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Tonsillitis and Tonsillectomy

1. What are the tonsils?

There actually are several types of tonsils. The tonsils that are usually responsible for tonsillitis and therefore removed in a tonsillectomy are called the palatine tonsils. These tonsils are collections of lymph tissue on the right and left side of the lateral upper throat (also called the oropharynx). A second set of tonsils, known as the lingual tonsils, are located at the base of the tongue. And a third set of tonsillar tissue, known as the pharyngeal tonsils or, more commonly, the adenoids, are located along the back wall of the uppermost part of the throat (in a region called the nasopharynx).

2. What do the tonsils do?

The exact role played by tonsils in the body's immune system is still an active area of research. It is felt that the tonsils play a role in fighting disease during early life. Studies have shown that the tonsils contains disease-killing cells called natural killer cells. Moreover, the tonsillar tissue can express surface immunoglobulins known as IgA, and white blood cells within the tonsils can also differentiate into antibody secreting cells.

3. What is tonsillitis and pharyngitis?

Tonsillitis is the term for an infection of the tonsils. Pharyngitis is an infection of the surrounding throat (called the pharynx). These two infections often occur at the same time. Symptoms of tonsillitis are fever, chills, sore throat and pain on swallowing.

4. What causes tonsillitis?

Acute tonsillitis can be caused by both viruses and bacteria. Generally, younger preschool children tend to get viral tonsillitis, and older children and adults get bacterial infections. Also, viral infections can lead to later infection by bacteria. Many of the viruses that commonly infect the upper respiratory tract (influenza, parainfluenza, rhinovirus) are also responsible for viral tonsillitis. The most common bacterial infections are beta-hemolytic streptococci, staphylococci, pneumococci and Hemophilus.

In the past, more serious bacterial infections also caused tonsillitis. These include diphtheria and scarlet fever. Immunizations and improved antibiotics have reduced the role of these bacteria. The tonsils can also become enlarged in infectious mononucleosis ("mono").

5. How is tonsillitis treated?

Tonsillitis is treated by a combination of supportive measures to relieve the symptoms and medicine against the organisms causing the infection. Supportive measures include increased fluid intake, anti-inflammatory medications and gentle salt water gargles.

Antibiotics are effective against bacterial infections. Penicillin is still effective against many of the infectious organisms, though some bacteria have developed resistance to this medicine and stronger antibiotics must be used.

Viral infections are not affected by antibiotics, and unnecessary use of antibiotics can actually make the situation worse. These infections are best treated by supportive measures alone.

Very severe infections require hospitalization. Inability to swallow can lead to dehydration that is best treated with intravenous fluid. Antibiotics are also more effective when given intravenously.

6. What can happen if tonsillitis is not effectively treated?

Tonsillitis can lead to a very severe condition called a peritonsillar abscess. An abscess is a collection of pus caused by tissue death and breakdown of the white blood cells fighting the infection. The swelling from an abscess can be so great that it blocks the airway and interferes with breathing. The infection can also spread out of the tonsil and into the neck and chest, which can be rapidly fatal.

For these reasons it is important that tonsillitis be treated under the guidance of a health care professional.

7. What causes repeated tonsillar infections?

A persistent tonsillar infections can lead to enlargement of tonsils and a condition known as chronic tonsillitis. Despite antibiotic treatment, the tonsils can remain infected. The tonsils can also trap food particles in small infoldings called crypts, producing small white stone-like particles called tonsilliths. These can produce inflammation and prolong the infection.

8. What is a tonsillectomy, and when should it be done?

Tonsillectomy is the surgical procedure for removal of the tonsils. As a treatment for chronic tonsillitis, tonsillectomy is done when medicine, supportive measures, and other non-surgical treatments are no longer effective. Each individual is different and it is not possible to give an exact number of infections needed before tonsillectomy should be considered. However, general guidelines based on past research have shown that individuals with 6-7 infections in one year or 2-3 infections per year for more than a few years would probably benefit from tonsillectomy.

In some cases tonsillectomy is a necessary operation and sometimes must be done on a near-emergency basis. This occurs if the tonsils are so large that they block breathing. Enlarged tonsils can also cause obstructive sleep apnea and are removed in those cases. Patients who are carriers of diphtheria (rare in these days) should undergo tonsillectomy. Tonsillectomy is also recommended in individuals with just one enlarged tonsil in order to biopsy the tissue.

A peritonsillar abscess must be drained in some way. Relatively small or contained abscesses can be drained by aspirating the pus with a needle, using a local anesthetic. More severe infections require a general anesthetic and drainage in the operating room.

9. How is a tonsillectomy done?

A tonsillectomy is a surgical procedure done under a general anesthetic. The tonsil is surrounded by a capsule of tissue. The surgeon uses special instruments to remove the tonsil by dissecting between this capsule and the adjacent throat tissue. Different surgeons have different techniques, but the most commonly-used methods are with electrocautery or with a cutting instrument (e.g. scalpel, scissors, etc.) For otherwise healthy individuals, tonsillectomy can in most cases the be done on an out-patient basis. The site where the tonsils were taken out heals on its own over a period of 7-10 days. Research has shown that removal of the tonsils does not hinder the bodies immune system.

10. What are the risks of tonsillectomy?

Tonsillectomy is done using a general anesthetic, and there always is a small risk of complications from the anesthesia. The major complication associated with the tonsillectomy itself is bleeding at the site where the tonsils were removed. This can occur right after the operation or up to seven to ten days afterwards when the scar covering the operative site falls off. Roughly 1-2% of patients who have tonsillectomy will have bleeding severe enough to require a trip to the emergency room. About one-half of these people will need to go back to the operating room to control the bleeding, and the other half will stop bleeding on their own. As with any surgical procedure, there are rare risks of other complications.

Post-operatatively, a tonsillectomy results in a very sore throat. The physician will prescribe pain medications and antibiotics to help relieve these symptoms. Some individuals cannot swallow enough fluids after the operation to prevent dehydration and must return to the hospital for intravenous fluids. The pain medications are also powerful and must be taken with care.

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