Tonsils & Tonsillectomy: Anatomy, Indications & How to Know If Yours Were Removed

Palatine tonsils are paired lymphoid organs in the lateral oropharynx (tonsillar fossae). They sample inhaled/ingested antigens and initiate mucosal immunity. They are largest in childhood and typically involute by adulthood.

Why Tonsils May Not Be Visible

• Previous tonsillectomy – Surgical removal (common in childhood for recurrent tonsillitis or obstructive sleep apnea).
• Natural atrophy – Tonsils shrink significantly after puberty; may be flush with pharyngeal wall.
• Anatomic variation – Small or recessed tonsils.
• Examination limitations – Poor lighting, gag reflex, patient positioning.

Tonsillectomy Indications (AAO-HNS Guidelines)

• Recurrent throat infection: ≥7 episodes/year, ≥5/year × 2 years, or ≥3/year × 3 years (with documented fever, exudate, adenopathy, GABHS+).
• Obstructive sleep-disordered breathing: OSA confirmed by polysomnography; adenotonsillar hypertrophy.
• Peritonsillar abscess (quinsy) – Often interval tonsillectomy after drainage.
• Malignancy suspicion – Asymmetric enlargement, ulceration.
• PFAPA syndrome – Periodic fever, aphthous stomatitis, pharyngitis, adenitis.

How to Confirm

• Ask parents/caregivers; review childhood medical records.
• ENT exam: Look for tonsillar fossa scars (white fibrous bands) where tonsils were.
• Imaging (CT/MRI) shows absent tonsillar tissue if needed.

Absent tonsils do not impair immune function long-term; other lymphoid tissue (adenoids, lingual tonsil, Peyer's patches) compensates.