viewed form and function in our bodies. So yeah, it's about the tonsils, but it's also about so much more than the tonsils. Always. I love when this happens.

Okay, so let's set the stage. With the introduction of germ theory in the mid-1800s and then widespread acceptance of it by the end of that century and a full-on war on infectious disease launched in the 20th, many physicians had started to look for a causative pathogen for every disease that came across their exam table. I've talked about this before many times. But they also began to try to tease apart why pathogens, mainly bacteria at this point,

acted the way they did. Why did the cholera bacterium colonize the gut while diphtheria was found in the throat? At what point and why did pathogenic bacteria invade the bloodstream? And to try to answer these questions, there arose a concept called focal infections. theory. Essentially, this idea, which was primarily popular in the U.S., especially in the early 20th century, and not so much elsewhere, this idea held that different infections arose in certain areas of the body, and if not contained, they could spill out into the bloodstream and travel to the rest of the body from there. So there were different like foci of infection, whether it was your throat,

whether it was your gut, and that's where that bacteria lived. And then if it overflowed, that's when it became super deadly went into your bloodstream. Okay. And this seemed to be especially popular among American surgeons, since most of the foci of infection were, quote, anything that is readily accessible for surgery, end quote, is one pathologist joked. And tonsils fit the bill exactly. They were located in the throat, which was seen as a major portal of infection along with the mouth and nose.

They were easily accessible. And centuries of successful removal suggested that they weren't missed all too much, provided you stopped the hemorrhaging. The question of whether their removal actually did anything didn't really seem to come into play, at least for a while. Personal experience from the surgeon was more the gold standard of the day. than say like a case control study or like statistics. Like if they thought it was great and then it was great kind of a thing? Anecdote leading all, right? Like I took the tonsils out of this patient that kept getting sore throats and now they don't get sore throats.

Uh-huh. Or you just don't see them anymore because there's nothing for you to surgery. Exactly. Oh, okay. I mean. Anyways. You know, it took a while for statistics to catch on. Yeah, yeah, yeah.

Yeah. Yeah. And of course, this wasn't like wide acceptance, right? This wasn't tonsillectomies for everyone. Surgeons varied in how enthusiastic they were about the procedure and how likely they were to recommend it. Some thought prophylactic removal was best. Like, you get to a certain age, get them out of there, get those tonsils gone. Others were more conservative, recommending removal only after multiple infections. But by and large, the predominant The predominant belief about tonsils was that no one knew exactly what they did, what their purpose was. But they did think that they were behind many systemic infections, harboring bacteria that entered the throat and then replicated in the tonsils and then were released to the rest of the body through the bloodstream.

So the tonsils were viewed as like this incubator of infection. Interesting. And so getting rid of them, ideal. No big deal. At the very minimum, the best thing you could do at the maximum. In a 1920s paper by Edwin Place, quote, the importance of the tonsils in the acute infections as a point of attack and as a portal of entry for infections is so much a matter of common experience as to require no demonstration here, end quote. citation not needed. Which I find kind of amazing, like how without much supporting evidence or direct investigation looking at what the tonsils actually did,

there was just like an assumption widespread that they were not important. I wonder how much of it could have been the bias of seeing only the abnormal that you see, right? Like if you only see the kids who are coming to you because their tonsils are giant and swollen and they're causing problems, take them out. You're fixing people. But you're not seeing all of the people who's not having any problems with their tonsils and who are living just fine.

Right? But it's like you only are seeing these, so they're only a problem. I don't know, but I don't know. I don't know. Well, and one of the things that I was saying, thinking about, as I read for this episode, was how much that attitude about like the tonsils not being important might have been driven by this idea of vestigial structures. So vestigial structures are structures that have remained in a species, but during evolution lost their primary ancestral function.

