What Is Tonsillitis? What Are The Tonsils?

Tonsillitis is an infection of the tonsils. It is caused by either a virus or a bacteria (usually the bacterium known as streptococcus – the same bacterium that causes “strep throat”).

Tonsillitis mostly occurs in young children.

What Are Tonsils? What are Adenoids?

The tonsils are a pair of small almond-shaped organs located of the mouth on both sides of the throat. The adenoids are similar to the tonsils but are located in the upper portion of the throat behind the nose, where they can’t be seen.

• At one time many doctors believed that tonsils had no real purpose and often routinely removed them to avoid tonsillitis. Today, tonsils and adenoids are seen as perhaps the “first line of defense” against disease-causing germs that enter the body through the nose, mouth, or throat.
• Tonsils and adenoids protect against germs during early childhood by producing antibodies . By attacking bacteria and viruses, antibodies play an important role in the body’s immune system. The problem is that in the process of protecting the body, the tonsils and adenoids can become infected themselves.
• As children grow and develop, the tonsils and adenoids eventually begin to shrink and are probably no longer important in protecting against disease-causing germs. Even in young children, removal of infected tonsils or adenoids does not seem to weaken the body’s defenses. There are many other tissues in the body that are part of the immune system. These tissues, known as lymphoid tissues, also make antibodies to fight against infection.

What Does Tonsillitis Look Like?

When tonsils are infected, they will look redder than usual and swollen.

• A grayish-white or yellowish coating may cover part or all of the tonsils.
• The surrounding area of the throat near the tonsils also may appear red and inflamed. There may be swelling at the sides of the neck as the lymph nodes grow larger while producing cells to fight the infection.

What Are The Symptoms Of Tonsillitis?

The main symptom of tonsillitis is a sore throat. It may develop either suddenly or gradually. It may be either mild or severe.

Your child may:

• Find that it hurts to swallow. If the pain is intense, the child may stop swallowing saliva and start to drool.
• Complain of an earache
• Have a fever of 101 degrees Fahrenheit or higher.
• Complain of a headache.
• Complain of a stomachache (this is quite common).
• Complain of general aches and pains, loss of appetite and may vomit.
• Have bad smelling breath.

Because the tonsils are swollen and enlarged, the child may have trouble speaking and may even experience difficulty breathing.

Can tonsillitis cause complications? 

Tonsillitis can occasionally become serious. For example, infection may spread beyond the tonsil to form an abscess , which is a localized collection of pus.

• An abscess that forms around an inflamed tonsil is known as a peritonsillar abscess or quinsy. This almost always develops on one side only, and usually in adults rather than children.
• Another type of abscess, one that develops mainly in young children, is a retropharyngeal (behind the throat) abscess . This usually causes high fever and great difficulty in swallowing. If detected very early, peritonsillar or retropharyngeal abscesses can sometimes be treated successfully with antibiotics. In most cases, however, surgery is required to drain the abscess.

Other Possible Complications

• The most serious complication of tonsillitis is rheumatic fever, which often is accompanied by rheumatic heart disease. Rheumatic fever develops only if the tonsillitis is due to a type of bacterium known as group A beta hemolytic streptococcus. It also usually occurs only in children who have had repeated infections that have not been adequately treated with antibiotics.
• Another complication of streptococcal tonsillitis is a type of kidney disease known as acute glomerulonephritis. However, whether glomerulonephritis can be prevented by early antibiotic treatment of streptococcal tonsillitis is not clear.
• A common complication of tonsillitis is infection of the lymph nodes in the neck, known as cervical adenitis. This type of infection can usually be successfully treated with antibiotics. Occasionally the infection progresses, an abscess forms, and surgery is required to drain it.
• Other possible complications of tonsillitis include middle-ear infections (otitis media) and sinus infections. More often, however, these infections develop at the same time as, or independently of, tonsillitis.

Is Tonsillitis Ever Serious?

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What are the symptoms of tonsillitis?

How Is Tonsillitis Treated?

Treatment of tonsillitis aims to relieve its symptoms. Surgery is very rarely required.

