Tonsillitis: What is commonly referred to as the tonsils are actually the palatine tonsils, because in addition to the palatine tonsils, humans have pharyngeal tonsils, pharyngeal tonsils and lingual tonsils, which together form the inner ring of the pharyngeal lymphatic ring. The palatine tonsils are a pair of flat, ovoid tissues located within the tonsillar fossa, which has small depressions on its surface called tonsillar crypts. When inflammation of the tonsils occurs, exfoliated epithelium, lymphocytes and bacteria accumulate at the opening of the crypt, at which point a punctate bean-like substance appears on the surface of the tonsils.
Disease Classification
Clinically, the size of the tonsils is classified as grade I to grade III
Grade I The tonsils are enlarged beyond the lingual-palatal arch, but not beyond the pharyngeal-palatal arch
Grade II Tonsils enlarged beyond the palatine arch but not reaching the midline of the posterior pharyngeal wall
Ⅲ degree Tonsil enlargement reaches the midline of the posterior pharyngeal wall or exceeds the midline of the posterior pharyngeal wall
Pathophysiology
When surgical removal of the tonsils is mentioned in outpatient clinics to patients with frequent recurrent tonsillitis, nine times out of ten, parents of both adults and children will say, “These tonsils are immune, they can’t be removed!” They are right about the first half of the sentence. The tonsils are an immunologically active organ that produces lymphocytes and antibodies that function to fight bacteria and viruses and immunize the entire organism. The oropharynx, which is a necessary route for eating and breathing, is more likely to hide germs and foreign bodies, and the tonsils, in collaboration with the rich lymphoid tissue of the pharynx, perform the task of defense and protection of this particular area. Thus, for a healthy person, the tonsils are like a gatekeeper, playing a guarding role. [1][2]
Causes of morbidity
The oropharynx is susceptible to inflammation by germs, which may be invasive or hidden in the tonsillar fossa. Under normal conditions, the tonsils are healthy because the epithelium is intact and the mucus glands are constantly secreting, so that bacteria can be discharged from the crypt with the shed epithelial cells. When the body’s resistance decreases due to cold, humidity, overexertion, excessive smoking and drinking, bacterial reproduction strengthens, the tonsil epithelial defense function is weakened, and the glandular secretion function is reduced, the tonsils become infected with bacteria and become inflamed. Tonsillitis is mainly caused by Streptococcus haemolyticus, but other pathogens such as Staphylococcus, Pneumococcus, H. influenzae and viruses can also cause it. [1]
Acute tonsillitis
Acute tonsillitis is a nonspecific acute inflammation of the palatine tonsils, often accompanied by some degree of acute inflammation of the pharyngeal mucosa and pharyngeal lymphoid tissue. It often occurs in children and adolescents, and is rare over the age of 50.
Disease classification
According to the pathology, it can be classified into three types: acute cicatricial, acute cryptic and acute follicular tonsillitis, but in terms of diagnosis and treatment, it can be divided into two types: acute cicatricial tonsillitis and acute purulent tonsillitis.
Clinical manifestations
1. Systemic symptoms: rapid onset, chills, high fever, up to 39-40°C, usually lasting 3-5 days, especially in young children who may have convulsions, vomiting or drowsiness due to high fever, loss of appetite, etc.
2. Local symptoms: Sore throat is the most obvious symptom, which is aggravated when swallowing or coughing, and can be radiated to the ear in severe cases, which is caused by nerve reflex. If children’s breathing is affected by enlarged tonsils, it may prevent them from sleeping, and they often wake up at night.
Physical examination
The lymph nodes in the neck, especially those at the angle of the jaw, are often enlarged and painful to the touch.
2.Pharyngeal examination shows that the tonsils are congested, enlarged, and there may be yellowish-white purulent secretions on the surface, and sometimes the exudate may fuse into a membrane.
3.Hematological examination: the total number of white blood cells is increased and neutrophils are increased.
