Sore throat is common and not always due to tonsillitis. Most acute sore throats are viral in origin. It is often difficult to tell the difference between viral and bacterial infections. Most patients recover within one week.
The most common bacterial cause is due to bacteria called group- A beta-haemolytic Streptococcus. (“Strep throat”).
Infection with bacteria can rarely lead to complications such as quinsy, (tonsil abscess) nephritis (kidney inflammation) and rheumatic fever, (heart and joint inflammation).
Antibiotics (e.g. penicillin for 10 days) will reduce the rate of complications, but the number of patients needed to treat to prevent one episode of a complication is large.
The commonest cause of chronic sore throat in adults is chronic pharyngitis, which is non-infective (E.g. smoking, alcohol, gastro-oesophageal reflux disease (GORD) = acid indigestion).
In acute bacterial tonsillitis, the patient is usually unwell, with large tonsils covered in white matter called exudates, a fever and sometimes headache and swollen glands in the neck. Other causes, such as glandular fever (particularly in teenagers) may cause a similar appearance. Ampicillin or amoxicillin may cause an unpleasant skin rash if glandular fever is the cause of the infection; penicillin is usually prescribed, as this does not produce this effect. Glandular fever is also known as infectious mononucleosis. The indications for routine tonsillectomy remain controversial. Family, medical and social factors may play a part in the decision process. Despite the absence of high-level scientific evidence to support tonsillectomy, patient and parent satisfaction rates are high for the health benefits following surgery.
Frequently asked questions
What are the tonsils and what is their purpose?
The tonsils form part of the upper food and air passage immune sampling system in early childhood. They help to establish systemic immunity, but probably become redundant after the age of three or four years.
Why do they cause problems?
Like the appendix, they may become acutely or chronically inflamed or infected.
When is tonsillectomy considered?
Generally for recurrent infections, airway obstruction causing breathing and eating difficulties or rarely, when a tumour is suspected.
Can you tell the difference between viral and bacterial tonsillitis?
This is not possible clinically, and treatment depends on severity of pain and general features (e.g. fever and swollen glands). Viral infections, e.g. infectious mononucleosis may be more severe than bacterial streptococcal tonsillitis.
How is glandular fever managed?
This depends on severity. If the systemic symptoms are severe with difficulty swallowing, severe pain and high fever, admission to hospital for intravenous antibiotics and steroids is indicated. Glandular fever may cause inflammation of the liver and of the joints.
Is there an age limit (both upper and lower) that tonsillectomy will be considered?
The small risk of preoperative or post-operative blood loss means that tonsillectomy is generally avoided in children under 15kg weight, approximately three years of age. There is no absolute upper age limit, if the patient is generally fit and the indications for surgery are appropriate. Is there a risk of contracting vCJD (“mad cow disease”) from the operating equipment during tonsillectomy? The National Patient Safety Agency is at the time of writing, conducting an anonymous collection of 100,000 tonsils across the UK to see if people carry the vCJD prion in their tonsils. The study is not yet complete, but the examination of thousands of tonsils has, so far, shown no evidence of risk of vCJD prions in tonsils removed during operations.
How are the tonsils removed in the 21st century?
The standard technique remains cold dissection with instruments and ties to the bleeding points. This is a safe technique, although the blood loss at the time of surgery may be higher and this is a consideration for small children having the operation. Many other techniques are available. Electric diathermy and Coblation dissection have the advantage of less blood loss at the time of surgery, but a slightly higher secondary bleed rate for some surgeons. The laser has fallen out of favour because of the much higher post-operative pain.
Is it true that not all the tonsil tissue is removed?
All the pharyngeal tonsil is removed at the time of tonsillectomy. The old technique of guillotine tonsillectomy sometimes left remnants that could grow back. These remnants could then become infected.
Who is suitable for day case surgery and who would require inpatient stay?
Generally, adults and children who are fit and well with no bleeding or bruising disorders are fit for day surgery.
What is the recovery time after surgery? Is there a difference in adults and children?
It is wise to allow a two week convalescence period. Children do seem to recover more quickly than adults, although the recovery is very variable for both groups.
What are the risks of tonsillectomy?
The risk of most concern is bleeding, either during the operation or during the recovery period. The risk is about 2-5%. Pain in the throat and ears is usual and requires effective analgesia. Paracetamol, ibuprofen and codeine are common combination painkillers after tonsillectomy. Some surgeons routinely prescribe antibiotics. Anaesthetic complications are rare. Damage to the teeth is a potential complication.