And so they appear not to serve a purpose. I always thought that, you know, appendix, and tonsils, whatever, we're all lumped together under vestigial structures. And that's what, like, I grew up thinking that tonsils were not necessary. And that's why people removed them. And they're just some remnant of evolution. Okay. But let's, I want to get into a little bit of, like, the origins of this. So this concept of vestigial structures gained traction, especially since Darwin's

on the origin of species and the descent of man in the mid-19th century. introducing the theory of evolution. And also in Robert Wiedersheim's The Structure of Man in 1895, where he listed dozens of vestigial structures in humans. Tonsils were not on Wiedersheim's list, but plenty of people believed that they didn't have a purpose any longer. So it seems plausible to me, at least, this is definitely a pet hypothesis, that the enthusiasm for tonsillectomies was driven in part by embracing the theory of evolution by natural

selection, where vestigial structures were seen as evidence for evolution. We know now, of course, that many structures previously considered vestigial, like tonsils and the appendix, aren't actually vestigial, like they still have a function. It might be slightly different than its evolutionary origins, but the fact that the fact that they have a function does not at all refute the existence of evolution, which is what many creationists will try to argue that like there is no such thing as a vestigial structure because there are no mistakes and also we didn't evolve from other organisms so all vestigial structures must have a function. I'm not going to get into that whole can of worms.

I will link to some papers about the concept of vestigial organs. which do exist, if you're curious and want to read more. But I just thought it was really interesting, sort of this timing of when vestigial organs and the theory of evolution was like gaining traction, growing in popularity, did that timing help to spur the frequency of tonsillectomies? That's really interesting. I don't know. That's my little pet hypothesis. But if it did, it certainly wasn't the only thing. Throughout the first half of the 20th century, surgery overall had experienced a tremendous shift. The combination of anesthesia, which had been around since at least the 19th century, antibiotics in the 1930s and 1940s, the growth of hospitals, and the formalization

of medical and surgical training had led to a rapid expansion of surgery overall, and the development of many specialties within surgery and medicine. And what better procedure to practice on and earn money on than the minimally invasive, generally low-risk tonsillectomy? It became a routine operation for so very many children. Wow. I couldn't find a ton of numbers, but I did read that in between 1928 and 1931, tonsillectomies accounted for a about one-third of all surgical operations. In 1920, in New York City alone, 47,000 tonsillectomies were performed.

By the mid-1900s, nearly half of the kids in some regions had had their tonsils removed. What? And an estimated 1.5 to 2 million individuals, largely children, had their tonsils removed in peak years in the U.S. Wow.

Yeah. Oh, gosh, with numbers like that, it's no wonder that it's like part of our collective consciousness. Right? Wow. And also like how amazing the shift has been. Yeah. And so tonsillectomies gained traction through parenting books, pediatricians, even just word of mouth. And they were hailed as all but essential if you wanted to ensure the health of your child. But while many surgeons and pediatricians were content to accept this as just fact, others had decided to apply a little thing called statistics. One of the largest and earliest studies comparing kids with and without tonsils with upwards of 20,000 children found results that were largely unsatisfying to tonsillectomy enthusiasts.

It did seem that there were some benefits, such as reduction in sore throats, cervical adenitis, otitis media, scarlet fever, diphtheria, rheumatic fever, and heart disease. Others found, like, the opposite trends with some of those. But when it came to sinusitis, colds, chickenpox, mumps, measles, tuberculosis, asthma, and hay fever, nothing. Or, as another study found, higher rates in those who had had their tonsils removed. Hmm. A reminder here to take this with a grain of salt, considering that it was the 1920s. Follow-up was patchy at best.

You know, statistics were developing. But these studies and many others that followed were the first signs that maybe tonsillectomies weren't like all that they had promised to be. Doubt continued to grow into the 1930s as people began to question the justifications that had previously been accepted without reservation, like the focal theory of disease, which by this time had fallen out of favor. Then there was the question of what a diseased tonsil looked like. Toncils, like many other body parts, come in all shapes and sizes, and they change, not just like over many years, but also they could change day to day. Absolutely. So what looks, you know, quote unquote, irregular to one surgeon could look totally normal

to another, also based on their personal experience. Is there a standard for tonsil size? No. Studies like the one I mentioned continued to cast doubt. on the utility of tonsillectomies with the author of that big study saying, quote, the desired relationship between the tonsils and the various infections in childhood is not as clear today as it seemed 10 years ago. Statistical and controlled clinical studies have obliged us to modify or even change our views on this relationship. Oh, the statistics, making things less fun for everyone.

