Occasionally people present with tonsils that are different in size to me. This is an important scenario. Assymetric tonsils may be associated with a number of conditions but most patients, unless significantly unwell will come to a surgical removal.
The reason for this is because there is a risk of one of the tonsils being associated with a malignant pathology. However, some people end up with assymetric tonsils after recurrent infections (tonsillitis). Occasionally tumours from outside the tonsil push the tonsil into the oropharynx making it look assymetrical.
One of the indications for a tonsillectomy is clearly an assymetric tonsil for a histological diagnosis and this should be carried out fairly quickly to get the diagnosis.
Snoring in children is not an infrequent occurence. However if significant and also mixed with obstructive symptoms this can be very disconcerting for the parent.
Obstruction of the airway causes the snoring and this is most often due to enlarged tonsils and adenoids relative to the space in the oral cavity and the back of the nose. It is for this reason that this condition can be treated by removal of the tonsils and adenoids – adenotonsillectomy a combination of both adenoidectomy and tonsillectomy.
However this operation is not to be underestimated because it is associated with risks that include bleeding, pain and infection. Careful selection of patients is therefore important and most children who have this procedure are having significant obstruction patterns with the snoring (obstructive sleep apnea), failing to thrive and are often tired and lethargic.
What is Tonsillitis?
Tonsillitis is an infection involving inflammation of the tonsils. There are two tonsils, situated on either side of the back of the throat and they form part of the body’s immune system. Like the rest of the immune system they contain special cells to trap and kill bacteria and viruses travelling through the body. When the main site of infection is within the tonsils they swell, become red and inflamed and may show a surface coating of white spots.
Tonsillitis is extremely common in children and young people but it can occur at any age. The characteristics of the disease are pain in the throat, trouble swallowing, fever, glandular enlargenment in the neck and in severe conditions, trismus (difficulty opening the mouth).
How do we contract Tonsillitis?
Whether due to viruses or bacteria, the infection is spread from person to person by airborne droplets, hand contact or kissing hence the term “kissing disease”. It is typically seen in young people but can on occasion effect the older adult, in these cases other possible causes need to be investigated.
There are many different individual viruses and bacteria that can potentially cause tonsillitis e.g. the Epstein-Barr virus, which causes glandular fever. The streptococcus group A is the most common cause of tonsillitis and sore throats – often known as ‘strep throat’. The incubation period between picking up the infection and the disease breaking out is two to four days – sometimes it can be less. Tonsillitis is usually a self-limiting condition, i.e. it gets better without treatment, and generally there are no complications.
Rarely pus can collect just deep to the tonsil itself as a result of infection. This typically produces one sided throat discomfort severe difficulty swallowing and often trismus (difficulty opening the mouth). This is referred to as a “Quinsy” and requires medical intervention.
Signs and symptoms of tonsillitis
- Sore throat.
- Pain or discomfort when swallowing.
- Inability to swallow oral secretions.
- Tonsils may be coated or have a covering of white spots on them.
- Trismus (difficulty opening the mouth).
- Glands in the neck and at the angle of the jaw may be swollen and painful.
- Loss or change in voice.
- In children, tonsillitis may include symptoms that appear less focused on the throat, such as poor feeding, runny nose, ear pain, and a slight fever.
- Visit to the general practitioner (GP) who may commence a course of appropriate antibiotics and analgesia, with advice on oral intake, hygiene and to return if condition does not improve.
- If the condition does not improve the GP should refer the patient either to a local ear, nose and throat (ENT) referral clinic or to accident and emergency (A&E) for review and treatment by an ENT specialist.
- If there is an inability to swallow the oral secretions the patient will need to be admitted for a minimum of 24 hours for re-hydration, pain relief and intravenous (IV) antibiotics and reviewed on a daily basis.
- Visual examination of the tonsils.
- Blood tests, including the mono-spot test to rule out glandular fever.
- Insertion of a venflon for administration of fluids and IV antibiotics.
- Regular temperature check
- Routine observations including oxygen saturation monitoring.
- Analgesia for pain relief both regular and as required. This is also to assist in reducing any above normal temperature. Paracetamol is the most common one given.
- Aspiration if thought to be a quinsy by a trained practitioner.
- If oral medication is not suitable then intra-muscular (IM) or per rectum (PR) should be prescribed.
- Fan therapy if necessary but taking care not to reduce the pyrexial patients temperature too suddenly.
- Documentation of fluid and oral intake.
- Ongoing reviews of care delivered and appropriate alterations, depending on patient response and results of investigations undertaken.
Within 24 hours of analgesia, IV fluids and antibiotics the patient often makes a dramatic recovery and is suitable for discharge home.
The patient is ready for discharge when;
- They are apyrexial
- Are managing adequate oral fluids and diet.
- Their pain is controlled on oral analgesia.
- Any investigations are complete and show no other underlying condition that requires immediate investigation / treatment.
What happens when discharged?
- The patient will continue on a course of oral antibiotics, which must be completed otherwise the infection may return.
- A seven-day supply of appropriate analgesia will be prescribed.
- Verbal and written advice on areas such as dietary advice, when to return to work & refraining or cessation of smoking and oral hygiene should be given to the patient or carer once discharged.
- If the patient suffers from tonsillitis i.e. 3-4 episodes annually and it affects work/ school attendance, they should be offered a tonsillectomy and if agreed, added to the ENT waiting list.
- A copy of their discharge letter will be given to the patient and one posted to their GP.
- They should be advised if their symptoms return they should see their GP and if appropriate the GP will refer them back to the hospital.
What is a Tonsillectomy?
Recurrent tonsillitis, quinsy, obstructive sleep patterns in children are all indications to remove the tonsils in the form of a tonsillectomy.
This procedure is performed under general anaesthetic. Post-operatively patients require regular analgesia and strongly encouraged to continue eating and drinking to speed up their post-operative recovery.
Having a tonsillectomy generally requires an overnight stay in hospital.
Over the years tonsillectomy has had a bad press and this may be related to the fact that previously many people had their tonsils removed surgically without a correct indication.
As an ENT surgeon tonsillectomy is a satisfying operation as it is now performed with specific indications and the results therefore are gratifying for the surgeon and satisfying for the patient.
Clearly you will not die of tonsillitis but it is a huge problem to adults and children. However, when thinking about state services paying for operations, those that are deemed the most life saving will always be paid for and those deemed not serious may not be seen to be value for money (amongst the politicians). It is imperative to understand that tonsillectomy for reccurrent tonsillitis significantly improves an individuals lifestyle and whilst tonsillitis is not life threatening a tonsillectomy can significantly improve the quality of life of individuals.