What are tonsils? What is their purpose? And what happens to my voice if I have them removed? These questions come up frequently when a young singer presents with recurrent sore throats and a tonsillectomy is being considered. And although I’ve covered this topic in these pages before (October 2006), most of my patients with chronic tonsillitis are college aged and many are singers, so it is time to revisit this topic.
For many singers, there is an anxiety surrounding tonsil surgery. Certainly, many voice teachers feel strongly (and overprotectively) that a singer’s tonsils should never be removed. To answer these questions and resolve unnecessary concern, I want to share with you my experiences regarding singers, tonsils, and tonsillectomy.
The tonsils are two almond-shaped structures that are located on either side of the back of the tongue. They sit each in a small hollow and are partly covered, front and back, by a thin sheet of mucous membrane and muscle: the tonsillar pillars. These pillars continue upward and come together as they enter the soft palate. This relationship of the tonsils to the soft palate is potentially an important consideration for vocalists—and one of the reasons singers hesitate to have the tonsils removed.
Tonsils, along with other lymphoid tissue, help you to acquire your immunity during childhood. These other structures include the adenoids, lingual tonsils, and bits of tissue in the small intestine. The tonsils, lingual tonsils, and adenoids surround the opening to the pharynx (Waldeyer’s ring) and create an “early warning system” that alerts the body against any antigenic substance that may be inhaled or ingested. Their important work, helping us develop antibodies, is completed during early childhood. This is the reason why tonsils usually start to atrophy during the teen years. In adults, tonsils are vestigial structures and they play no protective role against infections.
A doctor might normally suggest removing the tonsils for one of two reasons. In some cases, they harbor a chronic low-grade bacterial infection which flares up repeatedly. These patients tell us that whenever they get sick, they always get a sore throat. As the immune system weakens from a viral infection or physical or psychological stress, the bacteria harbored in the tonsils temporarily gain the upper hand, and clinical pharyngitis and tonsillitis develops. Tonsils in this situation are simply reservoirs of infection and should be removed.
Recurrent white debris in the tonsils is another manifestation of chronic tonsillitis. While this can to some degree be controlled by mechanically removing the white debris with Q-tips or your fingers, the reappearance of this material signals the fact that the tonsils are in fact chronically infected. When tonsils are chronically infected, scar tissue walls off the pockets of bacteria. Although the body does this as a protective mechanism, the scar tissue also prevents the buildup of adequate tissue levels of antibiotics. This is why with chronic tonsillitis, antibiotics can cause the infection to subside but not resolve.
The second indication for surgery is where the tonsils are markedly enlarged. While they may not be clinically infected, tonsils may be so large that they partially obstruct the airway during sleep, causing snoring and even sleep apnea. In some cases, the tonsils actually touch each other in the middle, so-called “kissing tonsils.” Even when they don’t touch, tonsils can obstruct during sleep. How? When you are asleep, the muscles of the pharynx relax—and with each breath, the tonsils are drawn together and into the airway.
Both of these conditions can cause problems that are specific for the singer. Chronic tonsillitis that occurs repeatedly with stress results in canceled auditions and performances, frequent visits to the doctor, and repeated courses of antibiotics. Even emotional stress can trigger infections—and whose life is free of stress?
Enlarged tonsils in singers have a direct mechanical impact on the voice. The singer may have difficulty achieving full vocal resonance and, in some cases, the voice always sounds somewhat covered. With truly massive tonsils, even the speaking voice has a “hot potato” quality. The mass of the tonsils can interfere with easy elevation of the palate during singing. Sleep apnea due to enlarged tonsils impairs rest, oxygenation, and the general quality of life.
If removal of the tonsils is medically indicated, it of course needs to be done properly. The singer’s main concern, postoperative scarring that might somehow tether the palate and impair its free movement, can be avoided with proper surgical technique. And this, in fact, is rarely a problem. The second concern, laryngeal intubation, can also be performed atraumatically, with no damage to the voice.
The important take-away is that when medically indicated and properly done, tonsillectomy usually has a positive effect—not just for the patient, but also for the voice. Patients have told me that following surgery they feel they have more room in the back of the throat. They feel that it is easier to bring the voice forward in the mouth and that the voice has a brighter, less covered quality. Some patients even feel that it easier to lift the palate, as it is no longer weighed down by the tonsils.
And, as is often the case, the “news” is not new. Here is what the eminent English laryngologist Norman Punt wrote on the subject over 25 years ago: “The recurrent argument about tonsils and adenoids has quieted down for the time being. There is really little to say. If they give trouble, take them out. The voice will not be adversely affected and if they are large, resonance and articulation will improve” (Punt, N.A. “Laryngology applied to singers and actors,” in Journal of Laryngology and Otology, Suppl. No. 6, 1983).
It is not my purpose to suggest here that tonsils be removed solely to improve your singing. Any surgery (except for cosmetic procedures) should be recommended only for appropriate medical reasons and only after weighing the alternatives of no treatment or other forms of treatment. I do, however, want to emphasize that removal of the tonsils can be done safely, even for singers, with improvement in the quality of your life and no negative impact on your voice.