Tonsils
Tonsils are encapsulated lymph system tissues located in either side of the throat. They contain 15-20 dents (crypts) covered with lymphoid nodules (Figure 1). Tonsils may be the source of chronic infections due to the bacteria settling into the crypts that they contain and recurring acute tonsillitis episodes may occur when the resistance of the body decreases because of any reason.
In addition, they may enlarge with the increase in lymph tissue due to recurrent infections and may lead to complaints like difficulty with swallowing, snoring, blocking of the air passage during sleep and apnea.
Figure 1. Tonsils
Adenoid
Adenoid tissue is located at the back of the nose, at the top of the nasopharyngeal space. It is not encapsulated and does not contain crypts (Figure 2).
When the adenoid tissue enlarges and blocks the rear holes of the nasal passage, complains like nasal obstruction, snoring, apnea may be observed.
At the same time, frequently recurring adenoid infections, disrupts the function of the Eustachian tubes that open to the both sides of nasal passage and balances the pressure in the middle ear, and result in negative pressure and fluid accumulation in the middle ear (otitis media with effusion) and recurrent otitis media.
Figure 2. Location of the adenoid tissue
ACUTE TONSILLITIS
It is an acute infection of the tonsils and its severity varies according to the type of the causative microbe and the resistance of the defense system of the patient.
Group A Beta Hemolytic Streptococci is the most common bacteria which causes acute tonsil infections.
Viruses (Influenza, parainfluenza viruses etc. ) also can cause similar acute tonsil infections.
Viral factors are more frequent in pre-school period and bacterial factors are more frequent in adolescents and young adults.
Symptoms:
In acute tonsillitis symptoms start rapidly with shivering and fever, throat ache occurs. The involvement of the muscles around the throat results in difficulty in swallowing. Head ache, weakness, joints aches are present. Symptoms generally recesses in 4-6 days.
Examination Findings:
Enlarged tonsils with varying amounts of white membranes and inflammation in the opening places of the dents (crypts) on the tonsils are found. Hemorrhagic foci on the tonsils, reaction in all lymphoid tissues of the throat may be present. Painful lymph node enlargement in the upper neck, at the back of the corner of the chin is typical.
Laboratory;
White blood cells increase in blood count. The causative microorganism is detected by examining the swab taken from the throat microscopically by gram staining, propagated in throat culture and may be shown by rapid streptococcus test.
ASO, CRP and sedimentation tests are helpful in the diagnosis.
The normal value of ASO is 166-200 u/dl, values exceeding these normal values are in favor of previous streptococcus infection.
Treatment; Ingredients of the treatment in acute tonsillitis are;
-
Adequate liquid consumption,
-
Rest
-
Oral antiseptics
-
Analgesics, antipyretic drugs
-
Antibiotics: Oral treatment should at least be continued for 7-10 days. According to the order of preference;
-
Penicillin
-
Amoxicillin Clavulinic Acid
-
Clindamycin
-
Erythromycin
-
If the clinical findings are severe, then treatment may be initiated as intravenous or intramuscular injection, considering the difficulty in oral administration of drugs. First choice is intramuscular (IM) procaine penicillin. After continuing the treatment with 800.000 u IM two times a day in adult patients for 3-4 days, with the improvement of the clinical findings, the treatment may be completed to 10 days with oral penicillin or may be terminated by 1.200.000 u intramuscular injection with depot benzathine penicillin for once. If beta-lactamase producing bacteria are found in the environment, the response to the treatment will be reduced. After the detection of this situation with culture, antibiogram should be performed and appropriate antibiotic administration should be started
Differential Diagnosis:
Infectious Mononucleosis: This is a viral disease with Epstein Barr Virus as the causative agent. It is frequently observed during school age. The infection, known as the kissing disease colloquially, is spread by the saliva and the droplets suspended in the air. Clinical findings are very similar to acute tonsillitis; high fever, throat ache, enlargement of the tonsils, redness and white-gray colored membrane covering the tonsils are observed. With the enlargement of the tonsils that are found in the throat, the virus spreads to the blood circulation and the liver and the spleen is enlarged. In the diagnosis, increase in cells called monocytes in the blood, monitoring the cells specific to this disease and immunological tests are used. Not having an in total white blood cell count, increase in sedimentation and CRP, elevation in liver enzyme levels, detection of enlarged liver, spleen are other findings that are helpful in the diagnosis. The evaluation of blood smears with microscope is very important in regard to the differentiation of other blood diseases that may lead to similar findings.
