My daughter, 32, has very large tonsils for her age, and has a lot of sinus problems. Her ENT is hesitant to do a tonsillectomy because of her age. I worry about later health risks since one tonsil has always been quite larger than other. One ENT said if you don't want to worry about lymphoma, have them out, but it won't be easy. Does the new laser tonsillectomy make things easier for adults?

M.

Americans have this bizarre fascination with the laser. Just because it uses an exquisitely expensive bit of high-tech gear, the procedure must be intrinsically better -- right? In the present example (tonsillectomy), the answer is "wrong." Lasers have their place. They are useful for a number of skin conditions, and they are also useful for some laryngeal conditions. They are not particularly helpful for tonsillectomy.
There are two forms of laser tonsillectomy (to my knowledge). In the usual form, the laser is used as a "hot knife" to excise the tonsil. This would provide a specimen (the excised tonsils), which could then be analyzed by a pathologist. By cutting the tonsils into small pieces and examining these pieces under a microscope, a pathologist could answer the "lymphoma question."

In the second form of tonsillectomy, the laser is used to burn the surface of the tonsils. This procedure is not a true tonsillectomy. (The tonsils are not removed.) The "lymphoma question" would not be answered. This procedure is supposedly less painful than the usual tonsillectomy. Obviously, since the tonsils are not completely removed, one risk of this procedure is that the tonsils could enlarge again and continue to cause problems.

Let's get back to your initial premise (unstated), that she needs to have her tonsils removed. Why? Size alone is a poor reason to justify the pain and risk of tonsillectomy at any age. In an adult, tonsils are removed for the following reasons:

1. Recurrent acute tonsillitis.
   
2. Chronic tonsillitis (tonsils that are always inflamed and painful).
   
3. Obstructive sleep apnea.
   
4. Asymmetry, which raises the possibility of tonsil cancer or tonsil lymphoma.
   

The fourth reason would seem to apply to your daughter, except for the fact that "one tonsil has always been quite larger than the other." How long is always? Tonsil cancer and lymphoma are not indolent diseases. You don't just stew in your juices for years with these conditions; untreated, they are rapidly fatal (within months). If your daughter has had asymmetric tonsils for many years, tonsil cancer and lymphoma are unlikely diagnoses.

Does tonsil asymmetry predispose her toward developing one of these malignancies? This, too, is very unlikely. (We docs are trained in the philosophy, "Never say never." Indeed, I can imagine rare circumstances -- emphasis on "rare" -- in which this asymmetry has some ominous implications for the long term.)

Tonsillectomy is a painful operation for adults, and the risks are not negligible. Thus, her tonsils should not be removed unless her ear, nose and throat doctor can justify the pain and risk of this operation.