Removing tonsils is one of the commonest surgical operations in children suffering recurrent tonsillitis. With each infection the tonsils become larger, which can lead to feeding and breathing difficulties. Children may become run down and lose weight if the tonsils are not removed.
It is usual to remove the adenoids at the same time as the tonsils. Adenoids are tonsil-like tissue behind the back of the nose above the soft palate. Although they cannot be seen as readily, they enlarge when tonsils do. By blocking the back of the nose, they cause snoring and sleep disturbance.
Repeated ear infections can also result from enlarged adenoids. This in turn can lead to the build-up of a glue-like material behind the ear drum, causing deafness. Some glue ear cases need a draining tube, called a grommet, inserted into the eardrum.
Removing children's tonsils and adenoids usually involves an overnight stay in hospital.
The Republic:
Rachel, an eight-year-old from Co Waterford, was referred, as a non-urgent case with enlarged tonsils, to a public ear, nose and throat (ENT) outpatients' department. Eighteen months later nothing had been heard from the ENT department and Rachel's parents were concerned about progressive hearing loss. She was also mouth-breathing, a sign that the adenoids were so enlarged that she was unable to breathe through her nose.
Rachel's GP re-referred her as an urgent case on March 16th, 1997. She was seen in outpatients on April 25th when her hearing loss was documented and she was also noted to have a build-up of fluid behind both ear drums.
Rachel was admitted to hospital for surgery on July 22nd, when her tonsils and adenoids were removed and grommet tubes inserted in both ears. She has made a good recovery and, in particular, had no residual deafness on follow-up.
As a contrast, Rachel's GP referred a 15-year-old boy for tonsillectomy on December 15th last. He was seen privately on January 9th and is to have surgery this month using private medical insurance, two months after the referral decision was made.
The cost of tonsillectomy and adenoidectomy in the public sector in the Republic, including hospital and doctors' fees, is £1,222 [Department of Health figure].
Northern Ireland:
James is a four-year-old in Belfast. In November 1999 he had grommets inserted by an ENT surgeon because of persistent ear pain and recurrent infection. James was referred for this procedure on July 1st, 1999, and was seen in outpatients two months later on September 8th. Surgery took place 41/2 months after this referral, on November 18th. His GP monitored him closely post-operatively to ensure his hearing returned to normal.
However, two audiograms in January and March 2000 showed continuing problems. James also had several tonsil infections during this time and so he was re-referred on June 14th with a view to having both tonsils and adenoids removed.
He was seen in ENT outpatients on July 31st and was listed for surgery. His tonsils and adenoids were eventually removed on November 21st. James stayed in hospital overnight with his mother. He missed seven school days after each surgical procedure.
Comparison: Both procedures carried out on James in Belfast took five months from the date of referral. In the Republic Rachel waited four months following an urgent referral, although if you include the first "mislaid" referral then the overall waiting time was 22 months.
A comparison between public and private healthcare in the Republic shows a private waiting time of two months; half of the time required for an "urgent" public patient to be seen.
There is considerable morbidity associated with a prolonged wait for tonsillar surgery. Ear problems develop, as illustrated by Rachel's case history. This can affect learning at school. Recurrent infections are more difficult to treat and the child becomes run down.
Significantly, the Northern practice is non-fundholding, so the referral system is a fixed one as it is in the Republic, without the facility to "shop around" different hospitals.
Neither the public system in the Republic nor the NHS in the North dealt with ENT problems as promptly as they might have.
Next week: The wait for those with chronic obstructive airways disease