Just kidding. Always, but also science at work. Yeah. On top of the whole rationale for tonsillectomies being called into question was the finding that many of the procedures had been incomplete with residual tonsil tissue found in well over half of some groups of patients. By the late 1930s, a reckoning had truly begun. But for a long time, that reckoning was more or less confined to the medical literature. Pediatricians continued to recommend tonsillectomy and adenoidectomy for their patients, not just in extreme cases or not just when they felt it warranted it, but it was like at the drop of a hat.

And this continued for decades. And parents who had maybe grown up having their own tonsils removed continued to ask for the procedure. for their kids, even long after that. The shift in attitude surrounding tonsillectomy and its rise and fall is, I think, one of the clearest examples that I've come across of the time lag in scientific research reaching application and general knowledge. Interesting. A new concept is put forth, like the tonsillectomy is maybe not being as necessary as once

thought. It takes a while until it's accepted among other researchers in that niche field because they've got to test it, confirm that there's evidence to support it. And then it takes even longer to sneak its way into application or textbooks and then even longer until it reaches the general public. So if you were a pediatrician trained during the time that tonsillectomies were all the rage and you learned in your med school training that, hey, if you have a kid that has one, sore throat, take them out. They're gone. Take them out prophylactically. Might as well. Then let's say that you go into teaching, you spend the rest of your career 30, 40, 50 years teaching the next generation of pediatricians potentially that this is a routine surgery of childhood. And this is a gross generalization. And this is like an exaggeration of how

things can be. Not really. Not usually. Not hugely. Not hugely. Aaron, just looking at you, like, mm-mm, happens every day. Like, how long does it take for a new generation of doctors to unlearn what had been previously accepted knowledge? And where is that older physician that one who's teaching all of these new physicians, where are they going to encounter dissenting views without routinely looking through primary literature? And without training in epidemiology or statistics, how are they going to assess how legitimate the conclusions of a study are. Oh, Erin, this is one of my favorite things because it's something I think about literally all the time at my other job, too, you know?

There is such a gap, not just in primary research and sort of getting that to non-specialty fields or like fields outside of that specialty. But then how long does that information then take to reach the general public. It's, it's so long, Aaron. Like, in the 1920s, it was probably even longer. And even today with the internet, it's still long. Oh, it's still so, it's so long. And in the case of tonsils, we have, like, decades, decades. It began to be realized in the 1920s, and then when did the trends really change? I would say 1960s, more widespread within the medical community, and then 1970s and 80s is when, like, the decline had really begun. Wow.

Yeah. And there were, like, still articles about the benefits of tonsillectomies in parenting books. And not all the time. Like, sometimes there was, you know, urging caution with tonsillectomy and, you know, recommended removal in only extreme cases. And this was not like, you know, we're not talking about, and then we turned a corner. and then, you know, immediate sharp differences in this. Like the conversation continued to exist around tonsillectomies.

So there was more negative press in the 1940s and 1950s. But like parents really wanted their kids to have tonsillectomies. And it wasn't just parents recommending it, right? It was pediatricians who had, that's what they had learned to do. That and the growth of voluntary health insurance plans post-World War II. which is likely why we see higher rates of tonsillectomy during that time period in children from middle and upper class families, i.e. those who could afford to pay for an elective surgery compared to those without insurance. That's sort of an interesting little tidbit. Sure is. And so,

like I said, 1960s doubt became more, you know, on the loudspeaker. In 1970s and 80s, rates had really declined. And part of this decline, I have no doubt, was the rise in antibiotic use, which could treat many infections commonly associated with tonsils and the growing specialization in pediatrics, where pediatricians rarely received surgical training, and so we're just less exposed to tonsillectomies overall. That's at least according to one paper that suggested that. In 1965 in the U.S., 1,215,000 tonsillectomies were performed. Just a couple of decades later, in 1986, that number had fallen to 281,000. And then it rose again in 1996 to 383,000.

