Swollen tonsils
Swollen or large tonsils is called tonsillar hyperthrophy in medicine. This condition is extremely common. It is caused by an inflammation when tonsils grow in size due to immune cells multiplying. Tonsil is a gland that is similar to a lymph node, only it sits in the throat (and is not hidden under the skin like other lymph nodes).
In this article:
- What Is swollen tonsils?
- Causes
- Other symptoms
- Complications
- Could it be cancer?
- Swollen tonsils with no pain
- Swollen tonsils without a fever
- One-sided swelling
- Why do tonsils get infected?
- Diagnosis
- Tests
- Prevention
- When to see a doctor
- References
What Is swollen tonsils?
Swollen or large tonsils is called tonsillar hyperthrophy in medicine. This condition is extremely common. It is caused by an inflammation when tonsils grow in size due to immune cells multiplying. Tonsil is a gland that is similar to a lymph node, only it sits in the throat (and is not hidden under the skin like other lymph nodes).
Tonsils are a part of the immune system, and play an important role in recognizing an infection or an allergen. They signal to the central immunity of the body when it needs to react upon intrusion. You can think of tonsils as outpost on the border of the country, where all proteins that you eat or inhale get checked.
The tissue of the tonsils is filled up with various immune cells – dendritic cells that identify proteins, and lymphocytes which kill intruders. If a person is allergic to a food or a cat fur, even a tiny particle will be recognized when it touches an immune cell in the nose or mouth. Then a full inflammatory attack is launched by immunity to destroy that protein and rescue a person. The tonsils become large and sometimes get infected, if the virus or bacteria get through the defenses.
Sometimes tonsils stay swollen even if there is no infection, or don’t shrink when infection is gone. In this case an allergy should be suspected.
Causes
Human paired palatine tonsils are lymphoid epithelial glands. They are part of the Waldeyer’s ring of lymphoid tissue protecting the entry into the inner portions of the lungs and guts:
- Tonsils
- Adenoids
- Lingual tonsils.
Palatine tonsils are strategically located to generate gut and lung protective (mucosal) immunity, as they are constantly exposed to dietary and airborne particles (antigens), bacteria and viruses.
The surfaces of the human body, including mouth and pharynx, are colonized by several microbes, mainly bacteria, that establish a symbiotic relationship with the human body. The good bacteria that safely lives in our organism is called microbiome. If there is no balance in our internal bacteria (overgrowth or lack of certain types), the immune system also becomes unbalanced.
Our protective immunity has certain cells that are responsible for protection from infectious organisms, as well as internal balance of the tissues and organs. Tonsils are predominantly B-cell organs, immunologically most active between 4 and 10 years old. If there is a problem with the activity of these cells, an allergic abnormal response to certain proteins develops instead of normal tolerance.
In children (also some adults) it was recently discovered that the immune B cell overpopulation due to chronic allergies or colonization with unwanted bacteria causing swelling and increase in size of tonsils (hyperplasia and hypertrophy).
Such enlargement is the major reason responsible for the obstructive sleep apnea (OSA), an extremely common disease, recognized as a major public health burden. OSA is characterized by repeated events of partial or complete upper airway obstruction (apnea) during sleep that lead to disruption of normal breathing with all the consequences implied due to lack of oxygen delivery to tissues.
Interestingly, scientists found that in children with large tonsils a different type of bacteria was present in the tonsil folds. It is not known what came first – a problem with immunity or imbalance of the microbiome.
Other symptoms
Swollen tonsils cause many symptoms of concern:
- Snoring
- Mouth breathing
- Neuro-behavioral problems
- Developmental concerns
- Eating aversion, swallowing disorders, gaging
- Dental problems
Babies and very young children who are breastfeeding may have a significant problem with sucking and spitting. This in turn affects growth and weight gain. Throat exam should be a part of workout for babies with growth retardation and breastfeeding/feeding issues.
The presence of snoring, whether associated with apnea or respiratory distress during sleep, is a frequent complaint among parents or caregivers. It is followed by restless sleep, frequent night awakenings, bruxism, somnambulism.
Chewing, swallowing, and speech problems are also observed. As we mentioned before, it is likely that the child with large tonsils will also have adenoidal hyperthrophy and ear fluid. All these factors may significantly impact an ability to develop normal hearing and speech, and should be addressed immediately. Mouth breathing is the first giveaway in children with congestion and swollen tonsils.
As children with tonsillar and adenoid hyperthrophy continue to use their mouth for breathing, the bones of the jaw do not develop properly causing crooked teeth and wrong bite. Maxillary arch atresia and the presence of high arched palate are common findings associated with cross-bite, which can already be observed in preschool children.