Diagnosis and differentiation
Based on the medical history, typical symptoms and examination, the diagnosis is relatively easy. It should be distinguished from pharyngeal diphtheria, scarlet fever, epidemic hemorrhagic fever, ulcerative membrane pharyngitis, mononuclear leukocytosis, granulocytic leukodystrophy and lymphoid leukemia. [1]
Chronic tonsillitis
Chronic tonsillitis is characterized by tonsillar hypertrophy in children and inflammatory changes in adults, i.e., recurrent acute tonsillitis. According to a survey of elementary school students aged 6 to 15 years, the incidence of this disease is 22,04%. This is due to recurrent acute tonsillitis or poor drainage of the crypt, bacteria tend to multiply in the crypt, when the tonsils become a hiding place for bacteria, once the resistance is reduced, tonsillitis follows. Chronic tonsillitis can also occur after certain acute infectious diseases.
Clinical manifestations
1. Recurrent episodes of sore throat.
2. Frequent throat discomfort, foreign body sensation, dryness, itching, and irritating cough.
3, bad breath.
4.Digestive disorders can be caused in gastrointestinal sensitive patients due to frequent swallowing of secretions and bacterial toxins in the crypt.
5, Due to toxin absorption, it can cause headache, weakness of limbs and low fever.
6. Excessive hypertrophy of the tonsils in children can affect breathing, swallowing, and speech disorders. If accompanied by adenoid hypertrophy can cause nasal congestion, snoring and stopping other otitis media symptoms.
Physical examination
1, examination can be seen in the tongue and palate arch chronic congestion, tonsillar hypertrophy; but some people with long duration of disease, tonsils are not large, or even atrophy. The tonsil surface is uneven, scarred, or has reticulated streaks.
2. There may be purulent secretions or cheese-like secretions at the opening of the tonsillar crypt, and the secretions spill out when squeezed.
Diagnosis and Differentiation
Based on the medical history, typical symptoms and examination, the diagnosis is easy. It must be distinguished from tonsillar malignancy, tonsillar hypertrophy caused by hematologic disease, and tonsillar keratosis. [1]
Disease Hazards
Dangers of tonsillitis
As mentioned earlier, the patient’s statement “The tonsils have an immune function and cannot be removed!” The first half of this statement is true, but the second half is wrong. In some cases, removal of the tonsils is beneficial to health! Under normal circumstances, the lymphocytes and antibodies of the tonsils destroy or control the germs and maintain the health of the organism. However, when the body’s resistance decreases, or when germs attack repeatedly, especially when the number of germs is large and virulent, inflammation of the tonsils can occur, with low fever, cough, and sore throat in mild cases; high fever, shortness of breath, and even convulsions in severe cases. If the treatment is not timely, when the body’s resistance is not enough to overcome the germs, the inflammation can spread to the surrounding tissues and can be spread to other organs via the bloodstream, causing inflammation and also causing systemic pathological reactions.
1, local complications: inflammation can spread to the surrounding, the most common is peri-tonsillar abscess; up can cause acute otitis media, rhinitis, sinusitis; down cause acute laryngitis, bronchitis, pneumonia, etc.
2, systemic complications: related to the metamorphosis produced by each organ to streptococcus. There are acute arthritis, rheumatic fever, acute pericarditis, myocarditis, endocarditis, acute nephritis, etc. Special vigilance should be given to the sudden death of patients with myocarditis.
The tonsils should be removed at this time because they have become the “culprit” of the health hazard.
The dangers of enlarged tonsils in children
Children can have physiological tonsillar hypertrophy, which can be of no concern to parents if there are no obvious symptoms. But if repeated inflammation can also cause tonsillar hypertrophy, children are in the growth and development period, parents will look at the immune function of the tonsils more seriously, hypertrophy of the tonsils will bring negative impact on the growth and development of children.
1, tonsil hypertrophy affects the child’s feeding, manifested as slow eating, the child’s body is thin and small.
2, tonsillar hypertrophy affects speech development, manifesting as slurred speech and slurred spitting.