But like, you know, that could be a number of different factors. And I should point out that the U.S., where all of these numbers come from, was the leading tonsillectomy country. The procedure was also popular in England, but not as popular, and it fell out of favor sooner. This re-examination of the necessity of tonsillectomies allowed for more careful consideration of when they should be performed, because as you talked about, as our firsthand demonstrates, there are still many cases where it is essential. But the history of tonsillectomies provides what I think is one of the most fascinating glist, limpses into the inertia of scientific knowledge, where it can take literally generations to incorporate new findings into practice and then generations more into general knowledge.

And that's the history of tonsils. I love that, Erin. This is one of my favorite ones to do recently, I think. I loved listening to it. So, Aaron, tell me, what's going to? going on with tonsils today. Okay. We're still doing them, but like, under what circumstances. Yeah. Okay. Let me tell you right after this break. Honestly, it was very difficult, pretty much impossible, to get any kind of data on like incidents, prevalence of tonsillitis,

or recurrent tonsillitis, or pharyngitis. Like, come on. It's, we can't do that. It's too common. It's so common. It's everyone everywhere all the time. I had a sore throat yesterday. Okay? It's nearly always self-limited. It's not an infection that we can track. But that doesn't mean I have no data for you. I found a very interesting paper out of the UK. It's a few years old now, but it was very interesting. What it looked at specifically was the incidence of tonsillectomy and the proportion of these tonsillectomies that were based on what they considered to be truly evidence-based criteria versus the proportion of tonsillectomies that were not fitting with evidence-based criteria. This was from 2005 to 2016, so like a little old but like not super old, so like current enough.

What's fascinating about this study is that what they found overall in conclusion is that, that in the UK, in the population that they looked at, it wasn't every kid in the UK, but it was several hundred thousand kids, about four in one thousand children. And this, again, was all in children. Four in a thousand met evidence-based criteria for tonsillectomy. So first of all, we can talk about what does that actually look like? Like what today is considered guideline approval evidence-based for tonsillectomy. Yeah. The major criteria is what are called the Paradise Criteria.

I don't know why. Don't ask why. And this is pretty, like, hardcore criteria. It is seven documented episodes of severe sore throat or tonsillitis in one single year. Seven. And part of it is that this is documented as severe sore throat. meaning that a sore throat that's not bad where someone doesn't go to the doctor wouldn't count because those episodes are considered to be less severe. Could you argue about access to health care, et cetera? Yes, definitely,

this is in the UK. They at least have a national health care system, okay? So it's seven episodes of severe sore throat in one year or five per year for two years in a row or three per year for three years in a row. Okay. Those are the most common criteria, the Paradise Criteria. The other criteria that they considered in this paper to be evidence-based was a tonsiler tumor, which makes sense. Yep. And a condition called P-F-A-P-A, which stands for periodic fever.

apthus stomatitis, pharyngitis, and adonitis. That's a lot of ituses. It's a lot of ituses. And what this actually is is like a genetic condition that results in these periodic fevers, these ulcers in the mouth, and a sore throat and swollen tonsils, adenoids, and lymph nodes and things like that. Okay. It's not super common.

It's a genetic disorder. We could probably do a whole episode on it. But those are the three things that they consider. as evidence-based criteria for tonsillectomy. Four in a thousand kids in this study met criteria. Like that was the overall prevalence. But less than one in seven of those kids had a tonsillectomy. Between two to three kids per 1,000 each year had a tonsillectomy,

But less than one in eight of the kids who had tonsillectomy actually had an evidence-based indication. Whoa. Yeah. So, like, lots of kids met criteria for tonsillectomy for what they considered evidence-based criteria for tonsillectomy did not have a tonsillectomy. Uh-huh. And many, many more kids did not meet criteria for tonsillectomy and yet had a tonsillectomy.

