Tonsillitis & Adenoids: How Do They Impact Your Health?

Illustration of inflamed tonsils.

The tonsils and adenoids are composed of tissues 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 oval-shaped 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-filled pockets or tonsil 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.

The tonsils and adenoids are part of the immune system 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 in their future immunity to disease or ability to ward off infections.

The most prominent symptom of tonsillitis and adenoid infection is a sore throat (pharyngitis). Other signs and symptoms of tonsillitis and adenoid infection include the following:

1. Fever
2. Bad breath
3. Congestion and runny nose
4. Swollen lymph nodes in front of the neck
5. Red, swollen tonsils with patches of pus (white spots)
6. Painful swallowing (odynophagia) or difficulty swallowing (dysphagia)
7. Loss of voice or muffled voice
8. Headache
9. Abdominal pain
10. Coughing up blood
11. With enlarged adenoids, breathing through the nose may be difficult and symptoms may include:
    1. Breathing through the mouth, especially in children
    2. Noisy breathing in the day; snoring at night is often observed
    3. Nasal-sounding voice

When there is a sore throat and cold symptoms such as congestion, runny nose, sneezing, and coughing, the cause is most likely a virus. Viral infection of the tonsils or adenoids usually resolves without treatment within two weeks.

Sore throat with a sudden mild fever, without symptoms of an upper respiratory tract infection, may point to a bacterial infection called group A beta-hemolytic streptococcus (GABHS). If these symptoms are present, see a doctor for diagnosis because of the risk of strep throat. Although strep throat will usually go away even without treatment, an untreated strep bacterial infection can lead to complications including rheumatic fever, which can permanently damage the heart.

When there is a sore throat that does not affect the tonsils, medical professionals call this pharyngitis. When both the throat and the tonsils are affected, it's called pharyngotonsillitis.

Tonsillitis may or may not be contagious, depending on the cause. If the cause is viral, it is usually contagious, but this depends upon whether or not a person has been exposed to that particular virus before. Mononucleosis, a viral cause of sore throat, is contagious the first time a person comes in contact with the virus, usually in childhood or adolescence.

If the cause of the tonsillitis is bacterial, it is also contagious. For example, strep throat is highly contagious.

If the tonsillitis and enlarged adenoids are chronic or caused by a chronic condition, such as sinusitis, hay fever or chronic rhinitis, it likely is not contagious.

The most common problems occurring with the tonsils and adenoids are

• acute,
• 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. Symptoms of acute tonsillitis can either come on suddenly, or be of a gradual onset of a sore throat usually accompanied by a fever.

Other signs and symptoms of acute tonsillitis include:

• Difficulty swallowing saliva
• Drooling
• Ear pain with swallowing
• Bad breath
• Tonsil surface may be bright red or have a grayish-white coating (exudate).
• Lymph nodes in the neck may be swollen.
• Fever

Strep throat 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 (for example, scarlet fever), sinusitis, pneumonia, and ear infections.

The Epstein-Barr virus causes acute mononucleosis and can lead to a very severe throat infection 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 develop 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 caught in the back of the throat.

Peritonsillar abscess

A peritonsillar abscess is a collection of pus around 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 signs and symptoms include:

• Frequent awakening from sleep
• Restless sleep
• Nightmares
• Bedwetting
• Mood changes
• Excessive sleepiness
• Heart problems

Some orthodontists believe 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 ears, leading to chronic ear infections.

Physicians make a diagnosis of tonsillitis and adenoid infection based on a medical history and a physical exam.

If symptoms suggest strep throat, the doctor may order a throat culture or rapid strep test, which medical professionals perform by swabbing the back of the throat and checking for the Streptococcus bacteria. This can be performed in the doctor's office. If a physician suspects the Epstein-Barr virus, which can cause mononucleosis, as a cause for the tonsillitis, a blood test for mononucleosis may be done.

Strep throat is more likely if at least three of the following signs or symptoms are present:

• Fever
• White or yellow spots or coating on the throat and/or tonsils (tonsillar exudates)
• Red spots on the roof of the mouth (upper palette)
• Swollen or tender lymph nodes on the neck
• Absence of coughing or sneezing

Antibiotic treatment may be needed if a bacteria caused the infection. In more severe, recurrent tonsillitis or adenoid infection, or in chronic cases, surgery to remove the tonsils or adenoids (tonsillectomy or adenoidectomy) may be recommended to cure the condition.

Various antibiotics treat bacterial infections of the tonsils and adenoids. Tonsillitis caused by the Streptococcus bacteria can lead to serious complications. Once treatment begins, it is important to take the full course of antibiotics as prescribed because if you stop taking the drugs before they are finished it can lead to adverse consequences and regrowth of the bacteria. Physicians consider surgical removal in situations resistant to medical therapy or in frequently recurrent tonsillitis infections.

Medical professionals often treat viral causes of tonsillitis or enlarged adenoids with only supportive care (hydration and control of fever) and over-the-counter pain medications. Do not give aspirin to a child or teen unless directed by a doctor due to the risk of a condition called Reye's syndrome. 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. People can remove chronic stones in the tonsil with a clean finger or with a blunt probe. A long course of antibiotics may treat massive enlargement of the tonsils and adenoids causing airway obstruction, or even a brief course of steroids to reduce inflammation (cortisone-related medications, such as prednisone and prednisolone).

If a doctor has diagnosed tonsillitis, some home remedies can help soothe the symptoms of a sore throat.

1. Throat sprays and lozenges: These can coat and moisturize the throat, and many have a topical anesthetic to relieve pain (consult a doctor before giving lozenges to young children; they can be a choking hazard)
2. Saltwater gargle: This helps clear mucus from the throat
3. Sipping warm beverages such as tea with honey, or broth can be soothing
4. Eating cold foods such as ice cream or popsicles can help ease pain

Some alternative remedies may help ease tonsillitis symptoms.

5. Slippery elm in lozenge form may help with pain relief
6. Serrapeptase is an enzyme that has anti-inflammatory properties and can help decrease pain and help with swallowing
7. Papain is an enzyme that can help treat inflammation
8. Andrographis can help treat fever and sore throat symptoms

Consult your doctor before using any alternative remedies. Doctors do not recommend many of these home remedies for use in children or adolescents as most have not been scientifically evaluated.

Tonsillectomy and adenoidectomy are indicated in people with repeated or persistent infections, particularly if they interfere with everyday activities. The American Academy of Otolaryngology defines repeated infections in children as seven episodes in 1 year, five episodes in each of 2 years, or three episodes in each of 3 years.

Tonsillectomy and adenoidectomy are also warranted in situations where there is an 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 to cure them.

A significant episode of tonsillitis is defined by one or more of the following criteria: (1) a temperature greater than 101 F (38.3 C); (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 cancer (malignancy) or tumor is a definite reason for surgery.

It should be emphasized that all decisions for or against removing the tonsils or adenoids 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 factors in the decision process.