Diphtheria: Initiation is slow, general findings are not conspicuous. Hoarseness, shortness of breath, krup table, lymph node swelling in the throat are observed. A thick, gray membrane, tightly attached to the base is present; when removed, occurrence of bleeding is typical. Since it releases toxins, affecting the nervous system and the heart, palpitation not compatible with fever may be detected. Diagnosis is made with Gram staining and throat culture.
Scarlet fever: Tonsillitis with a thick membrane, red appearance in the tongue (strawberry tongue) occurs. Widespread swollen rash is present on the body. Diagnosis is made with throat culture and immunological tests (Dick test, Schultz-Charlton fading phenomenon).
CHRONIC TONSILLITIS
Persistent inflammation of the tonsils usually develops as a result of recurrent infections. Enlargement of the tonsils, degeneration, blocking of the crypts occur. Though tonsils generally get bigger with recurring infections, sometimes they get smaller and then disappear. In chronic tonsillitis, the causative factors are the bacteria settled in the crypts.
Findings:
- Recurring throat aches
- Enlargement of the tonsils and increase in vascularization
- Foul smelling infected material accumulated in the crypts
- Feverish attacks, joint pains, weakness
- Swelling of lymph nodes in the throat (in active periods) becomes prominent
Treatment
Though preventive antibiotic (monthly depot penicillin injections) may be used in frequently recurring infections, generally removal of the tonsils (tonsillectomy operation) is preferred. If oversized tonsils are a big problem in children younger than the age 3, though not frequently inflamed, instead of removing the tonsils completely, their size can be reduced to relieve the air canal blockage in order to preserve their contribution on the immune system. The techniques related to this matter will be mentioned in the section on tonsil operation.
PERITONSILLAR ABSCESS
Occurs as a result of spreading of the inflammation beyond the tonsil capsule. The causative factor is usually bacteria, propagating in an oxygen-free environment (anaerobic). High fever, shivering, weakness, vomiting, difficulty in swallowing, slavering, difficulty in opening the mouth, difficulty in speaking are observed.
In the examination, swelling around the tonsils, edema, inflammation and membrane formation on the tonsils, are present. Edematous uvula is bended to the opposite direction.
Treatment
-
IV antibiotic administration is initiated
-
It should be effective against bacteria that are resistant to penicillin (Beta lactamase producing)
-
-
Analgesic, antipyretic drugs should be administered and oral hygiene should be maintained with gargles
-
Emptying of the abscess
-
Cellulites (the period in which inflammation does not accumulate) or localized small abscess may disappear with medication
-
When significant amount of inflammation accumulates, it should be emptied surgically
-
-
Removal of the tonsil - Tonsillectomy (when peritonsillar abscess is present= hot tonsillectomy)
-
Should not be performed when severe infection findings like high fever, weakness are present
-
In pediatric patients when emptying and patient follow-up is difficult and in patients with frequent tonsillitis or peritonsillar abscess history, tonsillectomy may be performed following antibiotic treatment of 12 hours.
-
TONSILLITIS COMPLICATIONS
In tonsillitis regional infection may spread to remote regions. Pericardium inflammations (endocarditis) due to obstruction and infections of the vessels, inflammation of the kidneys (nephritis), brain abscess may develop. Respiratory tract may obstruct due to the edema forming on the larynx. Spreading to the throat and accumulation of inflammation in the throat (throat abscess), pneumonia, lung abscess, ruptures in the major veins of the neck may occur.
Tonsillectomy and Adenoidectomy
The decision for surgery directed to tonsils and adenoids may be given in different situations.
