Tonsillitis

In this article:

• Treatment
• At-home care
• Allergy treatment for tonsillitis
• Antibiotics
• Tonsillectomy surgery
• Why tonsils need to be removed?
• How is tonsillectomy done?
• Tonsillectomy recovery
• References

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Treatment

As we know, tonsillitis is a very common condition in children and adults. It is self-resolving in most viral illnesses, and even in bacterial infections (such as Strep throat). Tonsillitis is very painful and children who develop infection of the tonsils feel miserable with high fever, too much saliva in the mouth and severe sore throat whenever they try to swallow. Small children may refuse to eat and drink, and get dehydrated as a result. So, it is extremely important to know measures that can help to get over tonsillitis. Coming to think about it, having some pain killers and throat lozenges at home is not a bad idea, as tonsillitis can start very abruptly.

The guideline update group of ENT doctors and scientists made strong recommendations for the following key action statements: 

1. Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. 
2. Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. 
3. Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

After the acute tonsillitis, tonsils may stay large and cause other problems (troubles swallowing, sleep apnea etc.). in such situations a specialist needs to be involved to assess the situation and find out if there are other conditions that cause tonsils to enlarge. Most common reason for big tonsils without infection is allergy. 

Why tonsils and adenoids stay large in allergic kids? Because tonsils and adenoids are lymph glands, and they increase in size if there is an environmental or food allergy. If allergy test is positive, the Allergist will treat a specific allergy and the tonsils will shrink down without unnecessary surgery.

Sometimes, no matter what you do, there is no other way to get rid of tonsillitis but to remove them. An ENT surgeon will consult you on all possibilities, and explain complications and care. Also, some tonsillitis may have complications, such as peritonsillar abscess, which is an emergency.

At-home care

It is important to know what to use to make tonsillitis go away faster. Here are some very effective measures:

• Drinking cold liquids or eating ice cream 
• Gargling throat with salt water (use sea salt, or the packages for the nose wash, such as NeilMed)
• Soft or liquified foods (apple puree, chicken broth, porridge)
• Avoiding hard foods that create pieces or crumbs (bread, nuts, grains, legumes)
• Avoid spicy or sour foods that can irritate tonsils and cause more saliva to be produced
• Rest is extremely important – sleeping long hours helps the body to recover
• Distracting activities – watching moving or playing games helps not to pay attention to a sore throat.

It is interesting that some children prefer warm liquids during tonsillitis, while others will find chewing on ice and eating ice cream the most helpful. You should try both to see what your child feels better with.

It is important to treat pain in the first 3 days when it can be very intense. The problem you will encounter is the problem with swallowing pills – it hurts. Also, some liquids or pain killers may give a burning sensation. So, try to mix it with food, or get gel caps. Most pain medicines can be found in your local store, and usually have all forms, such as coated tablets, liquid and caps.

Many find honey mixed with tea a great soothing remedy. Don’t forget that black tea has theine, which is close to caffeine so it may interfere with sleep if you have too much before bedtime.

Throat lozenges may help. There are many brands that even have antibacterial qualities and were found to be very efficient in tonsillitis treatment (such as Strepticil).

Allergy treatment for tonsillitis

Large tonsils that do not reduce in size between infections should be investigated for the underlying allergy. What are the most common reasons for tonsillar and adenoid hyperthrophy in children? Here are possible reasons:

• Food allergy or intolerance
• Indoor allergy (cats, dogs, cockroaches, dust mites)
• Mold environmental allergy
• Hay fever (grass and tree allergy)

Usually, there are other signs that you or your child may have large tonsils due to allergies:

1. Congested nose, postnasal drip and frequent sneezing
2. Eye allergy – itchy red eyes with tearing
3. Asthma and chronic cough
4. Eczema and atopic dermatitis
5. Family history of allergies

If you see any of these signs, it is time to do an allergy test and treat the reason for large tonsils. Request the consultation with an Expert Allergist.

Antibiotics

Antibiotics became a life-saving treatment in many severe cases of tonsillitis. Penicillin group is most frequently used, although other choices are also available in the situation of antibiotic resistant bacteria or for people allergic to penicillin.  Do not treat it at home – we recommend to see a doctor if you think antibiotics are needed. Why? Because only is rare situations antibiotics will be prescribed. The overuse or unnecessary use will only create more problems such as:

• Leaky gut syndrome due to killing of the gut bacteria
• Antibiotic resistance
• Allergy 
• Skin rashes

When should antibiotics be used in tonsillitis? First of all, it is important to do a throat swab. Bacteria is then cultured to see which type it is and what treatment will work for it. Also, without antibiotics strep throat goes away within a week, while on antibiotics the sickness may resolve on the second-third day. As infection is cleared faster, the child may return to school safely.