So their overall conclusion was that of the 37,000 tonsillectomy, was that of the 37,000 tonsilectomies that were performed in the UK in this time, in this population, each year, 32,000 of them were, quote, unnecessary. What is going on? Okay. Here's part of what's going on. A large proportion of the kids who underwent tonsillectomy in this study had one, two, or three, or sometimes four or five episodes of tonsillitis.

So they had severe sore throat, they had evidence of tonsill infection, but not enough per year to meet this evidence-based criteria. Okay. That's a big one. The other one is sleep apnea or obstructive sleep-disordered breathing. Which is not on the list of recommended whatever criteria? So in this paper in the UK, it's not considered an evidence-based indication. But the number of kids who have been having and who have been recommended for tonsillectomy and really adenoidectomy especially, and sometimes not both, sometimes just adenoidectomy, who were referred for tonsillectomies over that time period for obstructive sleep disordered breathing or obstructive sleep apnea increased over this time period. And it's really interesting because in this period.

paper in the UK, it was not considered an evidence-based indication. But what they did mention is that there is data that shows that adenoidectomy specifically, so removal of just that pharyngeal tonsil does reduce snoring and can show short-term improvements in the quality of life on a few different metrics for kids ages five to nine who have obstructive sleep disordered breathing or obstructive sleep apnea and who undergo adenoidectomy. But there isn't a lot of long-term data on its effectiveness and there is not necessarily data that it improves all possible outcomes or all possible complications associated with sleep disorder breathing. Okay. So according to this paper that was not enough evidence to consider it an evidence-based indication.

Does that make sense? Yes. It doesn't necessarily mean there's no utility in it or that it can't be beneficial. Right. It just means, according to this, there wasn't enough data. Yeah. So I think that that's an interesting part because part of this story of the number of tonsillectomies is like, how bad does it have to be to consider tonsillectomy evidence-based

versus not, right? Like, what outcomes are we looking at? How much data do we have to prove that? Like, what are we going off of? So that was in the UK. What's interesting is that that paper highlighted that the rates of tonsillectomy vary really widely across the globe. That paper specifically just mentioned that rates in Belgium, Finland, and Norway are about twice as high as in the UK, whereas Spain, Italy, and Poland significantly lower than the UK. And then in the U.S., rates tend to be about three times as high as in the U.K. So let's think about the U.S. for a quick moment here. Yeah, love to.

According to the American Academy of Odolaryngology and Headinck Surgery Foundation, and this was data that was in a 2019 update on their guidelines, but I think the data is older than that. There are about 289,000 tonsillectomies performed each year just on kids under age 15. It's really hard to get data on tonsillectomy in adults because it's a much, much less common procedure. Which, what's interesting about that number, 289,000,

is that, Erin, you said that that was the number at the end of the 80s. So, like, it just hasn't really changed, which I find really interesting. Well, that's what I was wondering about when you were talking about the criteria that recommend removal or whatever. How when were those criteria instituted? How often do we revisit criteria, admin, or take them off, whatever? Like, it's just all part of it. The most recent update that I could find was 2019, but those had been updated again in 2011. And so it's not that infrequent that this society seems to be updating their guidelines. And what's interesting about the American Academy of Otolaryngology's guidelines is that obstructive sleep disordered breathing is an indication for which they do recommend adenoidectomy.

