Tonsillitis

 

How does it occur?

Tonsillitis is inflammation of the tonsils caused by infection with either bacteria, or more usually, a virus.

Why does it occur?

Each tonsil, one on either side of the back of the throat, is a collection of lymph tissue that is the body's first line of defence against infection. Most of the time, the tonsils resist infection well, but occasionally they become infected themselves.

Tonsillitis can occur at any age, but it is especially common in children under 10 years old. The tonsils are fairly large in youngsters, probably because their immunity to common infections is still developing, but they shrink in size as the person approaches adulthood.

Some people seem more prone to the condition than others. Bottle-fed infants are more likely to develop tonsillitis, but in most cases nobody knows why certain people suffer from tonsillitis more than others. Children with frequent tonsillitis often grow out of this by the age of eight or nine.

What causes tonsillitis?

Tonsillitis can be caused by bacteria or by viruses. There are therefore many different germs that can result in tonsillitis. Most of these spread from person to person by direct contact and also through the air on tiny moisture droplets when someone coughs, sneezes or even talks - just like the common cold. Not everyone who spreads tonsillitis is unwell; some people carry germs and pass infection on without becoming ill themselves.

Although many different viruses can cause tonsillitis, the number of bacteria is more limited. The commonest bacterial cause is the group 'A beta-haemolytic streptococcus' (often called 'strep' for short). It usually responds to antibiotics, but unfortunately only about 10 per cent of adults (30 per cent of children) with a sore throat, have a 'strep' infection and even then, antibiotics have a limited effect in shortening the duration of the illness (see below).

 

What are the symptoms?

The usual symptoms of tonsillitis include:

  • sore throat, which is often worse when swallowing
  • fever
  • feeling generally unwell
  • enlarged painful lymph glands in the neck
  • sometimes earache (because the same nerves which travel to the throat, also travel to the ear)

Some children will complain of abdominal pain, either instead of, or as well as, a sore throat. This is thought to be partly as a result of an inability to describe where the pain is, especially in very young children, and partly because the lymph glands in the abdomen enlarge in response to the infection and for some reason cause abdominal pain. This is called 'mesenteric adenitis'.

It can be difficult, if not impossible, to tell the difference between bacterial and viral causes of a sore throat, without doing special tests. The appearance of the tonsils is not always a good guide. Pus is sometimes visible on the surface of the tonsils as white dots on bacterial tonsillitis, but this also occurs with some viruses, especially the Epstein-Barr virus that causes glandular fever.

What tests are done?

Tests to distinguish bacterial from viral tonsillitis include:

  • throat swab (sent to the laboratory, to see if any germs grow)
  • blood tests to see if the body is fighting an infection caused by the streptococcus bacterium

In practice, tests often take too long to be useful, so they are usually done only in difficult cases, or in recurrent tonsillitis. As yet, there is no quick test that can be done in the doctor's surgery that will detect a bacterial infection of the throat.

 

What is the treatment?

90 per cent of sore throats, including tonsillitis, get better within a week, whether or not they are treated with an antibiotic. As a result, in the huge majority of cases, only simple measures are needed such as:

  • drinking plenty of fluids
  • taking painkillers or throat lozenges to soothe the throat
  • taking (or gargling with) Aspirin or painkillers to control any fever
  • bed rest if feeling unwell

In theory, antibiotics should help those cases of tonsillitis caused by a bacterium, but in most cases, it seems that both viral and bacterial tonsillitis get better without antibiotics. Studies have shown only a difference of 8 to 12 hours in the length of symptoms between patients with tonsillitis who were treated with antibiotics, when compared with those who were not given antibiotics. Therefore, unless the patient is very unwell or there have been previous complications, it is now common practice to wait and see for 24 to 48 hours, before prescribing antibiotics. In fact, some research has shown that there is no difference in the number of complications from tonsillitis between those people treated with antibiotics and those who were not. The research also showed that, for some reason, children given antibiotics were at an increased risk of further throat infections.

If an antibiotic is prescribed, it is usually given as a five-day course of either penicillin or, in penicillin-allergic people, an antibiotic called Erythromycin, as these are particularly effective against the streptococcus bacterium.

What are the complications?

Considering that tonsillitis is a common condition, complications are really very rare. However, they are more likely to occur in bacterial than viral tonsillitis.

Tonsillitis may develop into quinsy, an abscess around one or both tonsils. This causes very severe sore throat and localised swelling in the soft palate (the floppy part at the back of the roof of the mouth), and usually needs admission into hospital.

Acute tonsillitis can develop into chronic inflammation, in which symptoms are ongoing and only partly relieved by antibiotics.

More remote complications of streptococcal tonsillitis include rheumatic fever (an inflammation of the heart valves and muscle), and acute glomerulonephritis (an inflammation of the kidneys). These are not due to direct spread of bacteria, but to an unusual immune reaction to streptococci, and are now rare in the western world.

 

How useful is tonsillectomy?

There are two main reasons why tonsillectomy (removal of the tonsils) is not done nearly as often as it used to be. Firstly, children very often outgrow attacks of tonsillitis, and secondly, tonsillectomy has not yet been proven to result in long term freedom from further throat infections. The research so far seems to indicate that children with severe tonsillitis generally suffered from fewer throat infections for two years after the operation, but that after this period of time, they had as many throat infections as children who had not had their tonsils removed. However, tonsillectomy is still sometimes recommended in the following circumstances:

  • for those who get recurrent attacks of tonsillitis (for instance, five or more attacks per year), especially where the attacks disrupt normal life, either in days off school or work
  • for those who have had quinsy
  • when the appearance of one or other tonsil is suspicious (for instance if it was thought to be malignant)

Tonsillectomy does have its drawbacks, including the small risk of complications such as bleeding or postoperative infection, and requires time off school or work. After the operation, the throat can be sore for three weeks.

Traditionally, tonsils are removed by carefully excising them (cutting with a surgical knife) from the side of the throat. Other techniques are being used where the removal is done either with cautery (a special hot cutting instrument) or by using a laser to 'shrink' the tonsils. The benefits or otherwise of these methods are still being assessed.

Adenoidectomy

Children who have their tonsils out sometimes have their adenoids removed at the same time. Like tonsils, the adenoids are lymph tissue, but at the back of the nose, higher up than the tonsils. Large adenoids may be removed if they cause glue ear or block the nose, or if they cause chronic infection. The adenoids are removed under anaesthetic and the patient may be kept in overnight. The treatment and recovery period are similar to that after a tonsillectomy.