A professor of Ear, Nose, Throat, Head and Neck Surgery at the University of Jos, Samuel Adoga, speaks about the causes and management of tonsilitis, in this interview with EMMANUEL OJO
What is tonsillitis?
Tonsillitis is one of the common ear, nose and throat diseases that we find around because in Ear Nose and Throat (ENT), we have various parts, so, this is specifically located in the throat.
Tonsils are lymphoid tissues. They are part of the defence mechanism of the body. They are scattered all around in the head and neck region and other parts and this defence system is actually named after someone called Waldeyer Ring. So, it’s like a ring – an outer ring and an inner ring. So, tonsil belongs to the inner ring. Tonsillitis, therefore, refers to the inflammation of the tonsils and these tonsils are located in a particular place. They are located at the back of the nose. We call those ones adenoids. Some are located in the palatine area and some are located around the tongue and we call them lingua tonsils.
So, the tonsils that we refer to most of the time are at the junction between the oral cavity and the throat. That’s the commonest one that people come around with. We have acute tonsillitis and chronic tonsillitis. These are the types in terms of time duration. Acute is usually between three to 14 days. Anything beyond 14 days is chronic. Then, when there are frequent bouts, we call them recurrent tonsillitis.
What causes tonsilitis?
There are several causes. For instance, it might be caused by viruses of different types. Examples of such viruses are rhinoviruses, respiratory syncytial viruses, adenoviruses and, of course, corona viruses, which we are still on.
These viruses live in the airway most of the time as normal commensal but they occasionally cause problems for us. So, they usually are the main causes. Apart from that, bacteria can also cause tonsilitis. The commonest bacteria involved include streptococcus, particularly haemolytic streptococcus. Then, Streptococcal pneumonia, Streptococcus aureus, then Hemophilus influenza. Other viruses like HIV also cause sore throat and it can be seen in people having the condition. Then people who are involved in oral form of sex too because of gonorrhoea, syphilis can develop tonsillitis. The condition can also be due to fungi.
With oral sex, it may happen but it’s commoner with people with STDs. That’s why when you see adults, particularly when they have such, you have to ask for history of oral sex, that will give you an idea of the positive organism that can help you reach diagnosis. In some rare cases, it is caused by tuberculosis organisms. Sometimes, eating of raw meat or fish and raw seafood can also cause tonsillitis as there are parasites from it like worms that infect tonsils.
What are the symptoms of tonsilitis?
When it starts with viral causes or bacterial causes, sometimes it’s very difficult to differentiate whether it’s virus or bacterial because it might come with fever, sore throats, cough sometimes; some people even come down with what is called ‘upper respiratory tract infection’. The person will be seen sneezing, having cough and runny nose. Those ones are precursors and then the symptoms again depends if it is complicated or not. The ones I have mentioned are non-complicated cases. It can become complicated if the beta Haemolytic streptococcal organism is the causative organism and it can affect the heart or kidney, damaging the heart valve so much. An example can be seen in one of our famous footballers who had to be operated. It is because this organism shares some anti-genetic materials with the heart valve, so they destroy the heart valves. Hence, the heart loses its function.
They can also cause inflation inside the heart – endocarditis. It can also cause rheumatic arthritis, joints pains, which are very serious warnings. It may also damage the kidney with glomerulonephritis.
Is there a link between tonsillitis and snoring?
Tonsillitis can happen in children and adults. Some people say from age three to 15 years and others say from age five to 15 years. Like I mentioned, there are lymphoid systems in various locations – at the back of the nose and at the junction between oral cavity and back of the nose. So, particularly in children or even adults, when they are enlarged, they obstruct the airway so that when someone is sleeping, the airway becomes very narrow. It’s like a valve, when you are sleeping, the muscles are more relaxed; so, negative pressures will affect the airway until it almost collapses on itself.
The uvula, which some people cut sometimes in children, begins to vibrate and make that rattling noise that we now hear. So, that’s the cause of snoring in some people, though there are still other causes, the one we are talking about is the very common cause of snoring.
In the last two weeks, I’ve had to do operations on adults because the junction between the oral cavity and the throat becomes very narrow, especially in fat people with short neck. So we have to remove the tonsil and remove the uvula and then stitch the place so that the airway becomes wide, so, snoring stops.
Can tonsilitis result in difficulty in swallowing or loss of appetite?
Yes. When there is acute inflammation, for instance, there is fever, pain, swelling and redness and then loss of function. The function of the throat is to swallow. Once there is pain and the place is inflamed, the person will lose appetite or have difficulty in swallowing. So, in that process, if you stop taking fluid or stop eating, you can become dehydrated (lose water in the body). Those are parts of the difficulties; Painful swallowing, loss of appetite, cough.
Who is most prone to this condition?