• It is not always necessary to identify the exact cause of tonsillitis before beginning treatment, but it generally is advisable to at least determine whether the infection is due to streptococcal bacteria, so that appropriate treatment can be started. A “rapid strep” test is now available. If the test is positive, it is almost certain that your child’s tonsillitis is caused by streptococcus bacteria. If the test is negative, a traditional laboratory culture will be needed.
• Tonsillitis caused by streptococcus bacteria must be treated with penicillin or other suitable antibiotics in order to prevent the development of rheumatic fever. Penicillin is the best drug to use, unless your child has an allergy to it. It should be given by mouth for at least 10 days. Taking penicillin for shorter time periods may not completely clear up the infection.

Alternatively, a single intramuscular injection of long-acting penicillin can be given, but this is relatively painful. For children who are allergic to penicillin, other suitable antibiotics are available.

• Tonsillitis due to viruses, like other infections due to viruses, does not respond to any currently known antibiotics.
• Acetaminophen or ibuprofen may relieve sore throat and other symptoms of tonsillitis. Aspirin is best avoided in children of any age because of the risk of Reye’s syndrome.
• Tonsillitis may sometimes be due to other types of bacteria that also may respond to antibiotic treatment. Judgments about such treatment should be left to your doctor.

Surgery for Tonsillitis. Tonsillectomy

A tonsillectomy is the surgical removal of the tonsils.

These are the criteria doctors use to decide whether the tonsils should be removed:

• Tonsillectomy is definitely required when the tonsils are so large they obstruct breathing, swallowing or both. Before surgery, however, antibiotics should be tried, perhaps for as long as a month, to see whether your child’s condition can be improved. Children with obstructing tonsils commonly sleep restlessly and may have periods during sleep when breathing stops for seconds at a time because of blockage of the airway. In some children, voice quality is so sufficiently altered by large tonsils (“hot potato” voice) that tonsillectomy is justified.
• Tonsillectomy also is justified if your child is having repeated bouts of infection, to the point that everyday activities are substantially disrupted despite adequate antibiotic treatment.
• Currently, tonsillectomy is believed to provide enough benefit to justify doing the surgery in children who have developed at least 7 “significant” episodes of throat infection in 1 year, or at least 5 in each of 2 years, or at least 3 in each of 3 years. “Significant” episodes are defined as those associated with one or more of the following:
  • Fever of 101 degrees F (38.3 degrees C) or higher.
  • Enlarged or tender lymph nodes in the neck.
  • A pus-like coating, known as exudate, covering the tonsils or the surrounding throat area.
  • Evidence that the infection is streptococcal in origin.
• Peritonsillar abscess, also called quinsy, is an abscess around the tonsil, usually following a tonsillitis attack. The infection causes a painful throat, high temperature, headache, impaired speech, drooling, and swollen tender lymph glands in the neck. Not all experts believe that surgery is called for following a single case of peritonsillar abscess. Often, no further difficulty develops once the condition is successfully treated. However, following a second peritonsillar abscess, tonsillectomy is definitely indicated.

Not every child who meets these minimum criteria should have a tonsillectomy. Many children will improve spontaneously without surgery sooner or later. The decision for or against surgery should take into account many factors including cost, convenience, and the preferences of the parents and the child.

Recent evidence indicates that children who are less severely affected by tonsillitis are usually not sufficiently helped by tonsillectomy to justify doing the surgery. Accordingly, it would seem prudent in most cases to limit tonsillectomy to children who meet the stringent criteria just specified.

PREPARING YOUR CHILD FOR SURGERY:

You should explain in advance to your child what is about to happen, in as much detail as possible, simply and reassuringly.

Children who are scheduled for a tonsillectomy should be warned that they will experience a sore throat and that swallowing will be painful after the operation, but that parents and medical personnel will do everything possible to minimize it.

• Many hospitals have coloring books and storybooks for children. These will help your child cope with the experience.
• It is important to not give your child anything to eat or drink-not even water- for at least 8 hours before surgery. If surgery will be done in the morning, this generally means no food or beverages starting at midnight the night before.

THE PROCEDURE (tonsil removal; tonsillectomy)

In children, removal of either the tonsils or the adenoids requires a general anesthetic. In adults the tonsils often may be removed under local anesthesia.