3, tonsil hypertrophy leads to breathing disorders during sleep, and if there is adenoid hypertrophy at the same time, snoring will occur, and in severe cases, there is breath-holding and oxygen deprivation, and sleep disturbance. Poor sleep in children will affect the secretion of growth hormone, leading to slow growth, and lack of oxygen to the brain will affect memory, hyperactivity, grumpiness and inattention.
Therefore, when your child has the above conditions appear, as a parent should think well, such tonsils do not need to be retained. [1][3]
Disease Treatment
Non-surgical treatment
1, drug treatment: acute tonsillitis, chronic tonsillitis acute exacerbation period to antibiotic treatment, drug use should be sufficient amount of full course of treatment. It can be supplemented by some oral Chinese medicine to clear heat and detoxify and reduce symptoms.
2, participate in physical exercise to enhance physical fitness and reduce the chances of upper respiratory tract infection.
3.Take vitamin C and other drugs appropriately.
Surgical treatment
1.Surgical indications
①Recurrent attacks of acute tonsillitis, more than 4 to 5 times a year, or history of peri-tonsillar abscess.
②Tonsils are excessively enlarged, which hinders breathing, swallowing and speech, and this phenomenon is common in children.
(③) Those with chronic low fever and no other lesions other than tonsillitis on systemic examination.
④Nephritis, rheumatism and other diseases due to tonsillitis should be operated electively under the guidance of a doctor.
2. Contraindications to surgery
① Less than 2 weeks after the onset of acute tonsillitis.
②Hematopoietic system diseases and hypocoagulation.
③ Significant hypertension, heart disease, tuberculosis. Otherwise, postoperative pharyngitis symptoms are aggravated.
④Women who are menstruating and 3-5 days before menstruation should not undergo surgery.
⑤ Patients with chronic pharyngitis may not undergo surgery if it is not very necessary, otherwise the symptoms of pharyngitis will be aggravated after surgery.
3.Minimally invasive surgery for tonsils
This issue is a common concern. An adult patient, who had tonsillectomy, recalled the surgery 5 years ago as follows, “It was worse than death, like being tortured!” He was exaggerating a bit, but it is true that tonsil stripping used to be very painful. At that time, local anesthesia was used and the stripping method was used, with more bleeding during the operation and severe pain caused by wound swelling after the operation. However, with the introduction of advanced technology from abroad, patients now do not have to suffer this kind of pain when they have their tonsils removed. Tonsillectomy is a minimally invasive procedure that is performed under general anesthesia, which is very safe and painless for patients. Because it is a plasma procedure, there is almost no bleeding during the operation and the wound recovers quickly afterwards.
If your child has enlarged tonsils and no history of recurrent inflammation, you can perform low-temperature plasma radiofrequency ablation, which preserves part of the tonsil tissue, thus reducing the volume of the tonsils and preserving the immune function of the tonsils, truly the best of both worlds! [3]
Expert opinion
I think now you have a general understanding of the function of the tonsils and tonsillitis. Under normal physiological conditions, the tonsils have an immune function, and it plays a guard role at the first gate of the body, but if the tonsils are repeatedly inflamed and have become a hiding place for bacteria and cause diseases in other organs, it should be looked at differently, and at this time it is not a guard, but an enemy that harms the body and needs to be removed without hesitation!
For children, if they have recurrent tonsillitis, they need to use antibiotics frequently, and as the saying goes, “medicine is three parts poison”, too many antibiotics are not good for health. If your child has enlarged tonsils, along with adenoids that cause snoring and breath-holding during sleep, parents should pay more attention to this because sleep disorders can affect your child’s growth and development, and lack of oxygen can affect brain development, leading to hyperactivity and memory loss. At this moment, as loving fathers and mothers, you should consider: “Keeping such tonsils is not good for the baby, it is harmful to the baby.”
In short, we should oppose both the “harmless theory of surgery” which is to remove all the tonsils regardless of their indications, and the negative attitude of waiting for the chronic inflammation of the tonsils, which affects the baby’s sleep and feeding.