It can happen in children and adults but the commonest age is usually age three to 15 or age five to 15, as said earlier. Usually, below three years, it is commoner at the back of the nose. We call that adenoids but sometimes, the tonsils at the back of the nose and in the throat may be affected at the same time and you will see the person snoring and mal-breathing.
It can happen in adults too and the symptoms can be quite painful. Even when you operate them, their recovery is quite painful than in the case of children. So, any age can be involved but when we see it in the very old people, we have to begin to think if it’s harbouring cancer. Then if there is bleeding from it or it has ulcers, we may begin to suspect possibility of tumour in it. Even sometimes in children, tumours can grow too because sometimes it’s part of the lymphoid tissues that can develop into tumours.
What are the complications of tonsillitis?
The most feared complications are some of those effects on the heart and kidneys – the rheumatic heart disease, rheumatic fever, endocarditis and then the glomerulonephritis.
There are a lot of people having kidney failures now, kidney disease, requiring transplant. When these kidneys are diseased like that, it might lead to ultimate kidney failure and that’s very devastating.
How is it diagnosed?
Diagnosis is from the history. The symptoms we talked about like pain and difficulty in swallowing, some persons may have history of catarrh, runny nose. That’s to tell you that it starts with virus, then bacteria could come in, leading to sore throat.
Sometimes you may see somebody with severe heart problem, increased heart beat, someone who easily gets tired and joint pain. That might tell you that it’s affecting the heart and the joints. If it’s affecting the kidney, there’s this very dark coloured urine like the colour of coke. You see it as if one is just passing coke for urine and very high temperature. Those are some of the symptoms it comes with. And then on some occasions, it can form pus, which we call tonsilla abscess. That’s another complication and you will see the person drooling, the lymph node in the neck will be tender because there is a kind of infection from that lymph node to other lymph nodes around it. So, if you touch the place, the person will tell you that it’s very painful. They have bad mouth odour because they are no longer able to brush or take care of their teeth again, then sometimes they position their neck in a place, not wanting to move it again because of what they are feeling.
Then, the other thing in their history is the symptom because you have to ask questions. Sexual history is very important.
How is tonsilitis treated or managed?
When you say managing the condition, management involves asking questions or taking the history, then conducting an examination. You have to do a thorough ear, nose and throat examination.
The management depends on whether it is viral or bacterial in origin. The person will need some painkillers and rehydration. Some people use certain things, like lozenges, to soothe the area. Sometimes, we tell people to gargle with saline solution, that is, warm water and salt. The symptoms resolve in less than three days because the body will contain most of the viruses easily but if it’s the bacterial type, we use antibiotics, particularly the penicillin group. People who react to this group of antibiotics, can use others.
On some rare occasions, some people have to be given steroids to reduce inflation but in doing that you have to make sure that such a person does not have a conditions, like diabetes and ulcer, that the steroid will worsen.
When it becomes recurrent after treatment with antibiotics, there are criteria that we use. Most of the time, if someone has like five episodes or more of the attack in a year, which is severe enough to stop the person from going to school or work, that’s an indication to remove the tonsil. So, that’s one of the ways to know that we need to operate this person. If it happens like once or twice in a year, leaving some intervals like three years before recurring, we can be giving drugs.
Can the removal of the tonsil lead to some complications in the throat?
The tonsil itself is part of the lymphoid tissues. If it is removed, it doesn’t lead to advanced ability to develop infection because there are so many lymph nodes to perform the function in the head and neck.
Some people take hot tea or liquid when they have throat infections. Are such practices healthy?
Those are not healthy practices. As you know, something is caused by bacteria and we know what drug to give and the quantity of the drug is measured but taking something hot won’t cure it. Apart from the inflammation, it may cause burns.
When these infections occur sometimes, the body might be able to fight it because it’s mild, so those traditional things don’t work. Some people tried it and they were lucky, it worked for them, then you see them advocating it but the good thing for us in medicine is that we know what is specific for treating the condition and we know the quantity to give and the duration.
How can tonsilitis be prevented?
Tonsillitis can come anytime of the year but often it comes with cold weather. When the cold weather comes, viruses become plenty. When people have these viruses, you see them having sore throats and all that. So, at that time, overcrowding is not advised and then. Good hygiene, ventilation are very important. Oral sex, raw seafood should be avoided.
Can tonsilitis be transmitted through saliva during kissing?
If it is the infective type, there is a need to educate people. Something like hepatitis can be transmitted through body fluids. So when you kiss, in such a process, you can transmit body fluids, so the person should be educated about such things. If it is gonorrhoea, for instance, that might also happen, so those contagious diseases should be avoided. Tuberculosis also can be that contagious. So, health education is very important but if those conditions are treated, couple can do whatsoever they like.