SITUATIONS THAT REQUIRE TONSILLECTOMY
-
Recurrent acute tonsillitis (more than five attacks in a year or more than three attacks in two successive years)
-
Concurrently with recurrent tonsillitis
-
Diseases of the heart valve
-
Feverish convulsions
-
-
Conditions that does not respond to treatment in chronic tonsillitis like
-
Foul breath
-
Resistant throat ache
-
Painful enlargement of the lymph nodes in the neck
-
Infection carrying that does not respond to medical treatment
-
-
Development of abscess around the tonsils
-
Obstructive growth in the throat
-
Snoring and chronic mouth breathing
-
Obstructive sleep apnea syndrome
-
With enlargement of adenoids and tonsils
-
Hypertension disease of the lungs – Cor pulmonale
-
Difficulty in easting
-
Speech disorders
-
Growth retardation
-
-
Occlusion disorder
-
Developmental disorders in facial bones (craniofacial
-
Tumor (malignancy) suspect (asymmetrical growth)
SITUATIONAS THAT REQUIRE (ADENOIDECTOMY)
-
Reasons related to infection;
-
History of adenoid infection that require antibiotic medication more then 5 times a year
-
Adenoid inflammation resistant to treatment (adenoiditis)
-
Middle ear diseases (With adenoid hypertrophy or without a distinct growth)
-
Fluid accumulation in the middle ear that does not respond to treatment (Chronic otitis media with effusion)
-
Frequent otitis media
-
Patients having a hole in the eardrum and with continuous discharge
-
Chronic sinusitis that does not respond to treatment
-
-
-
Reasons related to obstruction;
-
Excessive snoring and continuous mouth respiration during sleep
-
Obstructive apnea syndrome
-
With adenoid hypertrophy
-
Chronic lung disease, growth retardation, speech disorder
-
Occlusion disorder and teeth problems due to mouth respiration
-
Developmental disorders in facial bones.
-
-
Especially, while making decision for surgery due to recurrent infections, variables like the general condition of the patients, the affection extent of daily life, work and school life from the infections, the presence of allergy, the season in which the diagnosis are also effective. Since these infections are markedly reduced during summer, waiting till autumn in patients diagnosed in spring and administering vaccines and treatments that would boost the immune system during this process, controlling the allergy, if present, may be preferred. Though antibiotic treatment is always an alternative to surgery, the development of resistance due to frequent use of antibiotics, their effect on gastrointestinal system and allergic reactions should be considered. The application of depot penicillin is not frequently preferred since it is painful and has a risk for allergy development.
Tonsillectomy operations may be performed in the summer as well. However, especially in small children, it should be considered that, problems may be encountered due to the insufficient fluid consumption after tonsillectomy. In children who are decided to undergo ventilation tube insertion due to frequent recurrent fluid accumulation or fluid accumulation that does not respond to treatment in the middle ear, adenoidectomy contributes positively to decrease the infection prevalence though adenoid do not have an obstructive effect.
TONSILLECTOMY
Since tonsils contribute to the development of defense system (immune system) especially during the first 3 years of life, surgery may preferred to be delayed to age of 3 unless a growth that results in the obstruction of respiratory tract is present. Especially in this age group hypertrophic tonsils may be preferred to be reduced in size only with thermal welding, radio frequency or Coblation technologies.
The surgery is performed under general anesthesia and lasts for 10-20 minutes; however, with the stages of the preparation of the patient for surgery, bleeding control after the operation and the termination of anesthesia, it lasts for a total of 45-60 minutes.
Following the introduction of Thermal Welding and Coblation Technologies, due to the absence of hemorrhage in tonsillectomy the weight of the patient is no longer a criterion while making the decision for surgery (Figure 1).
Figure 1: Tonsillectomy with Coblator
In operations performed with Thermal Welding and Coblation, in addition to the absence of bleeding, the pain is significantly less and recovery is faster compared to standard operations and patients may return back to their normal diets within a shorter period of time.
During tonsillectomy, tonsils are removed completely with tonsillar capsules. In some operations, the lymph tissues that are located in the tongue base may enlarge to the region of tonsils and may result in the formation of lymph tissue in the lower axis of the tonsil.