Complications
Obstructive sleep apnea syndrome (OSAS) is the most severe form of respiratory sleep disorders, and affected children and adults may have severe problems:
- Attention and concentration deficits
- Hyperactivity, irritability
- Sleep disorders (terrors, sleepwalking etc.)
- Morning tiredness and daytime somnolence
- Decreased conceptual, verbal and non-verbal reasoning skills
- School disorders
- Delayed weight and height gain in children.
Could it be cancer?
Swollen tonsils are rarely the sign of cancer. If you are concerned about cancer possibility, it is important to schedule an appointment with Immunologist. A specialist will be able to examine you for other signs of cancer (weight loss, large lymph nodes etc.). It is important to have the correct diagnosis, as many things you read online are scary, and will cause unnecessary worries if you do not talk to a medical professional.
No previous case series for asymmetrical tonsils have detected tonsil lymphoma.
Swollen tonsils with no pain
This is the most frequent symptom of tonsillar hyperthrophy. As swollen big tonsils can be normal in children, you should not worry, unless there are other problems listed above.
Swollen tonsils without a fever
Tonsils do get bigger during viral infections, even if there is no fever. If you suddenly discovered large tonsils, don’t panic yet. It is possible you just did not notice them before. If the tonsils are red and there is also sore throat – you might be having a viral infection.
These symptoms usually go away within one-two weeks. It is a good idea to get checked with your primary care provider if swollen tonsils do not reduce back to normal size.
Swollen tonsils because of allergy. If there are other symptoms of the allergy, such as sneezing, red itchy eyes, congested nose – you need an appointment with an Allergist. The common conditions that may be present together with enlarged tonsils due to allergy:
- Food allergy
- Allergic rhinitis
- Eye allergy (red eyes)
- Postnasal drip
- Chronic cough
- Asthma
- Atopic dermatitis, eczema
One-sided swelling
Although it is more common to have both tonsils of the same size, one-sided swelling also does occur. Your child also may have asymmetric tonsils and be completely healthy. A literature search demonstrates plenty of reports of tonsil asymmetry in children with no malignancy found. A Turkish epidemiological study found asymmetrical tonsils in 1.7% of the healthy pediatric population.
Why do tonsils get infected?
Tonsils are glands that supposed to fight off infections. In some cases, bacteria or viruses get through the body defense mechanisms and infect the tonsillar tissue. Such situation leads to tonsillitis.
Most infections of the tonsils are self-resolving and need only supportive treatment for pain and discomfort. Only few tonsillitis actually need treatment with antibiotics, such as Scarlatina.
Diagnosis
Diagnosis of the swollen tonsils is straightforward – it is done by mouth exam. Unfortunately, finding the actual reason why tonsils continue to stay large can take some time. When you first see a doctor or a nurse practitioner, here is what is usually done:
- History. You will be asked to fill out forms with important medical facts, and answer plenty of questions if that is your first visit. The same will happen if you are referred to a specialist. Try to recall the timing and events that happen right before the tonsils became large
- Family history. Allergy and atopy run in families, so do large tonsils!
- History of exposure. As infections and allergies are the most frequent causes, try to remember if you got a new cat, or moved into a house with mold problems right before you have noticed swollen tonsils. A close contact with someone who has mononucleosis or strep throat is a giveaway for your large tonsils.
Tests
There are some tests that may help a doctor to discover why the tonsils are big:
- Blood analysis may show increased white cells in infection, or increased IgE and eosinophils if there is an allergy
- Allergy test. the blood analysis screening may demonstrate atopy. The skin test will identify which proteins (aeroallergens or food allergens) may be involved in tonsillar hyperthrophy
- Throat swab is done for infections. Rapid antigen tests may show that there is a Mono, COVID-19, or Strep throat.
Prevention
In many cases there is no way to prevent swollen tonsils. Once the cause of tonsillar hyperthrophy established, you can prevent a recurrence by:
- Healthy lifestyle that improves immune function
- Infection prevention
- Allergy control
When to see a doctor
There is no reason to worry if you saw big tonsils without any other symptoms. It happens frequently without any disease, and the cancer is extremely rare. So, it might be that you just never looked closely at your (or your child’s) tonsils before. The reason to see a doctor is when the large tonsils affect other functions:
- Breathing with open mouth
- Snoring and sleep apnea
- Problems swallowing, gaging with food
- Problems with speech development in children
- Frequent infections with strep throat
As we mentioned before, many children have large tonsil, which is normal. Do not rush to surgically remove tonsils, as they are an important organ of the immunity. Most of them will shrink down by adolescence.
References
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