Words Lim Teck Choon

When most people think about the immune system, they envision white blood cells rushing in the bloodstream to eliminate potentially harmful foreign microorganisms such as bacteria and viruses. Some will also associate lymph nodes with the immune system. There is another often underappreciated component to the immune system: two roundish lumps at the back of the throat known as the tonsils.

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The First Line Of Defense Against Infections

The tonsils we commonly think of are called the palatine tonsils. Prof Dr Balwant explains that these are the fleshy tissues located one at each side at the back of our throat or pharynx.

There are also other types of tonsils in our body, all located around the pharynx:

The pharyngeal tonsil, or adenoids, is a mass of tissue located on the roof of the space at the back of the throat (nasopharynx). The adenoids play a role in the immune system during childhood. They shrink as we age and eventually disappear during adulthood.

A pair of tubal tonsils (sometimes called Gerlach’s tonsils) are located on each side of the location where the auditory tube opens into the nasopharynx.

A pair of lingual tonsils are located on the back part of the tongue, one at each side.

These tonsil tissues are arranged to form what is called the Waldeyer’s tonsillar ring. This ring acts as the first ring of defense against infections by microorganisms that find their way in through the nose and mouth.

The tissues in the tonsils are similar to that found in lymph nodes. Like lymph nodes, tonsils can swell in size in the presence of infections.

Hence, our tonsils can serve as an indicator as to whether there is an infection happening in our body. “Tonsils are very necessary for children up to their teenage years,” Prof Dr Balwant reiterates. Hence, the current recommendation among many healthcare professionals these days is to keep the tonsils for as long as possible.

However, swollen tonsils due to infection can also be a painful bother. This condition, called tonsillitis, is ironically the main reason why many people had their tonsils removed in the past – a classic case of shooting the messenger for the bad news!

Heinrich Wilhelm Gottfried von Waldeyer-Hartz was an early 20th century anatomist and lecturer from Germany. He was the first person to detail the structure and function of lymphatic tissue in the neck and throat region, hence the naming of the tonsillar ring after him.

Tonsillitis: The Good & The Pain

Each time we breathe and eat, we are also inviting all kinds of microorganisms into our body. Some bacteria and viruses may be harmful, and often, because the throat is their first “pit stop”, that region becomes infected.

During an infection by bacteria or viruses, the tonsils sometimes become swollen, with white spots often seen on them. This condition is called tonsillitis, and the swollen tonsils are often accompanied by sore throat and fever.

6 Facts about Tonsillitis

1. It can happen at any age, but it commonly affects children from preschool (kindergarten) to mid-teens.

This is because tonsillitis is contagious, and children are frequently exposed to the bacteria and viruses responsible for tonsillitis while playing and mingling with one another at school. The frequent contact is also the reason why children may also experience recurrent tonsillitis.

However, Prof Dr Balwant advises adults who experience recurrent tonsillitis, especially those 30 years old and above, to visit an ENT specialist – the recurrent tonsillitis may be a sign of a more serious problem that needs medical attention.

2. The symptoms of mild tonsillitis – pain, swollen tonsils, fever – usually resolve themselves within a week or so.

However, some viruses and bacteria may cause more serious problems if left to their own devices. For example, the Streptococcus family of bacteria can give rise to strep throat once they infect the tonsils. If left untreated, there is a chance that the infection can advance to affect the blood and the urinary tract.

Therefore, it is advisable to consult a doctor if the tonsillitis is persistent despite us having received treatment over a period of time.

3. Other reasons to see an ENT specialist:

• The tonsils have swollen to an extent that we experience breathing or swallowing difficulties.
• There are swollen lymph nodes at the sides of our neck.
• Tonsillitis is usually accompanied by high fever (over 39ºC).

4. Mild tonsillitis can be treated with antibiotics (if it is caused by bacteria) and plenty of rest.

Prof Dr Balwant also recommends drinking plenty of fluids and gargling with salt water. Lozenges and warm tea mixed with honey can be helpful in providing relief. The doctor may also prescribe pain relief medications if the pain is especially bothersome.

5. While healthcare professionals recommend keeping the tonsils, surgical removal or tonsillectomy is sometimes necessary.

It may be the ideal solution for people who experience persistent, long-term tonsillitis or frequently recurrent tonsillitis. It is also recommended when other conventional treatments do not work.

6. Tonsillectomy may also be necessary if the infection has spread deeper into surrounding throat tissue. This condition, called tonsillar cellulitis, will lead to pus formation in the affected areas. When this occurs, the ENT surgeon will attempt to drain the pus while prescribing antibiotics if bacteria is responsible for the infection. If these efforts fail to yield the desired results, Prof Dr Balwant points out that the infected tonsils may need to be removed at a later date.

Other Tonsil Troubles

Stones In The Tonsils?

The surface of our tonsils isn’t smooth. In fact, there are various crevice-like pockets called crypts. According to Prof Dr Balwant, when bacteria, dead cells, mucus and other substances become trapped in these crypts, they can form soft aggregates that may eventually harden to become tonsil stones.

Symptoms. It is possible for some people to have tonsil stones without realizing this, as these stones may be small and do not cause any discomfort. If the stones grow to larger sizes, however, they may cause the tonsils to swell and give rise to bad breath, discomfort and issues associated with enlarged tonsils (such as difficulties in breathing and swallowing). Ear pain and ongoing cough may also be seen in some people. 

Treatment. Prof Dr Balwant reveals that for smaller tonsil stones, gargling with salt water after every meal may help to dislodge these stones and to reduce bad breath. Antibiotics may be prescribed when necessary to reduce the number of bacteria in the tonsils that contribute to stone formation. For more severe cases, the ENT specialist can remove the stones using a technique called cryptolysis. If all else fails to yield the desired result, tonsillectomy may be necessary.

Tonsil Cancer

Cancer can also develop in the tonsils. Like most cancers, we have not identified the precise causes, but it has been linked to smoking and the human papilloma virus (HPV). People who smoke or have HPV infection tend to have a higher risk of developing tonsil cancer. It can occur at any age, but the risk also increases with age.

Prof Dr Balwant adds that when cancer develops, usually only one tonsil is involved.

HPV is most commonly transmitted through oral, vaginal and anal intercourse, and people infected with HPV may not show any symptoms. Fortunately, HPV vaccines are available to protect against infection by the virus.

Symptoms. The early symptoms of tonsil cancer may be mistaken as those for strep throat, hence it may be worth visiting an ENT specialist when someone 30 years old and above has persistent, non-healing sore throat.

Other symptoms can include:

• One tonsil noticeably larger than the other
• Difficulties and/or pain when chewing, swallowing and speaking
• Blood in the saliva
• Swelling in the neck
• Severe ear pain
• Unintentional weight loss

Treatment. Early stage cancer treatment includes surgical removal of the affected tonsil followed by radiation therapy to kill any remaining cancer cells present in the region. For more advanced cancer, chemotherapy will also be included as part of the treatment regime, and more advanced surgery may also be necessary. Like most cancers, better treatment outcome is more likely if the cancer is detected at an early stage. HT

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