Especially following the removal of big tonsils, the region of the wound may be reduced by using sutures that disappear spontaneously in order to accelerate the healing of the wound and to reduce the pain after the operation. After the operations performed with Thermal Welding and Coblator, this method is required less.
Since children under the age 10 are not comfortable in a hospital setting and prefer to be in a house setting, they are generally sent to their homes following 2-3 hours of monitoring after the surgery. Child patients, living far away from the hospital, very small patients and adult patients having an additional pathology for each age group (diabetes, cardiac disease, convulsion, obstructive apnea etc.) have to be followed at least for one day in a hospital after the surgery.
Complications
Though very rare complications like traumatization of the vessels and nerves around the tonsils due to tonsillectomy, trauma of the chin joint, trauma in the neck cervical vertebra are identified, the most frequently observed complication is bleeding after the surgery.
Bleeding is most frequently seen within the first 24 hours. Another risky period is the 7th-14th days in which the white healing tissue that is formed at the site of operation falls off. Therefore, the first 2 weeks following the surgery is critical in respect to feeding. It is important to inform the patient to apply to a hospital if bleeding occurs in any period. In bleedings after tonsillectomy, the patient should be evaluated under general anesthesia and the foci of bleeding should be determined and bleeding should be stopped by an appropriate method. It will be appropriate for these intervened patients to stay at the hospital at least for one day for follow-up.
RECOMMENDATIONS AFTER TONSILLECTOMY
During the first 2-3 days period after the surgery, a slight pink bleeding mixed with saliva may occur. If bleeding with fresh red blood or bloody vomiting occurs, please inform your doctor.
PAIN: It is normal to have a certain amount of pain for 2 weeks after the operation. In general, the pain is less and lasts for a short period in children and decreases significantly within 3-4 days.
Pain is especially felt during swallowing and may involve the ear.
The intensity of pain varies according to people, generally simple pain killer are enough to relieve the pain, however, some people may require the administration of more potent pain killers.
FEEDING INFORMATION: Since the patient is still under the effect of general anesthesia within 2-3 hours following the surgery, he/she is not permitted to eat or drink. Your nurse will inform you about the time to start feeding through the mouth.
In general, plenty of warm water should be drunk, soft and non irritating foods should be consumed.
On the day of surgery and the 1st day after the surgery: Water, milk, fruit juices, stewed fruit, sherbet, ice cream, soup without granules, iced tea, yoghurt drink can be consumed in small amounts with frequent intervals.
2nd- 3rd days after the surgery: In addition, soft food like yoghurt at room temperature, starch mush, mashed vegetables, pasta, pudding. After the 4th day: Normal diet can be initiated on the condition that the food to be consumed are not irritating and very hot, do not consume food like edge of the bread, cracker, biscuits that have the risk of get stuck and irritation within the first 2 weeks.
During the period of 2 weeks following the surgery, you may not be able to swallow your food comfortably without the help of pain killer.
Keep these in mind:
- Avoid acidic products (Coke, oranges juice, lemon juice etc.)
- Do not use straw
- Take plenty of fluid
- Do not consume red and brown colored food and beverages (may be confused with bleeding) as far as possible.
- Avoid eating hot and spicy food.
SPEAKING: After the surgery, it is normal to speak through the nose and this may last for 3 weeks. This problem rarely lasts for a longer period and generally responds to treatment. The volume of the air cavity in the throat has a role in the formation of the voice and therefore, after the surgery, a slight permanent change in your tone of voice may occur after the surgery, proportional to the size of your tonsils.
FEVER: It is normal for your temperature to rise 0.5-1 degrees after the operation. Rise in the temperature for more than 0.5-1 degrees and fever for a longer period is generally due to being dehydrated. If you have high fever though you take plenty of fluids, then consult your physician.
FOUL BREATH: A white, grayish membrane will be formed at the site of the surgery. This membrane is a part of the natural healing process and disappears within 2 weeks on the average.
The site of surgery rarely is inflamed in people who consume insufficient amount of fluid and who is undernourished and foul breath may form. Inform your doctor about this situation.
