Tonsils

What Are the Tonsils and Why Are They Important in Children

The tonsils are clusters of lymphoid tissue located on either side of the throat, visible to the left and right of the uvula when the mouth is opened. In medical terminology they are also known as the “palatine tonsils”. Like the adenoid, they are part of the immune system; the tonsils are among the first to come into contact with microbes entering through the mouth and nose. For this reason they work actively during childhood, throughout the period in which the immune system is maturing, and physiologically appear relatively large.

Tonsil tissue is not in itself a “defect”, nor is it by default a structure that needs to be removed. The problem begins when the tonsils carry out this normal role to an excessive degree — that is, when they become inflamed frequently — or when their size reaches the point of obstructing the child’s airway and swallowing. These two problems operate independently of one another: a child whose tonsils become inflamed frequently may have small tonsils, while a child with very large tonsils may never have had an episode of inflammation. For this reason the decision-making process is not a simple assessment of “size”.

In paediatric ENT practice, tonsil surgery is a topic that, when performed with the correct indication, provides a marked improvement in the child’s quality of life; yet when recommended unnecessarily, it becomes an avoidable surgical burden. At the centre of the assessment, therefore, lies the question: “For this child, given the current presentation, which category applies?”

From the Parent’s Perspective: What Different Findings Mean

Tonsil problems fall into two main groups, and their findings differ:

The Pattern of Frequent Recurrent Infection

• Multiple episodes per year of throat infection with high fever
• Antibiotic use with every episode, the child being bedridden for the duration of the episode and unable to attend school
• White spots, discharge, and bad breath on the surface of the tonsils
• Marked pain on swallowing, the child not wanting to eat
• Episodes concentrated particularly in the autumn and winter months, but recurring in the summer as well
• The tonsils not fully returning to normal between episodes, with a chronically reddened appearance

The Pattern of Enlargement (Hypertrophy)

• Pronounced, regular snoring during sleep
• Pauses in breathing during sleep, with breathing resuming as though the child were “choking”
• The child’s mouth being constantly open during sleep, sweating, and tossing and turning at night
• Daytime fatigue, poor concentration, or conversely a hyperactive appearance
• Difficulty swallowing certain foods (especially large mouthfuls, dry bread, meat)
• A muffled tone of voice, as if there were a potato in the mouth (“hot potato” speech)
• Poor appetite and below-expected weight gain

Both patterns may be present together in the same child; in these cases the decision is clearer. Situations in which only one pattern is pronounced, however, require careful differentiation.

Causes and Risk Factors

• Recurrent upper respiratory tract infections: Bacterial complications following the viral infections frequently contracted during the nursery and school years.
• Streptococcal infections: Group A beta-haemolytic streptococci in particular are the most common bacterial cause of childhood tonsil inflammation; when not treated appropriately, they are significant in terms of distant-organ complications (rheumatic fever, kidney involvement).
• The natural course of immune maturation: The physiologically large size of tonsil tissue at young ages exceeds the usual limit in some children.
• Allergic background: Allergic rhinitis indirectly triggers tonsil problems by predisposing to frequent upper respiratory tract infections.
• Family history: A similar history in the mother or father supports a similar course in the child.
• Passive smoke exposure: Increases the frequency of recurrent infection.

The Diagnostic Process

In most cases, tonsil assessment is carried out through a careful history and physical examination, without the need for special imaging.

1. Detailed history: The febrile throat episodes of the past 1-2 years are counted. The points investigated for each episode are: the height of the fever, whether antibiotics were used, school days lost, and the interval between episodes. At the same time, sleep pattern, snoring, daytime fatigue, and difficulty eating are enquired about.
2. Physical examination: The size of the tonsils is recorded using a standard grading system (Brodsky/Friedman grades 1-4). In the same session the adenoid, eardrums, and nose are also assessed; in a child with a tonsil problem, adenoid enlargement frequently accompanies it.
3. Endoscopic assessment: Where necessary, the degree of obstruction in the upper airway is assessed endoscopically.
4. Audiological tests: In a child with a history of recurrent upper respiratory tract infection, the middle ear is also assessed; in the same session as the tonsil decision, it is determined whether ventilation tube treatment is required.
5. Sleep history and, where necessary, a sleep study: In children with pronounced snoring and pauses in breathing, a sleep study may be recommended to determine the degree of sleep apnoea; the threshold is lower particularly when there is an additional condition (obesity, heart/lung problem).