Here are reasons to use antibiotics in tonsillitis:

• Severe infection (high fever, unbearable pain, inability to drink and eat)
• Symptoms are not improving past 3-4 days
• Unusual bacteria in immunodeficient person
• Development of complications (peritonsillar abscess)
• Heart conditions with the risk of pericarditis.

Rheumatic fever was a common complication in the past. Because doctors were afraid it may develop, everyone with Strep Throat was prescribed antibiotics. Now we know that this risk applies only to very few situations listed above.

Tonsillectomy surgery

Tonsillectomy is the term for removing tonsils. It is also called T&A surgery if adenoids are taken out at the same time. In the United States, tonsillectomy is one of the most commonly performed surgical procedures. Over 500,000 cases per year are operated in children less than 15 years of age. According to the American Academy of Otolaryngology-Head and Neck Surgery, it is a “surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule.” 

Why tonsils need to be removed?

Before we knew how important this gland is in protecting us from infections, many children were left without tonsils any time they were big. Now doctors try to leave tonsils in as long as they do not interfere with eating and breathing. The term “kissing tonsils” describes the large tonsils that touch each other. 

Regarding recurrent tonsillitis, it is recommended to use watchful waiting in patients with fewer than seven episodes in the prior year or fewer than five episodes annually in the past 2 years or fewer than three episodes annually in the past 3 years.

 Sleep breathing disorder may start due to tonsils being too large and interfering with normal breathing while a person lays down and sleeps. As a result, there is not enough oxygen going to the brain, and the heart gets overstrained pumping the blood through the body. Signs of SBD include:

1. Loud profound snoring, 
2. Witnessed apnea, 
3. Restless sleeping, 
4. In children: growth retardation, poor school performance, and nocturnal enuresis.

Two common reasons for this surgery are:

• sleep breathing disorder (SBD)
• recurrent (too many) throat infections. 

How is tonsillectomy done?

The equipment required for tonsillectomy depends on the technique used. “Cold” tonsillectomy is performed using a Crowe-Davis or McIvor mouth gag, Allis clamp, no. 12 scalpel, curved Metzenbaum scissors, Fisher tonsil knife/dissector, Tyding snares, adenoidectomy curettes, and a St. Clair-Thompson adenoid forceps. “Hot” tonsil dissections are performed using monopolar cautery. Bipolar radiofrequency ablation (i.e., coblation) is also an option. Mircodebrider techniques are also used (especially when performing intracapsular tonsillectomies).

Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.

Several complications can occur with a tonsillectomy and include bleeding, velopharyngeal insufficiency, and dehydration.

Tonsillectomy recovery

As your surgeon about the post-surgery care. It is important to get prepared to avoid hospital visits. The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process. 

Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea.

Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). 

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References

Kocher JJ, Selby TD. Antibiotics for sore throat. Am Fam Physician. 2014 Jul 01;90(1):23-4. [PubMed]

Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary.

Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, et al.Otolaryngol Head Neck Surg. 2019 Feb; 160(2):187-205. https://pubmed.ncbi.nlm.nih.gov/30921525/ 

Pharmacologic management of post-tonsillectomy pain in children.

Jensen DR.World J Otorhinolaryngol Head Neck Surg. 2021 May 29;7(3):186-193. doi: 10.1016/j.wjorl.2021.03.004. eCollection 2021 Jul.PMID: 34430826 Free PMC article. Review.

Binotto M, Guilherme L, Tanaka A. Rheumatic Fever. Images Paediatr Cardiol. 2002 Apr;4(2):12-31. [PMC free article] [PubMed]

Ickrath P, Morbach H, Schwaneck EC, Gehrke T, Scherzad A, Hagen R, Hackenberg S. [Recurrent infections of the upper aerodigestive tract in patients with primary immunodeficiency]. HNO. 2019 Nov;67(11):819-824. [PubMed]

Morad A, Sathe NA, Francis DO, McPheeters ML, Chinnadurai S. Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review. Pediatrics. 2017 Feb;139(2) [PMC free article] [PubMed]