Sore throats a constant problem?

Our immune (infection fighting) system is very active in the nose and throat (pharynx) areas. This system is organized into clusters of tissue, also called lymph nodes. These nodes are connected throughout the body by lymph vessels, which open into the blood system. The lymph fluid opens into the large veins that enter the heart. From here, lymph is pumped along with many blood cells that help fight infections. The lymph system helps the body fight infection by filtering out germs (bacteria and viruses).

There are four distinct clusters of lymph tissue in the back of the throat:

• The tonsils (palatine tonsil) - located on each side of the back of the throat, beside the tongue;

• The adenoids (pharyngeal tonsil) - located behind the nose in the middle of the roof of the throat;

• The Eustachian tube tonsils - located on each side of the roof of the throat, adjacent to the opening from the throat to each ear;

• The tongue tonsil (lingual tonsil) - a pair of clusters of lymph tissue in the very back of the tongue

Each of these is connected by a band of lymph tissue, along the sides of the throat, the lateral pharyngeal band. Everything that we eat and breathe must pass by this ring of lymphoid tissue in the throat.

In most children under ten years of age, the immune system is working overtime fighting infections from viruses and bacteria. Repeated irritations and infections may cause lymph glands to swell. Exposure to foreign substances such as allergic pollens, in susceptible individuals, may also cause the lymph glands to become enlarged. With time, usually around the time of puberty, the tonsils and adenoids shrink in size. The symptoms due to enlarged size usually decrease with age. The symptoms associated with infections are not due primarily to the size of the tonsils or adenoids.

When repeated infections or irritation causes enlargement, several symptoms are associated with enlarged adenoids. You may notice:

• Difficulty breathing through the nose
• Mouth breathing
• A muffled sound to the voice (hot potato voice)
• Noisy breathing
• Snoring while sleeping
• Poor Attention / Forgetfullness / Irritability
• A chronic sensation of drainage in the back of the nose and upper throat

When repeated infections or irritation causes enlargement, several symptoms are associated with enlarge tonsils. You may notice:

• Change in the voice (hot potato voice)
• Difficulty swallowing
• Noisy breathing
• Coughing up clumps of debris from the tonsils
• Snoring while sleeping
• With severe enlargement, pauses in breathing with loud snoring

Tonsillitis occurs when the tonsils become infected and swollen. During an acute (sudden) infection, the tonsils may be quite red and be covered with a white or yellow coating. Doctors call this condition acute exudative (covering) tonsillopharyngitis (inflammation of the tonsils and pharynx).

Symptoms of Acute Tonsillitis:

• Sore throat
• Pain when swallowing
• Fever
• Swollen glands (lymph nodes) in the upper neck
• Headache is common with strep throat

Many viruses and many bacteria can cause tonsillitis. The most common include:

• Herpes simplex virus
• Streptococcus pyogenes - 'strep throat'
• Epstein-Barr virus - the cause of infectious mononucleosis (mono)
• Adenovirus
• Cytomegalovirus

Bacteria cause between 15 and 30 percent of cases of acute tonsillitis. To determine the cause, many tests are commonly performed. While most episodes are viral in origin, only a throat culture helps determine whether the infection is viral or bacterial in origin. The symptoms and  signs of viral versus bacterial tonsillitis are very similar. To the observer, the condition looks the same in most individuals.

Most of the time, tonsillitis occurs in children. Strep throat is most common in children between the ages of 5 and 15 years of age, while viral tonsillitis is more common in younger children. Anyone exposed to another person who has an acute infection, may acquire the infection, as in most cases the affected individual is contagious.

• Acute Tonsillitis - those affected usually have fever, sore throat, foul breath, difficulty or painful swallowing, and tender, enlarged lymph nodes. These symptoms usually resolve in 5 - 7 days, but may persist up to two weeks despite therapy

• Recurrent Tonsillitis - same symptoms, with multiple episodes over time

• Chronic Tonsillitis - chronic sore throat, bad breath, soreness with swallowing, perhaps, enlarged and tender neck lymph nodes

• Peritonsillar Abscess - severe sore throat, fever, bad breath, difficulty opening the mouth, usually with a muffled (hot potato) voice. This is due to infection around the tonsil, and typically occurs seven to ten days after the onset of symptoms

Viral tonsillitis, that is, culture negative tonsillitis, is best managed with supportive, symptomatic care. This includes analgesics, such as ibuprofen or acetaminophen. Fluid replacement and pain control are all that is necessary.

Bacterial tonsillitis, that is culture positive tonsillitis, commonly strep throat, is treated with antibiotics, pain control and fluid replacement. Other bacteria may also caused tonsillitis, but the problems associated are less severe than with step throat - also called Group A Beta-hemolytic step,  Streptococcus pyogenes, or simply step.

When the infections are recurrent, generally 4 or more episodes per year, or three episodes per year, three years in a row, tonsillectomy (surgical removal of the tonsils) is recommended. Chronic sore throat may have many causes other than infection of the tonsils.

Tonsillectomy is still commonly performed in children, occasionally in adults. The actual procedure performed does not vary with the age of the patient.

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Reasons tonsils are removed - tonsillectomy -- include:

• Recurrent tonsillitis - 4 or more episodes in one year, 3 or more episodes in three __consecutive years;
• Peritonsillar abscess - generally, four or more weeks after resolution
__of the acute infection;
• Enlargement of one tonsil;
• Swollen tonsils that make it hard to breathe or eat;
• Swollen tonsils contributing to snoring, especially if pauses occur with sleep
__- sleep apnea;
• Presence of attention deficit disorder, associated with restless sleep
__and loud snoring;
• Ulceration (a sore that won't heal) present on one tonsil;
• Chronic bad breath with debris in the tonsils - cryptic tonsillitis

Reasons adenoids are removed - adenoidectomy -- include:

• Often removed at the same setting as tonsils in children with chronic upper airway obstruction;
• Chronic mouth breathing;
• Chronic, recurrent sinus infections in children, under age 10;
• Abnormalities in dental growth - high arched palate;
• Need for more than one set of eardrum tubes for recurrent ear infections

• The surgery is performed under general anesthesia, that is, the patient is put to sleep for a short time
• The duration of surgery is generally 20 - 30 minutes, and is performed in an outpatient surgical facility or hospital operating room
• The adenoids are removed through the back of the throat, with the surgeon seated at the patient's head. No external skin incisions are made.

Routinely, I use a technique called Coblationฎ Tonsillectomy. I feel this technique results in less discomfort after surgery. Most patients resume a normal diet in 3 - 5 days after surgery, compared to 7 - 10 days using the outdated electrocautery technique. (Coblationฎ is a registered trademark of Arthrocare Corporation. All rights reserved)

When I evaluate each patient, as an individual, we discuss the treatments for tonsillitis, the alternative treatments available, and whether surgery is a good option. Much of the time, surgery is not the best option. But, when the condition is chronic or recurrent, tonsillectomy often provides the best long-term solution.