The tonsils function as the first outpost of the body's immune defense system at the portal of easiest entry for germs into the body - the mouth. They lie just below and behind the soft palate, with a pillar of tissue just in front of (anterior to) them. The tonsils become enlarged for several reasons - infections, both viral and bacterial, as well as allergic stimuli. They become enlarged because immune cells (lymphocytes) take up residence there in response to infection or serious exposure to infectious or allergic stimuli.

If the tonsils are quite large, they can cause some respiratory obstruction, but no matter how large they seem, tonsils rarely cause obstruction to swallowing (unless the throat is sore, of course - that is an issue of soreness, not physical obstruction). Thus removing the tonsils just because they appear large to parents or grandparents is not advisable.

The actual indication for removal of the tonsils is chiefly abscess formation, because peritonsillar abcess is a potentially serious infection, often treated intravenously in the hospital. If a child has had one episode, he or she is likely to have another, and the simplest thing is to remove the tonsils. Recurrent bouts of streptococcal pharyngitis are sometimes used to justify tonsillar removal, but much less so in recent years. Sometimes there is significant respiratory obstruction during sleep associated with enlarged tonsils and adenoids; this too, can be a sufficient and reasonable reason for removal.

The reticence to remove these tissues (both tonsils and adenoids) basically stems from, as with all surgery, consideration of the risks involved compared with the benefit to be gained. There is the ususal anesthetic risk attendant to any episode of general anesthesia, and then the surgical risks of significant hemorrhage during and after the procedure.

Parents get alarmed when for some reason or other they peer into their child's throat and see white patches on the tonsils. Often the child is not even sick in the least. This crud on the tonsillar surface is just old dead skin cells sloughing off and oozing out of the deep pits in the tonsil. White crud on the tonsils does not warrant a trip to the doctor if your child is not sick. You have undoubtedly experienced times when you felt a piece of something in the back of your throat. It was cheesy in texture and rather foul-tasting. This was just a "caseous plug" of old material that popped up out of a deep tonsillar pit or "crypt." It meant nothing.

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