Tonsil disease

What are the tonsils and adenoids, and what do they normally do?

The tonsils and adenoids are masses of lymphoid tissue, that are similar to the lymph nodes or "glands" found in the neck, groin and armpits.

The tonsils are the two masses on the side walls of the back of the throat seen, when you look into the back of the throat. The adenoids are lymphoid tissue high in the throat at the back of the nose and above the roof of the mouth (soft palate).  They are not visible through the mouth without special instruments.

Tonsil DiseaseThe tonsils and adenoids are near the entrance to the breathing and eating passages, where they can catch incoming germs, that cause infections. They "sample" bacteria and viruses and can become infected themselves. Scientists believe they work as part of the body's immune system by filtering germs that attempt to invade the body, and that they help to develop antibodies to germs. This happens primarily during the first few years of life, becoming less important as we get older. Children who have their tonsils and adenoids removed suffer no overall loss in their immune resistance.

On the right is a photograph of a patient with tonsillitis. The tonsils are swollen and there are areas of white exudate on the tonsils. The tonsils have pits in them called crypts, which fill with debris. The openings to these crypts often appear white when infection is present.

What affects tonsils and adenoids?

The most common problem affecting the tonsils and adenoids are recurrent infections (throat or ear) and/or significant enlargement or obstruction that causes breathing and swallowing problems. "Tonsillitis" means inflammation of the tonsils. This may due to a bacteria, or germs, which in some instances respond to treatment with antibiotics. Often infections are due to viruses and do not respond to antibiotics.

The tonsils may become repeatedly infected in some people especially children and young adults. Chronic tonsillitis occurs when there is so much damage to the tonsils that they remain infected, and do not respond well to antibiotic treatment.

What are the symptoms of tonsillitis?

Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs and symptoms are:

  • redder than normal tonsils
  • a white or yellow coat on the tonsils
  • a slight voice change due to swelling
  • sore throat
  • uncomfortable or painful swallowing
  • swollen lymph nodes (glands) in the neck
  • fever
  • bad breath

Chronic or long-term infection can sometimes lead to significant enlargement of the tonsils and adenoids. This may cause difficulty breathing, with snoring and restlessness at night. At times there may be large pauses between breaths (sleep apnoea.). Sleep apnoea may result in poor growth and development and excessive tiredness during the day. Severe cases may result in heart strain.

Enlarged adenoids and their symptoms

If you or your child's adenoids are enlarged, it may help be hard to breathe through the nose. Other signs of constant enlargement are:

  • breathing through the mouth, instead of the nose most of the time

  • nose sounding blocked when the person speaks
  • noisy breathing during the day
  • recurrent ear infections
  • snoring at night
  • breathing stops for a few seconds at night during snoring or loud breathing (sleep apnoea)

Chronic adenoid enlargement may lead to changes in the growth of the upper jaw and changes in tooth position. There is some evidence in older children (over age four), that chronically infected adenoids may sometimes contribute to the development of glue ear and recurrent ear infections.

What are the main treatment options for tonsillitis?

It is important to remember the most common infections of the throat are viral "colds". They do not benefit from antibiotics. Symptomatic relief is most beneficial. Drink plenty of fluids.

The most frequent treatment recommended for bacterial tonsillitis is oral antibiotics (commonly a penicillin type such as amoxycillin) in association with pain relief and bed rest. These are usually given for 7-10 days.

For recurrent tonsillitis, or enlarged tonsils and/or adenoids, adeno-tonsillectomy or tonsillectomy can be very beneficial. When there is airway obstruction, severe snoring or sleep apnoea as a result of enlargement of the adenoids and/or tonsils, they should be removed. There are no absolute criteria to determine when adenotonsillectomy is necessary for recurrent or chronic tonsillitis. The minimum criteria recommended by the American Medical Association and the American Academy of Paediatrics are the occurrence of four episodes of tonsillitis in the preceding year. Important considerations are the severity of each infection, the speed of response to oral antibiotics (or if there are side effects of antibiotics such as allergy, thrush or diarrhea), and the amount of time needed off work or school because of infections.

Your child and tonsillectomy

Talk to your child about his/her feelings and provide strong reassurance and support throughout the process. Encourage the idea that the procedure will make him/her healthier. Be with your child as much as possible before and after the surgery. Tell him/ her to expect a sore throat after the surgery and possible sore ears. Reassure your child that the operation does not remove any important parts of the body, and that he/ she will not look any different afterward. If your child has a friend who has had this surgery, it may be useful to talk about it with that friend.

What's involved in tonsillectomy or adenotonsillectomy?

This is a half-hour to 45 minute operation performed in hospital. The operation is performed through the mouth. There are no cuts necessary on the neck, and there are usually no stitches in the throat. There is a small raw patch (like a graze) on each side of the throat afterwards, which takes 2-3 weeks to heal fully. The raw patch forms a scab, which becomes white because of the moisture in the mouth.

While healing takes place, the throat is very sore for ten days, and regular pain relief is important to ensure a smooth recovery. Removal of the adenoids alone is not usually uncomfortable.

Regular pain relief, including paracetamol and an anti inflammatory, such as ibuprofen ("Brufen") or diclofenac ("Voltaren") is prescribed for ten days, to make the post operative course as comfortable as possible. A supply of lemonade ice-blocks in the freezer provides soothing relief.

One to two weeks off work or school is usually necessary for full recovery.

Are there any risks with tonsillectomy?

It is very common for pain to be worse on Day 5 after the surgery. There is no easy answer as to why this is. None of my interventions over the years seems to have made any difference.

In my hands less than 1% of patients bleed in the first 4-6 hours after surgery. Approximately 2% of my patients will have bleeding from the raw tonsil bed 10-14 days after the surgery. This is usually minor as a result of the scab coming off, and usually stops by itself, but may look dramatic and very concerning. If the bleeding continues for more than 10 minutes you need to be assessed and readmission to hospital and possible cautery (heat sealing) to seal off any abnormal bleeding points may be necessary.

It is important to tell me if you have a history of bleeding troubles, or if there is a family history of bleeding disorder (e.g. von Willebrand's disease). Aspirin containing products where possible should be avoided for two weeks before and after tonsillectomy, as this may aggravate bleeding.

Because many people with recurrent tonsillitis are "run down," they actually report an improvement in their general wellbeing and immunity. Many parents report a dramatic improvement in the health of their children after adeno-tonsillectomy. The level of satisfaction with the surgery one year afterwards is extremely high.

The risks of general anaesthesia are very low for most otherwise healthy people.

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