Infections And Surgical Removal Of Tonsils And Adenoids

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Infections And Surgical Removal Of Tonsils And Adenoids

Tonsils and adenoids are tissues that generally partake in the body’s defense mechanism...

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What are the tonsils and adenoids? What are their functions?

Tonsils and adenoids are tissues that generally partake in the body’s defense mechanism (such as antibody production) in that they act against microbes entering the body through the mouth or nose as well as some other harmful structures (antigens, etc.). They are part of a formation called the Waldeyer’s Ring which is located around the oral and nasal orifices as a first line of defense.

Could you please give some general information about tonsilitis? 

Infections of the tonsils are more prevalent in childhood. They usually have a quick onset, with symptoms like sore throat, fever, sweating and shivering. Accompanying complaints are difficulty in swallowing, headache, weakness, and joint pain. In most patients, tonsilitis comes together with infections of the pharynx and adenoids.

Tonsilitis is mostly caused by viruses (70 to 80%). It has been reported that a majority of bacterial infections are caused by GABHS (Group A beta-hemolytic streptococci). The disease is transmitted through droplets. GABHS most often cause tonsilitis in children aged 5 to 15. Diagnostic cultures are used to diagnose infections caused by GABHS.

Physical examination is mostly insufficient to decide whether an infection is of a viral or bacterial nature. Infections caused by GABHS are characterized by red spots on the tonsils, followed by edema and white spots (cryptic tonsils). Fever and swelling of the lymph nodes in the neck are among the expected findings in these patients, whereas the symptoms in viral infections mostly include cough, runny nose, red eyes and diarrhea.

How is tonsilitis treated?

Drinking plenty of fluids and resting are very important while treating the disease. Antipyretics should be administered to treat fever and weakness. Supportive drug treatment like sprays, gargles or pastilles can be used to treat sore throat. If caused by GABHS, antibiotic therapy must be administered. The aim of antibiotic therapy is to reduce complaints rapidly, prevent side effects (abscess, rheumatic fever leading to rheumatic heart disease, kidney problems etc.), and avoid spread of the disease. The antibiotics that can be used are penicillin, cephalosporins, azithromycin, erythromycin and clarithromycin. Antibiotic treatment should be continued for 10 days. Recently, a single dose of steroid (10 mg dexamethasone i.m) is also recommended in addition to the foregoing.

Could you please give some information about adenoiditis? 

The symptoms seen in adenoiditis are purulent nasal discharge, fever, postnasal drip and cough. Adenoiditis is oftentimes accompanied by sinusitis and middle ear infection.

Avoiding cigarette smoke, dusty environments and daily nasal cleaning are effective in preventing adenoiditis.

Adenoiditis can be confused with certain other diseases including sinusitis, foreign body in nose, allergy, hypertrophic conchae, and deviated nasal septum.

What can be done to treat adenoiditis? 

Daily nasal cleaning, staying away of dusty and/or smoky environments and avoiding allergic substances play an important role in treatment. Patients are advised to take plenty of fluids, take antipyretics/painkillers, and use antibiotics in bacterial infections.

When is a tonsillectomy needed? 

Tonsillectomy is done for reasons like infection, obstruction or tumor.

1- Infections:

The tonsils should be removed in cases where any of the following occurs:

  • In children, recurrent tonsilitis 3 to 5 times in a year or more than 3 times in 2 consecutive years. In adults, recurrent tonsilitis 2 or more times in a year
  • Tonsillar abscess during recurrent tonsilitis
  • Febrile convulsion attributable to recurrent tonsilitis
  • Tonsil stones
  • Bad breath, constant sore throat or swelling of the lymph nodes in the neck due to recurrent tonsilitis
  • Valvular heart disease or rheumatic fever leading to rheumatic heart disease accompanied by recurrent tonsilitis
  • Non-healing middle ear infection accompanied by recurrent tonsilitis

2- Obstruction:

The tonsils should be removed if enlarged tonsils give rise to any of the following:

  • Obstructive sleep apnea
  • Sleep disorders, swallowing difficulty, growth / developmental delay, speech disorder that cannot be explained otherwise
  • Facial growth disturbances attributable to obstruction

3- Tumor-related reasons:

The tonsils should be removed due to suspected tumor in the following cases:

  • Disproportionately enlarged tonsil compared to the other (suspected tumor)
  • Tumor foci investigation in cases of neck metastasis of unknown origin

Note: Recurrent bleeding in tonsils is also a reason for tonsillectomy.

