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Tonsils 101 : a crash course

Updated: May 6, 2022

TGIF dear friends, and welcome back to TGIF DR EUAN's blog post!

This week we are looking at a common problem that affects many of us / our children, at some stage of our lives: Tonsillitis or Tonsil Infections.

Q: What are Tonsils?

Tonsils are small roundish / ovoid-shaped organs at the back of the throat. You can usually see them if you look in the mirror with a torchlight. There are usually symmetrical Left & Right tonsils. If we see asymmetrical or a unilaterally enlarged tonsil, then we get a little concerned that there may be an abnormal growth or tumour in that one tonsil.

As part of the lymphatic system, the tonsils play an important role in health as they act as the first line of defence for the body. As infants & young children, such lymphoid tissue helps to recognise and process antigens on viruses and bacteria, prompting our immune systems to mount a defensive response.

The palatine tonsils form a part of the Waldeyer's Ring of lymphoid tissue: the Adenoids (which we discussed last blog post), the pharyngeal or palatine tonsils (which are what we see in the mirror at the back of our mouths) and the lingual tonsils (on the back of the tongue, just beyond our line of sight). Waldeyer's ring is a circle of immune / lymphoid tissue to process antigens presented by viruses and bacteria which enter our nose and mouth, thereby training our immune system to recognise such invaders and repel them.

Q: What is Tonsillitis?

Tonsillitis is inflammation of the tonsils, two oval-shaped pads of tissue at the back of the throat — one tonsil on each side. Signs and symptoms of tonsillitis include red, swollen tonsils, sore throat, difficulty swallowing and tender enlarged lymph nodes on the sides of the neck. This is usually in response to an infection posed by a virus or bacteria as it is inhaled or ingested.

Sometimes, patients see me as they have noticed that when they brush their teeth and look inside their mouths, they can see large gold ball sized tonsils, or even Tonsilloliths or tonsil stones (which are often calcified food particles that can be embedded in the pits of the tonsils on its surface. I do have some patients who like to brush their tonsils to clean their pitted surface of such food debris; however, most of us would probably start to gag when we touch our tonsils!

Tonsillitis is generally the result of an infection, which may be viral or bacterial. Viral aetiologies are the most common. The most common viral causes are usually those that cause the common cold, including rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. These typically have low virulence and rarely lead to complications. Other viral causes such as Epstein-Barr (causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause tonsillitis.

Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS), but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been cultured. Bacterial tonsillitis can result from both aerobic and anaerobic pathogens. In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria should even merit consideration as an aetiology. In sexually active patients, HIV, syphilis, gonorrhoea, and chlamydia are possible as additional causes. Tuberculosis has also been implicated in recurrent tonsillitis, and clinicians should assess patients' risks, especially in immunocompromised patients.

Sometimes it is very important to know if it's a viral and bacterial infection, and which type of bacteria as some may be very lethal and even life-threatening in patients with immature or weakened immune systems.

This illustration shows a cluster of Streptococcus species, often implicated in bacterial infections of the tonsils

Q: What are the common symptoms?

Tonsillitis most commonly affects children between pre-school ages and the mid-teenage years. Common signs and symptoms of tonsillitis include:

  • Red, swollen tonsils

  • White or yellow coating or even patches (called exudates) on the tonsils

  • Sore throat

  • Difficulty or painful swallowing

  • Fever (above 38 deg C)

  • Enlarged, tender glands (lymph nodes) in the neck

  • A scratchy, muffled or throaty voice

  • Bad breath

  • Stomach ache

  • Neck pain or stiff neck

  • Headaches

In young children who are perhaps too young to articulate how they feel, we can observe signs of tonsillitis such as:

  • Drooling due to difficult or painful swallowing

  • Refusal to eat

  • Unusual fussiness

Q: When should I seek immediate medical help for me/my child's tonsillitis? What are some "danger" signs to look out for?

The most important consideration is to obtain an accurate diagnosis if you / your child has symptoms that may indicate tonsillitis.

Do call your doctor if your child is experiencing:

  • A sore throat with fever

  • A sore throat that does not go away within 24 to 48 hours

  • Painful or difficulty swallowing

  • Extreme weakness, fatigue or fussiness

Do get immediate care if your child has any of these signs:

  • Difficulty breathing

  • Extreme difficulty swallowing

  • Excessive drooling of saliva

Q: What is the treatment for Tonsillitis?

1. Symptomatic Relief:

Most often, with viral infections, your GP will prescribe medications to alleviate fever/pain/headache/sore throat. This may include common medicines eg Paracetamol (Panadol), Difflam or Thymol gargle. Some older patients prefer to gargle with warm salt water which is alright.

Remember to take adequate rest, or request for a Medical Certificate (MC) to recover before you return to work.

Also, remember to hydrate well, and drink lots of water.

If the fever spikes, a cold compress or sponge bath may help to bring the fever down.

2. Anti-biotic Treatment

If your GP suspects a bacterial infection, he/she may take a throat swab to confirm this, or start empirical treatment with an antibiotic such as Augmentin (Amoxycillin / Clavulanic Acid) or Penicillin V; if you are allergic to Penicillins, then Erythromycin or Clarithromycin may be used instead.

Nowadays, we recognise the overuse of antibiotics for the treatment of common Upper Respiratory Infections. (URI) as this may lead to antibiotic resistance and encourage the rise of SuperBugs aka bacteria which are very resistant to treatment. Therefore, only take antibiotics if your GP thinks it is indicated.

3. Surgical removal of the Tonsils, also known as a Tonsillectomy.

In cases where the patient suffers from:

  • Recurrent Acute Tonsillitis (say 5 to 6 episodes per year)

  • Chronic Tonsillitis (persistent symptoms for > 3 months)

  • Quinsy (peri-tonsillar abscess)

In this case, your GP may refer you to see an ENT Specialist for an assessment and to perhaps consider an operation to remove the tonsils permanently.

In my own practice, I often base the necessity of surgery on how badly the repeated bouts of throat infection affect the patient's life. For example, a student missing school, or a worker taking repeated MC off work. Together, we then make a joint decision on whether to proceed with a Tonsillectomy.

A tonsillectomy is performed under General Anaesthesia (GA) and both tonsils are removed, leaving a tonsillar bed which then heals over in about 1 to 2 weeks. Nowadays, most ENT surgeons perform the operation as a Day Surgery case, unless the patient has medical issues which may warrant an overnight stay, e.g. Severe Obstructive Sleep Apnoea (OSA) etc. These may require post-operative observation for a longer period.

Well, folks, I hope this blog post has given you a better insight into your tonsils: what they are, what they do, and what to do when they get infected. If in doubt, do consult your ENT Specialist for a consultation.

Have a restful weekend as we gear up for the Lunar New Year and welcome the Year of the Tiger 🐅 on 01 February 2022! And as they say colloquially: HUAT AH! 🧧🧧🧧🧧

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