Tonsils are specialized lymph nodes placed in oral cavity and pharynx and therefore form a part of immune system. Since the oral cavity and the first part of respiratory system are one of the exposed entryways for microorganisms into the body, it can be said that tonsils are one of the first lines of defence against different infections. Whenever we use the world “tonsil” in everyday speech, we usually mean palatine tonsils – lymph nodes the size of a larger almond, located between the palatoglossal arches on the both sides of oral cavity and which can be easily seen by a throat examination with a spatula. Because of an inflammation, tonsils become red and swollen, and dim white dots can be seen on their surface – inflammatory exudates. The inflammation is followed by sore throat and difficulty in swallowing, and in more complicated cases, the swelling and painful lymph nodes on throat (which can be felt by hand on the outside, and which the non-professionals usually consider to be greatly enlarged tonsils), general symptoms (increased body temperature, joint and muscle pains etc.). More difficult inflammations are usually called angina (tonsillaris).
The most common cause of tonsil inflammation in children is beta-hemolytic streptococcus, but tonsil inflammation can be caused by other bacteria, as well as many viruses. The spread of inflammation cause is generally liquid in nature, therefore in order to prevent the disease it is very important to teach children to cover their mouth while they cough or sneeze. Risk of infection is greater in closed spaces, especially when there is a large number of people in close contact for an extended period of time (such as children who are in schools or kindergartens, adults who are due to their profession constantly in contact with a large number of people – professors and health workers, waiters in cafes, people employed at information deks and similar). Also, it is important to note that smoking (whether active or passive) increases the risk of upper respiratory tract inflammation, as tobacco smoke dries the mucous membrane and weakens the local immune system.
Beside palatine tonsils, whose iflammation usuallz causes a standard headache, children often have problems in connection to so-called “third tonsil.” Third tonsil (pharyngeal tonsil, adenoid vegetation) is an odd lymph gland placed at the turn of nasal cavity to pharynx (in the part of respiratory system that is medically called nasopharynx), and is also a part of the immune system with a considerable role in defense against infections. As it is positioned in a relatively limited anatomical space, in the case of its swelling there problems with nasal breathing occur. With age the adenoid reduces, and the space of nasopharynx increases, so the problems with the third tonsil usually appear with preschool children. Children with an enlarged adenoid constantly breathe on mouth and snore as they sleep, and they often have ear problems. Namely, there are canal openings that connect the nasal cavity with the middle ear (so called Eustachian tube) which are important for proper functioning of hearing mechanism. In the case those canals become clogged by the enlarged adenoid, ear inflammations, gathering of the liquid discharge in the middle ear or hearing problems can be caused. Adenoid is placed in the part of respiratory tract that cannot be seen by a standard examination in general or paediatric ordination. If the primary health care professional that the symptoms indicate an enlarged adenoid, he will direct the child to an examination and further check up with otolaryngologist.
Contemporary examination if performed with a flexible fibre endoscope – an optical instrument which consists of a miniature camera and an optical fibre less than 2 mm in girth, which is gently inserted into the child’s nose. The examination lasts only a couple of seconds and gives the doctor a correct visual information on the size, appearance and position of the third tonsil within the area of nasal cavity. Insertation of the fibre endoscope is completely painless and children, if informed by their parents beforehand, endure it without crying or fear. In the case bad hearing is suspected, child will be sent to additional examinations to subspecialist, audiologist, who will perform audiometric examination of the ear, and then a test to determine if there’s a discharge in middle ear (tympanometry). Children having chronic middle ear inflammations (more than 3 to 4 times a year) are suggested to remove the third tonsil regardless of its size, as the procedure removes the chronic tissue which causes the infections. Also, with children, enlarged adenoid can be the cause of chronic cough.
Tonsillectomy is a medical term for a surgical removal of palatine tonsils, and adenectomy refers to the removal of third tonsil. Today, with children, during every tonsillectomy the third tonsil is removed as well. On the other hand, with children who have trouble breathing through nose or ear problem – but without reoccurring throat inflammations – only adenectomy is recommended. In the last couple of decades the number of tonsillectomies was greatly reduced, because throat inflammations can be successfully cured with modern antibiotics. US data show that in the 1950s more than a million tonsillectomies were performed per year, and that the number had fallen to around 600.000 during 1990s. Still, tonsillectomies and adenectomies are still the most common surgical procedures in child room.
When making the decision on tonsillectomy bear in mind that removing the tonsils is a serious surgical procedure which is performed under general anaesthesia when children are concerned (with adults, it can be performed with a local anaesthetic). Furthermore, in adults, recovery after the removal of palatal tonsils can take even up to 2-3 weeks (due to the pain in oral cavity). Tonsillectomy is accepted and proven surgical method of reducing throat pains with a high percentage of success and patient satisfaction, but which should be only considered after the failure of conservative therapy and recommended only with strict adherence to indications for that procedure.
The most common indications for removal of palatal tonsils are reoccuring episodes of acute inflammations (clinical indications to recommend tonsil removal to children and adults are five or more tonsil inflammations a year), chronic inflammation of tonsils characterized by chronic changes in tissue along with constant pain in that area. Less common indications include the manifestation of peritonsillar abscess (collection of pus in the area of tonsil and surrounding soft tissue), breathing and swallowing difficulties due to tonsil size, and obstructive sleep apnea syndrome. It is suggested that tonsillectomy is preceded by a six month monitoring as to establish the clear pattern of symptom manifestation and to clearly evaluate what will be accomplished by surgery. It is wrong to believe that there will be no further throat inflammations. Liquid-transferred microorganism will still occasionally find their way to mucous membrane and cause inflammation – but considerably rarely, and most inflammations will be of lesser intensity.
Otorhinolaryngology specialist will rarely see the patient during the acute episode of throat pain, therefore the diagnosing the reoccurring acute tonsil inflammations will be left to general practice doctor or the primary pediatrician for the most part. Therefore it is desirable that the primary health care professional refer the patient to otorhinolaryngologist with as many information as possible, with which it is easier to evaluate if the tonsil removal is necessary. During the otorhinolaryngologic examination, the appearance of oral cavity, the presence of permanently enlarged lymph nodes on neck and information on the systematic difficulties can further aid the diagnosis.