The tonsils are collections of lymphoid tissue lying on either side at the back of the throat. The adenoids are clumps of the same lymphoid tissue lying at the back of the throat high up behind the nose.
Lymphoid tissue is present throughout the body, in the lymph glands which lie in the neck, under the arms, in the groins, and along the course of the large blood vessels. The spleen, which lies in the abdomen high up under the left ribs, and the thymus, in the upper chest in front of the heart and lungs, are also part of the lymphoid system.
This tissue is concerned with the production and storage of one type of white blood cell, the lymphocyte. These cells are part of the immune system of the body.
Tonsil and adenoid tissue increase in size up to about 8 years of age, then slowly regress, so that in adult life the tonsils are small and insignificant and the adenoidal tissue has all but disappeared.
In the past few children escaped into adult life with their tonsils and adenoids still intact.
Operations to remove these organs are still among the most common operations performed, but they are done less frequently than in the past.
“Routine” tonsillectomy and adenoidectomy have given way to operations only for well-recognized reasons, such as infection or enlargement.
The adenoids may enlarge to such an extent that they obstruct the passageway behind the nose, leading to mouth breathing and snoring.
The enlarged adenoids may also block the eustachian tubes which connect the middle ear to the back of the throat. These tubes allow the free passage of air into the middle ear and keep the air pressure equal on either side of the eardrum. The blockage leads to a middle ear infection.
The tonsils often become infected. Acute tonsillitis is usually due to infection by the streptococcus germ.
There is a high temperature, a sore throat and the lymph glands in the neck are enlarged and tender. Sometimes in small children, there is no complaint of soreness of the throat, but it is easy to see the child has trouble in swallowing.
Middle ear infection often accompanies tonsillitis, especially in children, but there may be pain referred to the ear from the throat without any infection in the ear.
The tonsils are unusually enlarged, red, and covered with pus in acute infection.
In making the diagnosis, it is important to exclude diphtheria. This is rarely seen now. but can still occur in children who have not been immunized.
In older children and adults, tonsillitis is often diagnosed when the condition is really glandular fever or infectious mononucleosis.
The streptococcus remains sensitive to penicillin and this is the first choice of antibiotic. In those who are allergic to penicillin, erythromycin is usually given.
The infection usually responds quickly to these antibiotics. But if it should be a glandular fever, then the patient does not respond in a few days and this may make the doctor search further for the true diagnosis.
Blood tests may not help at the start, as the typical changes of glandular fever may take up to a week to show on a blood test.
Sometimes an attack of acute tonsillitis may lead to an abscess behind the tonsil.
This is known as a quinsy. This abscess will, like others elsewhere in the body, need to be opened and the pus drained. Once the infection has settled down, the tonsils will need removal. One attack of quinsy is a definite reason for the operation.
Recurrent infection of the tonsils especially if associated with ear infections are the main reasons why tonsils are removed.
Because of the function of tonsils as a barrier to infection, they should not be removed without just cause. Size alone is rarely a sufficient cause.
If the child suffers four or more definite attacks of tonsillitis over one or more years and if the tonsils between attacks show evidence of chronic infection, then these are indications for operation. A recurrent ear infection may tip the scales in favor of operation.
Poliomyelitis is now rare, but during an epidemic, the tonsils should not be removed.
Many doctors in general or family practice have gained the necessary skill in this procedure of tonsillectomy and adenoidectomy, and are competent to operate. Others are unhappy with surgery and may refer their patients to a ENT surgeon; that is, an ear, nose, and throat specialist.
Most pediatricians (children’s specialists) are reluctant to recommend the removal of the tonsils.
It may benefit those children who suffer recurrent infections of the tonsils to give them a regular small dose of penicillin and to keep them on this for a year or more.
This is not dangerous and is done as a routine in those children who have had rheumatic fever. This condition is regarded as due to a reaction of the body to the toxin or poison produced by the streptococcus germ. Long term treatment with the penicillin will, in most cases, prevent reinfection in the throat and a recurrence of the rheumatic fever.
The operation may be done under a local or general anesthetic. Children normally only stay for one or two days in the hospital, but adults are there for almost a week. The main complication of operation is bleeding.
This can be so severe that the child may need taking back to the operating theatre and having a further anesthetic and oversewing of the tonsillar bed to control the bleeding. Sometimes transfusion may be necessary.
There was a period when the swing away from the operation was so marked that very few operations were carried out even when strong indications were present.