When is an adenoidectomy needed? 

Adenoidectomy is done for reasons like infection or obstruction.

1- Infections: 

The adenoids should be removed to treat any of the following:

  • Fluid buildup in the middle ear persistent over longer periods of time
  • Recurrent middle ear infections
  • Middle ear infections with discharge that does not respond to drug therapy
  • Discharge that cannot be stopped with drug therapy in patients that have ear tubes inserted into the eardrum
  • Chronic sinusitis that does not respond to drug therapy

2- Obstruction: 

The adenoids should be removed if enlarged tonsils give rise to any of the following:

  • obstructive sleep apnea accompanied by enlarged adenoids
  • growth / developmental delay, speech disorder, facial and chin growth disturbances that are accompanied by enlarged adenoids and cannot be explained otherwise

What are the points to consider in patients before their adenoids and/or tonsils are removed? 

There is no definite age limit for these surgeries. However, post-operative undesirable side effects can be more frequent among patients younger than 4 years old.

Bleeding tendency must be ruled out prior to surgery.

Before surgery, the patient should be assessed for occult cleft palate. Particular attention should be paid to children with Down syndrome. (increased dislocation risk in cervical spine)

When should adenoidectomy and tonsillectomy be avoided? 

Generally speaking, bleeding tendency and cleft palate are contraindications for surgery. Surgery should be rescheduled to a more convenient date if the patient has an active infection or is taking blood thinners.

How are adenoidectomy and tonsillectomy done? Could you please briefly explain the techniques used for surgery? 

Both surgeries are preferably done under general anesthesia. However, tonsillectomy can also be performed under local anesthesia in adults.

Special instruments called adenotome or curette are used to remove the adenoids, while there are several techniques available for tonsil removal including cold knife, cautery, laser, radiofrequency or microdebrider. Each technique has its own advantages and disadvantages.

Can tonsils be reduced instead of complete removal? 

Nowadays, partial removal of tonsils instead of complete removal is a popular practice in children who suffer obstruction due to enlarged tonsils. Patients whose tonsils are removed partially experience less postoperative pain and they can resume their normal lives quicker. However, in the long run, tonsil tissue left behind in partial removal is more likely to grow back and cause complaints anew when compared to complete removal.

What side effects can be seen after adenoidectomy and tonsillectomy? 

There may be some side effects in the aftermath of these surgeries.

Bleeding: Excessive bleeding is quite uncommon in these surgeries. Nevertheless, bleeding can be more likely to occur in patients with history of frequent infection or adhesions to surrounding tissue or if surgery is done when infection is still active. Bleeding risk in these surgeries has been reported to a range between 0.1 and 5%.

Hypernasality: Neither surgery should be done if the patient has cleft palate or occult cleft palate. Hypernasality risk is between 1/1500 and 1/10000.

Pain: While postoperative pain after adenoidectomy is well tolerable, pain after tonsillectomy may last for 1 week up to 10 days after surgery.

Is removal of the tonsils and adenoids harmful to the immune system? 

To date, no harm to the immune system has been reported after these surgeries.

Can the tonsils and adenoids grow back after surgery? 

The rate of cases where a patient needs to be reoperated due to the adenoids growing back after adenoidectomy is 0.5%. The chance for the tonsils to grow back after tonsillectomy, thus requiring reoperation, is almost zero.

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