Is there any long-term risk to having your tonsils removed (e.g. reduced immune function)?
There is no good evidence that tonsillectomy reduces immune function or makes people more prone to chest infections. If possible, it is probably wise to avoid tonsillectomy in children less than three years of age as the tonsils may be functioning to help establish their immunity.
What makes you decide to remove the adenoids at the same time?
The adenoid is usually removed for symptoms of upper airway obstruction with tonsillectomy. It may also be removed to help treat glue ear at the same time as grommet insertion. As these are common conditions, more than one of these procedures may be indicated in a child at the same time.
What exactly is a quinsy, and how should they be managed?
A quinsy is an abscess that forms around the tonsil. Initially there is a swelling of the tissue around the tonsil and then the abscess forms. Generally, admission for fluids and antibiotics by a drip is required. If the abscess is pointing it may be lanced with local anaesthesia.
Are there alternatives to having the tonsils removed?
Your child will not always need to have his or her tonsils out. You may want to just wait and see if the tonsil problem gets better by itself. Children often grow out of the problem over a year or so. The doctor should explain to you why he or she feels that surgery is the best treatment.
Antibiotics may help for a while, but frequent doses of antibiotics can cause other problems. A low-dose antibiotic for a number of months may help for to keep the infections away during an important period such as during examinations. There is no evidence that alternative treatments such as homeopathy or cranial osteopathy are helpful for tonsil problems. You may change your mind about the operation at any time, and signing a consent form does not mean that your child has to have the operation. If you would like to have a second opinion about the treatment, you can ask your specialist. He or she will not mind arranging this for you. You may wish to ask your own GP to arrange a second opinion with another specialist.
Before your child’s operation
Arrange for a couple of weeks off school. Let us know if your child has a sore throat or cold in the week before the operation - it will be safer to put it off for a few weeks. It is very important to tell us if your child has any unusual bleeding or bruising problems, or if this type of problem might run in your family.
How is the operation done?
Your child will be asleep. We will take his or her tonsils out through the mouth, and then stop the bleeding. This takes about 20 minutes. Your child will then go to a recovery area to be watched carefully as he or she wakes up from the anaesthetic. He or she will be away from the ward for about an hour in total.
How long will my child be in hospital?
In some hospitals, tonsil surgery is done as a day case, so that he or she can go home on the same day as the operation. Other hospitals may keep children in hospital for one night. It may depend on whether your child has their operation in the morning or the afternoon. Either way, we will only let him or her go home when he or she is eating and drinking and feels well enough.
Can there be problems?
Tonsil surgery is very safe, but every operation has a small risk. The most serious problem is bleeding. This may need a second operation to stop it. About two children out of every 100 who have their tonsils out will need to be taken back into hospital because of bleeding, but only one child out of every 100 will need a second operation. Please let us know before surgery if anyone in the family has a bleeding problem.
During the operation, there is a very small chance that we may chip or knock out a tooth, especially if it is loose, capped or crowned. Please let us know if your child has any teeth like this. Some children feel sick after the operation. We may need to give your child some medicine for this, but it usually settles quickly.
Your child’s throat will be sore
Your child’s throat will get better day-by-day. Give him or her painkillers regularly, half an hour before meals for the first few days. Do not give more than it says on the label. Do not give your child aspirin - it could make your child bleed. (Aspirin is not safe to give to children under the age of 16 years at any time, unless prescribed by a doctor).
Eat normal food
Eating food will help your child’s throat to heal. It will help the pain too. Always give him or her a drink with every meal. Chewing gum may also help the pain.
Your child may have sore ears
This is normal. It happens because your throat and ears have the same nerves. It does not usually mean that your child has an ear infection.
Your child’s throat will look white
This is normal while your throat heals. You may also see small threads in your child’s throat - sometimes these are used to help stop the bleeding during the operation, and they will fall out by themselves. Some children get a throat infection after surgery, usually if they have not been eating properly. If this happens you may notice a fever and a bad smell from your child’s throat. Call your GP or the hospital for advice if this happens.
Keep your child off school for 10 to 14 days
Make sure he or she rests at home away from crowds and smoky places. Keep him or her away from people with coughs and colds. Your child may also feel tired for the first few days.
Bleeding can be serious
If you notice any bleeding from your child’s throat, you must see a doctor. Either call your GP, call the ward, or go to your nearest hospital emergency department.
by Peter Robb & Haytham Kubba
Disclaimer: This publication is designed for the information of patients. Whilst every effort has been made to ensure accuracy, the information contained may not be comprehensive and patients should not act upon it without seeking professional advice.