• The mouth is held open to expose the tonsils.
• The tonsils are grasped with clamps and pulled toward the middle of the mouth. The tonsils are removed by gentle dissection of the surrounding tissues.
• Bleeding is controlled either by pressure, sutures, clamps or ties, or with use of electrocautery, a procedure in which heat is applied to blood vessels to seal the ends that have been cut during surgery.
• If the adenoids are to be removed, this is done using a specially designed instrument that passes through the mouth and into the upper part of the throat behind the nose, where the adenoids lie.

How Long Is The Stay In Hospital

Increasingly, tonsil and adenoid surgery is being performed on an outpatient basis early in the day, with the patient leaving the hospital that evening. However, some surgeons prefer to have the patient remain in the hospital overnight, so they can deal with any immediate complications more promptly and effectively.

Possible Complications of Tonsillectomy

• As with any operation, there is always a small risk associated with general anesthesia.
• Bleeding from the operation site may occur immediately after surgery, or several days later when the crust that has formed at the operative site drops away. Bleeding usually can be readily controlled, but occasionally requires a return to the operating room for more intensive treatment. Rarely, blood transfusion may be required.
• The risk of bleeding can be minimized by avoiding surgery during and immediately following episodes of infection and by avoiding the use of aspirin to control pain following surgery, as aspirin can reduce the blood’s ability to clot.

What To Expect After Tonsil Removal (tonsillectomy)

What to expect after tonsil removal surgery:

Your child will likely experience moderate nasal congestion and drainage, a sore throat, and earaches for a few days after surgery. Allow about two weeks for full recovery. During this time, keep your child from engaging in strenuous physical activity.

• It is best for a parent to be at the bedside when the child wakes up from surgery.
• Be prepared for your child to experience substantial pain while swallowing for the first day or two. Swallowing may continue to be somewhat painful for 4 or 5 days.
• Use acetaminophen or ibuprofen to relieve pain. Aspirin should not be used. Ice packs applied to your child’s neck may also help.

• When your child’s appetite returns, encourage him or her to eat and drink. Many children find it more comfortable to swallow warm liquids than cold ones.

Activity

• Your child should rest for 2 or 3 days, and then resume normal activities gradually.
• Have your child avoid vigorous exercise for two weeks after surgery.
• Bathe or shower your child as usual.

Diet

• Following tonsillectomy, swallowing tends to be quite painful for the first day or two and somewhat painful for 4 or 5 days. Nonetheless, you should encourage your child to eat and drink as soon as any postoperative nausea has subsided. Many children find it more comfortable to swallow warm liquids than cold.

Back To School

Usually, children can return to school (and adults to work) about a week after surgery. However, if there have been any complications or if your child does not feel perfectly well, return to school should be delayed accordingly. Rest at home not only helps recovery from surgery but also helps to minimize contact with other children who may have contagious respiratory infections.

What About Adenoiditis?

The main symptoms of adenoiditis are nasal stuffiness and nasal discharge. In this respect, adenoiditis is not really distinguishable from the common cold. In children who develop a common cold, the adenoids become inflamed as part of the illness.

If nasal stuffiness and discharge persist for longer than about 10 days-especially if the discharge has a greenish, pus-like appearance-the illness may no longer be a common cold. Instead, it probably has progressed to adenoiditis and/or sinusitis.

How Is Adenoiditis Treated?

Treatment for adenoiditis shares both similarities and differences with treatment for tonsillitis.

• Because obtaining a culture from the adenoids is not as simple as obtaining a culture from the tonsils, doctors usually base their treatment on the nature of the clinical symptoms.
• Unless a respiratory infection is particularly severe, it is reasonable to first assume that it is caused by a virus and use of antibiotics is not indicated.
• Once your child has had symptoms for 10 days or so without signs of improvement, treatment with an antibiotic, usually for 10 days to 2 weeks, would be appropriate.

When Is Adenoid Surgery Justified?

Surgical removal of the adenoids is appropriate when the adenoids are so enlarged that your child consistently has difficulty breathing through the nose, and the condition is not substantially improved by antibiotic treatment.