ACTIVITIES AFTER THE SURGERY: Children should rest at home for 2-3 days after the surgery. They can go back to school 6-7 days after the operation. They should not perform sports activities for at least 14 days.
Adults may start working 7-10 days after the surgery, following the control examination. They should avoid sports and strenuous activities for two weeks.
Patients can have a bath following the 3rd- 4th day of the surgery, but with lukewarm water for a period of 15 days.
ADENOIDECTOMY
Adenoid generally starts to grow after the age of 1 and shrinks after the age of 10 and is not observed in most of the patients during examination after the age 13-15. It grows rapidly when the child undergoes frequent upper respiratory tract infections when he/she starts daycare or school and may result in nasal congestion, sleeping with the mouth open, snoring and obstructive sleep apnea in patients with very big tonsils, especially significant during sleep.
Adenoid tissue plays a role as the focus of infection in the back of nasal cavity and may lead to middle ear problems due to the affection of the functions of the Eustachian tube and may lead to chronic sinus infections by disturbing the normal ventilation and drainage of the sinuses. Other drawbacks of mouth respiration are its negative effects on the tooth health and the development of the facial bones and its negative effects on growth, development and mental functions due to different mechanisms related to insufficient oxygen intake.
Unlike tonsils, following the growth of adenoid tissue that has not been shown to have a significant contribution in the development of the defense system of the body, if nasal respiration can not be provided despite treatment directed to the infections, adenoid is preferred to be removed regardless of the age. Adenoid, which is a capsule-free structure, cannot be removed completely during the surgery and a certain amount of tissue remains in nasopharynx. Therefore, in patients, operated during young ages may require another operation in the coming years, though rare.
RECOMMENDATIONS AFTER ADENOIDECTOMY
During the first 2-3 days period after the surgery, a slight pink bleeding mixed with saliva may occur. If bleeding with fresh red blood or bloody vomiting occurs, please inform your doctor.
During the same operation, in patients undergoing paracentesis operation (tube insertion to the eardrum or scratching the eardrum), slight bloody discharge in small amounts may occur during the first few days, if plenty of yellow-green discharge occurs or if the discharge lasts for a long period, then inform your doctor.
PAIN: After the surgery, a slight pain involving the ear may be present. It generally responds to simple pain killers.
FEEDING INFORMATION: Since the patient is still under the effect of general anesthesia within 2-3 hours following the surgery, he/she is not permitted to eat or drink. Your nurse will inform you about the time to start feeding through the mouth.
In general, plenty of warm water should be drunk, soft and non-irritating foods should be consumed. Soft foods like yoghurt at room temperature, starch mush, mashed vegetables, pasta, pudding.
After the 1st day: Normal diet can be initiated on the condition that the foods to be consumed are not irritating and very hot.
SPEAKING: After the surgery, it is normal to speak through the nose and this may last for 3 weeks. The volume of the air cavity in the throat has a role in the formation of the voice and therefore, after the surgery, a slight permanent change in your tone of voice may occur after the surgery, proportional to the size of your tonsils.
FEVER: It is normal for your temperature to rise 0.5-1 degrees after the operation. Rise in the temperature for more than 0.5-1 degrees and fever for a longer period is generally due to being dehydrated. If you have high fever though you take plenty of fluids, then consult your doctor.
FOUL BREATH: The site of surgery can rarely be inflamed more frequently in people consuming not sufficient fluid and undernourished and foul breath may form. Inform your doctor about this situation.
ACTIVITIES AFTER THE SURGERY: Children should rest at home for 1-2 days after the surgery. They can go back to school 4-5 days after the operation. They should not perform sports activities for at least 7 days.
It is appropriate to not having a bath for a period of 3-4 days. After that, they can have a bath but only with lukewarm water for a period of the first 10 days.
Patients undergoing an ear operation (ventilation tube insertion) during the same surgery have to protect their ears when having a bath or swimming in the pool or sea till their doctors tell them the contrary. For this purpose, it is generally sufficient to place a cotton pad, smeared with petroleum jelly in the center. If water contact is not present, then the ear canal should be left open for ventilation.
For alternative methods of protection (Head bands, ready to use earplugs etc.), consult your physician.
