Tonsillitis

What is tonsillitis? Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation may involve other areas of the back of the throat including the adenoids and the lingual tonsils (areas of tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by Streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient's history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

     • Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia
       (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth        breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These
       symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
     • Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
     • Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical
       nodes.
     • Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty
       opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or        her mouth).

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history.

A physical examination of a young patient with tonsillitis may find:

     • Fever and enlarged inflamed tonsils covered by pus.
     • Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis associated with the presence of
       palatal petechiae (minute hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be        enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children aged        5-15 years.
     • Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with        acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
     • Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
     • Signs of dehydration (found by examination of skin and mucosa).
     • The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis,
       particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise and low-grade fever
       accompany acute tonsillitis.
     • A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed
       without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
     • Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV)
       tonsillitis.
     • Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw may be        present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.

Tonsils and Adenoids

Insight into tonsillectomy and adenoidectomy

     • What affects tonsils and adenoids?
     • When should I see a doctor?
     • Common symptoms of tonsillitis and enlarged adenoids
     • and more...

Tonsils and adenoids are on the body’s first line of defense—our immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose at the risk of their own infection. But at times, they become more of a liability than an asset and may even trigger airway obstruction or repeated bacterial infections. Your ear, nose, and throat specialist can suggest the best treatment options.

What are tonsils and adenoids?

Two masses of tissue that are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two masses on the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth without special instruments.

What affects tonsils and adenoids?

The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.

When should I see a doctor?

You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she will use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

     • Medical history
     • Physical examination
     • Throat cultures/Strep tests - helpful in determining infections in the throat
     • X-rays - helpful in determining the size and shape of the adenoids
     • Blood tests - helpful in determing infections such as mononucleosis

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children.
Chronic infection can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and potential hearing loss. Recent studies indicate adenoidectomy may be a beneficial treatment for some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., cortisone) is sometimes helpful.

How to prepare for surgery

Children

     • Talk to your child about his/her feelings and provide strong reassurance and support
     • 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 surgery.
     • 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 helpful to talk about it with that friend.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome).

     • If the patient or patient’s family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.
     • A blood test and possibly a urine test may be required prior to surgery.
     • Generally, after midnight prior to the operation, nothing may be taken by mouth (including chewing gum, mouthwashes, throat lozenges, toothpaste, water.) Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.

When the patient arrives at the hospital or surgery center, the anesthesiologist or nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient until discharged. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer any questions you may have.

After surgery

There are several postoperative symptoms that may arise. These include, but are not limited to, swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Any questions or concerns you have should be discussed openly with your surgeon.

Tonsillitis and its symptoms

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

     • Redder than normal tonsils
     • A white or yellow coating 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

Enlarged adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may 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 sounds “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 apnea)

Treatment for tonsillitis:

Specific treatment will be determined by the physician(s) based on:

     • patient's age, overall health, and medical history
     • extent of the disease
     • expectations for the course of the disease
     • patient's tolerance for specific medications, procedures, or therapies
     • patient's (or family's) opinion or preference
     • the cause of the infection

Tonsillitis caused by a viral infection is treated differently than tonsillitis caused by a bacterial infection. Generally, tonsillitis caused by a bacterial strep infection can be successfully treated with an antibiotic medication. Viral tonsillitis is not treated with antibiotic medications, as antibiotics are ineffective at defeating viral infections, but may be treated with other antiviral medications.