Removal of the adenoids is also appropriate in children who have had persistent otitis media (infection or fluid in the middle-ear), even after having surgery to place tubes in the ears.

Tonsillitis and Tonsillectomy: Frequently Asked Questions

Here are some frequently asked questions related to tonsillitis and tonsillectomy:

Q: Years ago, children’s tonsils were removed often. Why is it different today?

A: At one time doctors believed that tonsils had no real purpose and routinely removed them to avoid tonsillitis. Today, tonsils and adenoids are seen as perhaps the “first line of defense” against disease-causing germs that enter the body through the nose, mouth, or throat.

Q: Shouldn’t a child with tonsillitis always be given penicillin?

A: It depends on the cause of the tonsillitis. If it is caused by bacteria, it should be treated with penicillin or another antibiotic in order to prevent complications. But if it is caused by a virus, it will not respond to any currently known antibiotics.

Q: Our child has recurring bouts with tonsillitis. At what point should we consider tonsillectomy?

A: Tonsillectomy is required when the tonsils are so large they obstruct breathing or swallowing or both. Children with obstructing tonsils commonly sleep restlessly and may have periods during sleep when breathing stops for seconds at a time because of blockage of the airway. In some children, large tonsils alter voice quality. Tonsillectomy also is justified if your child is having repeated bouts of infection, to the point that everyday activities are substantially disrupted despite adequate antibiotic treatment. See the section, “When Is Removal Of The Tonsils Justified” for important details.

Tonsillitis and Tonsillectomy: Putting It All Together

Here is a summary of the important facts and information related to tonsillitis and tonsillectomy:

• Tonsillitis is an infection of the tonsils that can be caused either by a virus or by bacteria.
• Sore throat, pain while swallowing, fever, and difficulty speaking are common symptoms of tonsillitis.
• Penicillin is the best antibiotic for treating tonsillitis, unless your child is allergic to it. This medication should be taken for at least 10 days.
• Most children do not require surgical removal of their tonsils. There are definite indications for removal.
• Children who have surgery to remove the tonsils are often able to come home the same day, but should rest for 2 to 3 days and avoid vigorous exercise for 2 weeks.

Tonsillitis and Tonsillectomy: Glossary

Here are definitions of medical terms related to tonsillitis and tonsillectomy:

Abscess: A collection of pus that requires surgical drainage.

Adenoidectomy: Surgical removal of the adenoids.

Adenoiditis: An infection of the adenoids.

Adenoids: Gland-like lymphoid tissue at the back of the throat behind the nose that may help protect against infection.

Antibodies: Proteins made in the body that fight infection and destroy harmful organisms (bacteria and viruses) or toxins.

Cleft Palate: A birth defect that consists of a fissure in the tissues of the roof of the mouth.

Lymphoid tissue: Part of the body’s immune system that helps protect it from germs.

Peritonsillar abscess: A collection of pus surrounding an infected tonsil. Can occur as a complication of tonsillitis.

Retropharyngeal abscess: A collection of pus at the back of the throat. Can occur as a complication of tonsillitis.

Reye’s Syndrome: A disorder associated with using aspirin that can affect children after a viral illness.

Rheumatic Fever: A disease that is caused by the body’s reaction to infection by a bacterium known as group A beta hemolytic streptococcus. The disease can cause inflammation of the joints and damage to the heart.

Streptococcus: A type of bacterium that may infect tonsils. Infection with this bacterium, if not treated with penicillin or other appropriate antibiotic, can lead to rheumatic fever.

Tonsillectomy: Surgical removal of the tonsils.

Tonsillitis: An infection of the tonsils.

Tonsils: Oval masses of lymphoid tissue at the back of the throat that may help protect children against infection.

Tonsillitis And Tonsillectomy: Additional Sources Of Information

Here are some reliable sources that can provide more information on tonsillitis and tonsillectomy:

The American Academy of Family Physicians 
http://familydoctor.org/

American Academy of Otolaryngology – Head and Neck Surgery 
Phone: (703) 836-4444
http://www.entnet.org

U.S. National Library of Medicine 
http://www.nlm.nih.gov/