Treatment Approaches: Medical First, Surgical If Necessary

Medical Treatment of the Acute Episode

In acute tonsil inflammation of bacterial origin, an appropriate antibiotic is used, supported by culture or a rapid strep test. The full course of treatment (usually 10 days) must be completed; an antibiotic stopped early predisposes to recurrences and distant-organ complications. In presentations thought to be of viral origin, rest, fluid intake, and symptomatic medication are sufficient.

Situations in Which Surgery Is Considered

The established international indications for tonsil surgery (tonsillectomy) are as follows:

Criteria for frequent recurrent infection (Paradise criteria):

• 7 or more episodes in the past year, or
• 5 or more episodes in each of the past 2 years, or
• 3 or more episodes in each of the past 3 years

Each of the episodes is expected to include a documented fever, clinical findings, and a physician’s assessment. In cases falling below these criteria, waiting is generally the appropriate approach, because the frequency of episodes usually decreases on its own as the child grows.

Other indications:

• Obstructive sleep apnoea due to the size of the tonsils
• Hypertrophy of a degree that affects the child’s swallowing, feeding, or speech
• Recurrent peritonsillar abscess (abscess formation around the tonsil)
• Chronic tonsillitis not responding to antibiotic treatment
• Suspicious, one-sided enlargement (rare; requires further investigation)

How the Surgery Is Performed

Tonsillectomy is performed via the mouth while the child is under general anaesthesia; there is no skin incision. Alongside classic tonsillectomy, in which the tonsil is removed entirely, a tonsillotomy (intracapsular/partial) technique, in which part of the tissue is preserved, may also be preferred in cases aimed at opening the airway; this technique offers less pain and faster recovery, and is particularly relevant in procedures performed for sleep apnoea in the younger age group. In cases performed because of frequent inflammation, complete removal is preferred.

In most cases the adenoid is also assessed in the same session as the tonsil surgery; if necessary, an adenoidectomy is performed under the same anaesthesia. This is an established approach to avoid giving the child anaesthesia twice.

The procedure takes 30-45 minutes. Discharge is usually planned for the same day, sometimes after one night of observation.

The Process and Recovery

Recovery after tonsil surgery is longer and more painful than after adenoid surgery. This is a fact that parents should be aware of in advance; however, with well-planned pain management and diet, the process can be managed safely.

• First 24 hours: Throat pain; paracetamol is used at regular intervals and ibuprofen as required. Aspirin is not given. Plenty of fluid intake is the most important supportive treatment.
• Days 1-3: Throat pain is generally most intense during this period. Cold, soft foods (yoghurt, ice cream, purée, soup) are recommended. Hot and acidic foods (orange juice, tomato juice) are restricted during this period.
• Days 4-7: A white layer (fibrin) forms inside the mouth; this is normal, part of the healing process, and does not call for alarm. Temporary bad breath may occur.
• Days 7-10: The fibrin layer begins to lift. This period is approached carefully in terms of the risk of delayed bleeding; for this reason the restriction on activity covers this period.
• Days 10-14: Recovery is largely complete. The child returns to a normal diet, and subsequently to normal activity.

What matters during recovery is: plenty of fluid intake, regular administration of painkillers (planned, rather than only when there is pain), avoiding strenuous physical activity and hot baths, and an environment free of smoke. Swimming pools, the sea, and air travel are not planned during this period without the physician’s approval.