But they also say that the evidence is not as strong for this indication as it is for those paradise criteria indication really. And the newest guidelines have a strong recommendation. So like whenever you look at guidelines, it's always like low quality, moderate quality, high quality in terms of like the evidence behind it. And then what is the recommendation? Is it like a think about it or like a we kind of recommend it or we strongly recommend it? That's like how guidelines are worded. So they updated their guidelines to strongly recommend holding off, watchful waiting, unless a kid has had at least seven, unless a kid meets these criteria, essentially, the Paradise Criteria. So it seems like the guidelines are really, in terms of recurrent infections, moving more towards pause, wait, treat with antibiotics, let's really wait and see if this

kid truly needs a tonsillectomy. But in the case of sleep disorder breathing, maybe the numbers are going up as we get more evidence for it. Yeah, okay. At this point, we still don't have a ton of evidence for it, especially in the long term, but there is evidence for short-term improvements in sleep outcomes, as well as behavioral parameters like school performance and things like that, because not being able to sleep affects a lot of your life. Yeah.

Or not being able to breathe while you're asleep, I should say. Right, right. I mean. Yeah. So that's kind of where we stand with tonsillitis and tonsillidectomies. And when it comes to what I wanted to talk about with like the future of tonsils, I really didn't know where I wanted to go. There seemed like so many possibilities. But luckily I found this fascinating paper took me to a place I never expected.

In 2021, you ready for this air? And it's pretty excited. I don't know. I better be. In 2021, there was a paper published in Nature Medicine by someone named Wagar at all, I think. Sorry if I pronounced it wrong. Here's what they did, Aaron. They took tonsil tissue, just like tissue from discarded tonsils after a tonsillidectomy, I presume, and grew it in cell culture.

Cool. And what this tonsil tissue did was re-aggregated itself into little. little organoids, little baby tonsils on your little cell culture plate. And then what they did was they exposed these tiny baby little tonsils to things like, for example, a live attenuated flu vaccine, which is something that we know a lot about how these flu vaccines work in our bodies and what kind of an immune response it generates. And they did this to study the immune response in these little baby organoid tonsils on a cell culture plate. What they were doing is creating a new type of model system to be able to study

the human immune response, and specifically our antibody mediated immune response, which again, our tonsils are particularly good at, especially for things like respiratory infections. We have underestimated and underappreciated tonsils for far too long. I agree. That's That is so cool. It's so cool. They went beyond. They also tested it with like SARS-CoV-2 infection and vaccines. And then there was another study that I'll also link to that like just really

specifically looked at using this as a model for SARS infection, for SARS-CoV-2 infection. It is a fascinating, amazing tool to be able to study things like future vaccine development, to be able to test things and see what kind of an immune response is generated in a very realistic human model rather than just animal models, which are far from perfect because animal immune systems are not the same as ours. Really cool, really exciting. I have a couple fun papers for people to read. Tonsils. Amazing. I know.

If people want to read more, boy, have we got something for you. Oh yeah. So we got lots of sources. I'm going to shout out two in particular. So I already shouted out that one by McNeil from 1960, a history of tonsillectomy to millennia of trauma, hemorrhage, and controversy. And then the other one that I want to shout out, although I do have more, is by Grobe from 2007, the rise and decline of tonsillectomy in 20th century America. Fascinating. I have a few tonsil papers that I want to shout out, three of them. One by Cooper at all. Mucosa Associated Lymphoid Tissues is the title, and it was, again, about all malt, and it was really a great read.

Bathala at all from 2013 was a review on the mechanism of sore throat and tonsillitis. Super fascinating and really gets at why ice cream? Why ice cream? cold inhibits the release of a lot of these cytokines, and it can also, like, inhibit the actual pain receptors. So, like, cold is what you want in your throat when it hurts. Oh, my gosh, there's more there. You can read about it. Okay. And then another one by Arambula at all from 2021 that was anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils. And then, of course, I have links to those recent papers about tonsil organoids and using them to start.

study our immune response, you can find the list of sources from this episode and every single one of our episodes on our website under the episodes tab. Thank you so much again, Aaron, the third Aaron of the episode. Love it for sharing your story with us. We really appreciate it. We do. We do. Thank you also to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to Tom Brigh Fogel for the amazing audio mixing. Love it. Thank you to Exactly Right Network. And thank you to you, listeners. We hope that you liked this episode. Yeah, I hope so. I think we certainly did.

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