Situated on the side walls of the mouth behind the tongue, the palatine tonsils are a familiar subject for many people. Though they act as an immune barrier in much the same way as the adenoids1, the fact that the tonsillectomy is traditionally associated with free ice-cream seems to get most people's attention. However, there is more to the tonsils than their being surgically removed, and so this Entry takes a quick look at a range of disease of the tonsils.
Inflammation of the tonsils, or tonsillitis, may seem quite a simple disease. However, its appearance can be similar to that of an ordinary sore throat, and its rarer complications can be very serious indeed. Tonsillitis is usually caused by a viral infection or the bacteria Streptococcus pyogenes. Rarer causes of tonsillitis include the Epstein-Barr virus (see Glandular Fever below), diphtheria, and more unusual infections in those with compromised immune systems.
Run-of-the-mill tonsillitis usually consists of a fever, a painfully sore throat, difficulty swallowing and a general malaise. Headaches and earaches also occur, and, as with other viral infections, infants are at risk of febrile convulsions if they are allowed to become overheated. A look in the mouth reveals bad breath along with enlarged, reddened tonsils which may or may not be covered with pus, and a similar swelling of the lymph glands in the neck can be felt.
Treatment of acute tonsillitis consists of simple measures such as rehydration along with paracetamol to bring down the fever, with or without antibiotics depending on the likely cause. Antibiotics are used judiciously as they will not help with viral tonsillitis, and amoxicillin can precipitate a rash in those with glandular fever. In severe cases, such as where the patient is unable to swallow, admission to hospital and intravenous antibiotics and fluids are required. Complications include quinsy and other abscesses (see below), middle ear infections, and post-infective immune diseases such as rheumatic fever and post-streptococcal glomerulonephritis2, though the latter are now less common due to the use of antibiotics in appropriate cases.
Also known as infectious mononucleosis and 'kissing disease', glandular fever is caused by infection with the Epstein-Barr virus. While many individuals catch the disease as a child without developing any symptoms, those who are over the age of ten when first exposed to it may develop severe tonsillitis and swelling of other lymph glands such as those in the neck, armpits and groin. The spleen may also be affected, and the disease is associated with a fever, headache, muscle aches and tiredness.
Glandular fever has a much longer time span than ordinary tonsillitis, with the initial symptoms appearing around 40 days after infection and the disease itself taking a few weeks to clear. Once the symptoms have developed, the disease can be diagnosed with a throat swab or blood test. There is no specific treatment for the disease other than paracetamol, ibuprofen or steroids, all of which are used to treat the symptoms. Complications of glandular fever include rupture of the spleen, meningitis, anaemia, and Myalgic Encephalomyelitis (more commonly known as ME or 'chronic fatigue syndrome').
Quinsy and Other Abscesses
An abscess is a collection of pus that can occur when part of the body is infected. A quinsy is an abscess between the back of a tonsil and the adjacent throat wall, and can complicate an untreated bout of tonsillitis. The added infection causes the individual to become more ill, with the fever becoming higher and the difficulty of swallowing worsening. The sore throat produces pain in the ears, and worrying symptoms such as a change of voice and difficulty opening the mouth occur.
Abscesses can also occur in the wall behind the nose (retropharyngeal abscesses - see the Entry on Adenoids for more detail) and in the neck (parapharyngeal abscesses). In all cases, the treatment is intravenous antibiotics and surgical drainage of the offending abscess. This can be quite a simple operation using a local anaesthetic to numb the area and a syringe to withdraw the pus. Complications of quinsy include septicaemia3 and obstruction of the airways. Around 10% of abscesses return despite treatment, and in this case a tonsillectomy is usually required.
While acute tonsillitis is a very common disease, it's not quite enough of a reason to cut someone's tonsils out. This is where recurrent infections come in, as although individuals are healthy in between attacks, the symptoms can be so severe as to interfere greatly with education or work. If this is the case then, after five episodes have occurred in the same year, the SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend removal of the offending glands.
Tonsil stones, or 'tonsilloliths', can form in the deep crypts of the tonsils. The stones generally consist of calcium compounds and have a craggy white appearance. Though they can be painful, tonsil stones are generally harmless and some can be easily removed once they erupt out of the tonsil surface. Others may require surgical removal by a partial or complete tonsillectomy. As a tonsil stone may present as a single swollen tonsil, it is important to consider the possibility of cancer when diagnosing stones.
While a small degree of asymmetry of tonsils is quite normal in children, both tonsil cancer and lymphoma can rarely present as a gross enlargement of one tonsil. Tonsil cancer usually presents as a painful hardening and ulceration of the tonsil, whereas lymphoma presents as a painless enlargement without ulceration. Though rare, these diseases are serious and require urgent treatment, including a tonsillectomy.
As mentioned above, both recurrent tonsillitis and abscesses can be indications for the removal of the tonsils, as are obstructive sleep apnoea (OSA) and suspected cancer or lymphoma. Various methods such as cutting, freezing, diathermy (electric cutting) and laser surgery can be used to completely or partially remove the tonsils via the mouth. Partial removal of the tonsils, or tonsillotomy, has been shown to produce a reduction in post-operative pain, but does not reduce the risk of major complications and is used to treat OSA, as residual tonsils can still become infected and painful. Complete removal of the tonsils has not been proven to cause any medically-significant increase in nose and throat infections4.
The operation leaves the patient with a sore throat lasting for around ten days and may also cause ear pain. A couple of weeks off school or work doesn't go amiss. The complications of the operation include bleeding, which should be seen urgently by a doctor, and infection, which can best be avoided by staying away from communal areas, drinking lots of fluid and eating properly. That, by the way, means lots of toast5.