Tonsils and Tonsillitis: Diagnosis and Treatment

Pharyngitis is the general medical term used to describe a sore throat. That all too familiar feeling of razor blades in our throat is most commonly from infection, but it also can be a result of allergy, trauma, toxins, or even a malignancy, although rare.

If due to an infection, the etiology is more likely a virus than a bacterium. The most common bacterium is group A streptococcus. But it may be difficult to distinguish viral and bacterial causes of a sore throat.

Either way, the tonsils, particularly in children, are to blame in the majority of cases. The treatment of tonsillitis is largely supportive, but the inevitable question that arises is whether the child needs to have their tonsils removed.

What are the (palatine) tonsils?

What everyone calls tonsils in the back of the throat are part of a ring of lymphoid tissue known as Waldeyer’s ring. Waldeyer’s ring's most prominent features include the palatine tonsils, adenoid or pharyngeal tonsils, and lingual tonsils which are on the back of our tongue. For our purposes here, I will refer to the palatine tonsils which we all know so well, as the tonsils. The adenoids which hide behind the soft palate are often removed along with the tonsils.

Waldeyer’s ring is a combination of lymphoid tissue representing the gateway for both our respiratory and digestive tracts. Waldeyer’s ring of lymphoid tissue is our first line of defense against potential aggressors such as bacteria and viruses. In a sense, think of Waldeyer’s ring as a shield against the outside world.

The tonsils lie on the side walls of the back of our throat. They are the part of Waldeyer’s ring that is most visible, and therefore most maligned. They are nestled in between two pharyngeal muscles in a groove which can be deep or shallow.

This is important since the appearance of the tonsils varies depending not only on their overall size, but if they are superficial or deep. I have seen small tonsils that look huge on the surface and vice versa. For most of us, tonsils involute gradually at puberty, and after we reach age 60 there is usually very little tonsil tissue remaining if they had not already been previously removed. Older adults can still get tonsillitis, though.

Tonsils have a number of grooves and pits where food, debris, and infection get caught. The tonsils are surrounded by a tough fibrous capsule which lies between the lymphoid tissue and the muscle layer. Large blood vessels and nerves pass through the muscle to the tonsils. When tonsils are removed, the key to surgical success is identification of the tonsillar capsule to avoid bleeding from those blood vessels.

Diagnosis of tonsillitis

Tonsillitis can be acute, recurrent, or chronic. Most children present with the following signs and symptoms:

  • Fever and chills.
  • Sore throat.
  • Foul breath.
  • Ear pain.
  • Red pharynx with white or yellow patches.
  • Poor appetite, dehydration.
  • Hoarseness or muffled voice.
  • Stiff neck.
  • Dysphagia (difficulty swallowing).
  • Odynophagia (pain with swallowing).
  • Enlarged and tender neck lymph nodes.

Although there are many possible causes of tonsillitis, it is important to understand that ¼ or more cases are bacterial and a result of Streptococcus. A thorough history is vital to make sure the diagnosis is more complicated.

Most of us are familiar with throat cultures being the criterion standard for detecting a streptococcus infection. That is still true since the presence of white patches in the throat, redness, fever and enlarged lymph nodes are not as accurate. Throat cultures such as the rapid antigen detection test (RADT) are improved with higher rates of accuracy unless the patient has already been treated with an antibiotic.

Many children have a viral etiology of the infection at first and then it becomes both viral and bacterial, so they still require antibiotics in addition to analgesics and fluids. Older children and young adults may develop a more serious deep infection of the neck. That infection is thought to be a complication of tonsillitis called “Quincy” or a peritonsillar abscess. That interesting story warrants its own separate article so it will not be discussed here.

Treatment considerations

As in many other cases of upper respiratory infections, antibiotics should be given only if there is no response to supportive care or there are worsening signs such as high fevers or obvious indications of bacterial infection.

The standard of care for ages has been penicillin or a derivative. Not only had penicillin been effective, but also successfully avoided serious complications of untreated tonsillitis such as rheumatic heart disease. I am not too old to be well aware of soldiers like my grandfather who did not have access to penicillin on the battlefield and ended up dying young because of a faulty heart valve later in life.

The point is antibiotic treatment, particularly with penicillin-like drug is vital. Clinical improvement is rapid, usually within a few days. Fortunately, there are many good alternatives today for those who have penicillin allergies. Some like azithromycin or Z pack is remarkable in that it may only require a few oral doses. In some recurrent cases of tonsillitis, long-term therapy of 3-6 weeks of antibiotics can even avoid a tonsillectomy altogether.

Who needs their tonsils removed?

Even today, many parents ask, “Do they still remove tonsils? I thought that was a thing of the past.” The answer is an emphatic yes. It is still one of the most common outpatient surgeries for children. It is performed almost exclusively by well-trained ENT surgeons with low risk.

Infectious disease specialists, family physicians and pediatricians teamed up with ENT surgeons to develop specific guidelines as to when a tonsillectomy is indicated. As mentioned previously, usually this involves removal of the adenoid as well since both are susceptible to infections.

The indications for surgery include:

  • 6 or more infections in 1 year.
  • 5 or more infections in 2 consecutive years.
  • 3 or more infections in 3 years in a row.
  • Chronic or recurrent infections that have not been responsive to antibiotics.

Other considerations:

  • Upper airway obstruction causing snoring, obstructive sleep apnea, or other issues.
  • Time missed from school or work.
  • Severity of the infections, such as need for prior hospitalization.

A final note

The COVID-19 pandemic placed a special burden on all procedures involving the nose, nasopharynx, oral cavity, and oropharynx. Whenever possible, the recommendation was to defer procedures such as tonsillectomy because of the high likelihood of virus being present. Fortunately, the incidence of COVID-19 infections continues to wane, and things are slowly getting back to normal.

The vast majority of children who need to have a tonsillectomy with or without adenoidectomy should still have the elective surgery since the benefits of the surgery far outweigh these risks. Precautions should be taken including pre-operative COVID-19 testing and vaccinations.


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