What are the tonsils and adenoids?

The tonsils and adenoids are composed of tissues that are similar to the lymph nodes or glands found in the neck or other parts of the body. Together, they are part of a ring of glandular tissue (Waldeyer's ring) encircling the back of the throat.

The tonsils are the two masses of tissue on either side of the back of the throat. Normal tonsils are usually about the same size and have the same pink color as the surrounding area. On their surfaces are little depressions, called crypts, which may appear deep and contain pus pockets or stones.

The adenoids are located high in the throat behind the nose and soft palate (the roof of the mouth) and unlike the tonsils, are not easily visible through the mouth. A tonsillectomy and an adenoidectomy (commonly referred to as a T & A) are surgical procedures performed to remove the tonsils and adenoids.

What is the purpose of the tonsils and adenoids?

The tonsils and adenoids are thought to assist the body in its defense against incoming bacteria and viruses by helping the body form antibodies. However, this function may only be important during the first year of life. There is no evidence to support a significant role of the tonsils and adenoids in immunity. Medical studies have shown that children who have their tonsils and adenoids removed suffer no loss whatsoever in their future immunity to disease or ability to ward off infections.

What are common problems affecting the tonsils and adenoids?

The most common problems occurring with the tonsils and adenoids are recurrent or chronic infections and significant enlargement (hypertrophy).

Acute Tonsillitis

Acute tonsillitis is an infection of the tonsils caused by one of several possible types of bacteria or viruses. Acute tonsillitis is characterized by either the sudden or gradual onset of a sore throat which is usually associated with fever. The patient may stop swallowing saliva, start to drool, complain of ear pain with swallowing, and have bad breath. The surface of the tonsil may be bright red or have a grayish-white coating (exudate). The lymph nodes in the neck may be swollen. Fever can be present.

Strep throat (tonsillitis) is a specific type of infection caused by the streptococcus bacteria. Strep tonsillitis can cause secondary damage to the heart valves (rheumatic fever) and kidneys (glomerulonephritis). It can also lead to a skin rash (scarlet fever), sinusitis, pneumonia, and ear infections.

Acute mononucleosis is caused by the Epstein-Barr virus, and can lead to a very severe throat infection which is characterized by the rapid enlargement of the tonsils, adenoids, and lymph nodes of the neck. It also causes extreme malaise and tiredness. The sore throat and gland swelling can last for one week to a month and does not respond to the usually prescribed antibiotics.

Chronic Tonsillitis

Chronic tonsillitis is a persistent infection of the tonsils. Repeated infections may cause the formation of small pockets (crypts) in the tonsils which harbor bacteria. Frequently, small, foul smelling stones are found within these crypts. These stones (tonsilloliths) may contain high quantities of sulfa. When crushed, they give off the characteristic rotten egg smell which causes bad breath. They may also give a patient the sense of something being caught in the back of the throat.

Peritonsillar Abscess

A peritonsillar abscess is a collection of pus behind the tonsils that pushes one of the tonsils toward the uvula (the prominent soft tissue dangling from the back of the upper throat. It is generally very painful and is associated with decreased ability to open the mouth. If left untreated, the infection can spread deep in the neck causing life-threatening complications and airway obstruction.

Enlargement of (Hypertrophic) Tonsils and Adenoids

Obstruction to breathing by enlarged tonsils and adenoids may cause snoring and disturbed sleep patterns that may lead to sleep pauses or sleep apnea. Other features include frequent awakening from sleep, restless sleep, nightmares, bedwetting, mood changes, excessive sleepiness, and even heart problems. Some orthodontists believe that chronic mouth breathing from large tonsils and adenoids causes improper alignment of the teeth (malocclusion). Chronic enlargement and infection of the adenoids may lead to infection of the air passages around the nose (sinusitis) or nasal drainage/obstruction, and/or may affect the eustachian tube of the ear, leading to chronic ear infections.

How is tonsillitis and adenoid infection treated?

Bacterial infections of the tonsils and adenoids are treated with various antibiotics. Tonsillitis caused by the streptococcus bacteria can lead to serious complications, and must be treated. Often the diagnosis of strep throat is confirmed by a throat culture or rapid-strep tests in the doctors office. Once treatment begins, it is important to take the full course of antibiotics as prescribed because premature discontinuance of therapy can lead to adverse consequences and regrowth of the bacteria. Surgical removal is considered in situations resistant to medical therapy or in frequently recurrent infections.

Viral causes of tonsillitis are often treated with only supportive care (hydration and control of fever). Antibiotics are not effective for viral infection of the tonsils.

A peritonsillar abscess should be drained either by removal of fluid with a needle and syringe (needle aspiration), cutting open with a scalpel (incision), or tonsillectomy. Chronic stones in the tonsil can be removed with a clean finger or with a blunt probe. Massive enlargement of the tonsils and adenoids causing airway obstruction may be treated with a long course of antibiotics, or even a brief course of steroids (cortisone-related medications, such as prednisone and prednisolone).

When should the tonsils and/or adenoids be removed?

Tonsillectomy and adenoidectomy are indicated in persons with repeated or persistent infections, particularly if they interfere with everyday activities. In general, repeated infections in children are defined as six to seven episodes in one year, or four to five episodes in each of two years, or three episodes in each of three years.

A significant episode of tonsillitis is defined by one or more of the following criteria: (1) a temperature greater than 101°F; (2) enlarged or tender neck lymph nodes; (3) pus material coating the tonsils; or (4) a positive strep test.

In adults, the severity, frequency, and hardship associated with repeated infections are considered more important than the absolute number. Chronic infections characterized by bad breath and/or tonsillar stones causing significant disability are also indicators for tonsillectomy.

Tonsillectomy and adenoidectomy are strongly considered in those patients who are suffering, or may suffer serious complications of infection. These include peritonsillar abscess, history of streptococcal complications (rheumatic heart disease, glomerulonephritis), or neck abscess. Suspicion of malignancy or tumor is a definite reason for surgery.

Tonsillectomy and adenoidectomy are also warranted in situations where there is enlargement of the tonsils and adenoids to such an extent that it causes severe sleep problems (snoring and breath holding), sleep apnea, dental abnormalities, and difficulty swallowing. Adenoid enlargement alone, or in combination with tonsillar enlargement, can cause nasal obstruction, recurrent ear infections, or sinusitis. If these conditions are resistant to medical therapy, surgery is indicated.

In should be emphasized that all decisions for or against surgery are dependent upon the individual patient's particular situation. Additional factors, such as tolerance of antibiotics, concurrent medical problems, school achievement/progress, and family preferences are also important in the decision process.

Tonsillitis and Adenoid Infection At A Glance

• Tonsils and adenoids are composed of tissues that are similar to the lymph nodes or glands.
  
  
• Acute tonsillitis is an infection of the tonsils caused by one of several possible types of bacteria or viruses.
  
  
• Chronic tonsillitis is a persistent infection of the tonsils and can cause tiny stone formation.
  
  
• Peritonsillar abscess is a collection of pus behind the tonsils.
  
  
• Obstruction to breathing by enlarged tonsils and adenoids may cause snoring and disturbed sleep patterns.
  
  
• Bacterial infections of the tonsils and adenoids are treated with appropriate antibiotics. Viral infections are not.
  
  
• Tonsillectomy and adenoidectomy are indicated as follows: (1) in persons with repeated or persistent infections; (2) when serious complications of infection occur; and (3) when enlargement of the tonsils and adenoids causes breathing, swallowing, or dental problems.

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