The matter of the effect on immunity is asked about frequently: when the tonsils are removed, the child’s immunity is not weakened; other lymphoid tissues that take on the same role (in particular the base of the tongue and other pharyngeal lymphoid tissues) carry on this function. Clinical observation indicates that children whose tonsils have been removed become ill less often within a short time and that their school attendance improves.

The Effect on School and Development

The long-term effects of tonsil problems are not limited to the days of an episode alone. A child who has 7 episodes a year loses not only the days of the episodes but also the periods of malaise before and after them. In practice this means being unable to attend school regularly, falling behind in lessons, and missing out on social activities.

In cases related to enlargement the picture is different: the child is not ill, but is unable to sleep well every night. A child who sleeps poorly at night may show daytime inattention, dozing in class, or conversely hyperactive behaviour; this picture is sometimes confused with attention deficit disorder. It is a course frequently observed in paediatric ENT practice that, once the sleep pattern is restored after surgery, daytime fatigue, the concentration problem, and even school performance recover markedly.

When sleep apnoea caused by the tonsils is left untreated, it may, in the long term, even affect the growth curve through the cardiovascular system and the release of growth hormone. This is the concrete reason why the picture of the merely “snoring child” should not be taken lightly.

The Parent’s Concern: “Is It Too Early?”

Another question families often raise is, “Can a child have surgery at this age, or could we wait?” The answer depends not on the child’s age but on the severity of the presentation. If the tonsils are causing sleep apnoea, the cost of waiting is high: the child continues to sleep poorly every night, and the effects on growth and concentration accumulate. In the pattern of frequent inflammation, on the other hand, waiting is sometimes reasonable, because after the age of 6-8 the frequency of episodes usually decreases on its own. The decision is made according to the child’s overall picture, far beyond a “surgery with every febrile episode” approach.

When to Consult a Paediatric ENT Physician

The following situations are grounds for an assessment; none of them in itself means surgery:

• More than 5 febrile throat infection episodes in the past year
• Successive episodes requiring antibiotic treatment
• The child snoring regularly, particularly when pauses in breathing are noticed
• The child’s mouth being constantly open during sleep, sweating, restless sleep
• Marked difficulty swallowing foods such as large mouthfuls, meat, and bread
• Persistent muffled speech, bad breath
• One-sided enlargement of the tonsils (rare; assessed separately)
• Serious disruption to the child’s school attendance because of episodes

The decision is not merely a check against a numerical threshold; the child’s general health, any accompanying adenoid or middle-ear problems, the impact on quality of life, and parental observation are assessed together. The assessment of an experienced paediatric ENT physician allows the correct boundary between surgery and waiting to be drawn; in most cases this boundary lies far beyond a “surgery with every febrile episode” approach.

Commonly Confused Points

It is helpful to underline some of the points parents frequently ask about. “Tonsil-shrinking” treatment comes up in some practices; in situations where the decision to remove has been made because of frequent inflammation, shrinking alone is not sufficient, because the real problem is not size but the focus of infection. Conversely, in cases of sleep apnoea caused solely by enlargement, the tonsillotomy technique, in which part of the tonsil is removed rather than the whole, stands out for its faster recovery and less pain. This choice is planned according to the child’s age, presentation, and the surgeon’s experience; the assumption that “every tonsil operation is the same” is not correct.

The second commonly confused point: the expectation that the child will never again have a throat infection once the tonsils are removed. This expectation is not realistic. After the tonsils are removed, the frequency of throat infection decreases markedly; however, the other tissues of the throat can also become inflamed (pharyngitis). What matters is that the cycle of febrile, antibiotic-requiring presentations that left the child bedridden before surgery no longer recurs.

The third matter: bad breath. This is a common parental complaint; tissue debris accumulating within the crypts of the tonsils (caseous plugs, or tonsil stones) can be the cause of this odour. Odour alone is not in itself an indication for surgery; however, if a picture of frequent inflammation and enlargement is also present, this complaint too is largely eliminated after surgery.