Tonsils refer to each of the large and small tissues of lymphoepithelial tissues located in the upper respiratory tract, tasked with defending the body. But this concept is used in practice to describe the throat tonsils, which are the largest of the tonsils, namely the palatine tonsils. So, the concepts of tonsil and tonsils are used as synonyms with the throat tonsil/palatine tonsils unless otherwise is indicated.
The tonsillar ring or the tonsil sequence is a concept that refers to all tonsils, large and small, located in the upper respiratory tract: the tissues of the tonsils found in the human body do not consist of only the tonsils of the throat, that is, the palatinas of the tonsils. The tonsillar ring, called the Waldeyer’s lymphatic ring or lymphoepithelial system by physicians, consists of many tonsillar tissues of different sizes. The structure is called a ring is because it surrounds the throat like a ring. The parts that make up this ring or sequence of tonsils are the left and right tonsils of the throat, adenoid in the middle, mini tonsils of the tongue base and other mini tonsils scattered in the pharynx with lateral bands of the pharynx, especially in the upper part of the pharynx, surrounding the mouth of the Eustachian tube. The palatine tonsils are found in the space between the tongue base and the soft palate, suspended on the side walls of the middle part of the pharynx and is the size of a cherry. The palatine tonsils are located at the entry of the throat like a pair of guards before the entry of the digestive tract. These are wrapped in capsules in the connective tissue structure that sticks tightly to their own tissues but forms a loose connection with the surrounding muscles. The adenoid is located by itself, on the ceiling of the pharynx, right in the middle. The adenoid is behind the nose, and stands like a guard before the respiratory system. There are no capsules around this tissue, and there are no certain boundaries between it and the pharynx tissue. The tongue base tonsils are located in the back third of the tongue, called the tongue base. The tongue base tonsils do not have capsules either. There are no exact boundaries between them and the tongue base tissue.
The tonsilar ring’s structure is similar to that of the lymph nodes, but it has a special anatomy that facilitates encounter with antigens and absorption by the tissue: in each of the tonsillar ring elements, there is a deep tissue where the lymphoid cell groups are located and a specialized surface tissue that creates channels or folds to ensure contact with the deep zone. Because of this special composition of lymph tissue and surface tissue called epithelium, the structure that forms the tonsils is called lymphoepithelial tissue. Each of the throat tonsils contains 8-10 small channels called crypts. The smaller simple form of crypts is also found in the tongue base tonsils. In the adenoid, there are no canals, only folds of tissue. Channels and folds provide an increase in surface tissue that facilitates contact with foreign antigens and guarantee access to deep tissue. The lymph tonsillar ring comes into intense contact with pathogenic substances that come through the respiratory and digestive tracts, followed by the body’s first immune response. This way the first immune response, is quickly and strongly created. The tonsils produce B and T lympocites and antibodies and secrete them into the throat cavity.
The period in which the tonsillar ring is active is related to age. The tonsils begins to develop in infancy, experience their most active period between the ages of 3-10, and regresses functionally and in size starting from puberty.
The relation between the tonsils ring and the microorganisms is as follows: various aerobic and anaerobic bacteria most notably the staphylococci and non-hemolytic streptococci live as a colony with the tonsills and the throat tissue. These bacteria, which do not cause disease under normal conditions, are called bacterial flora. When the body’s immune system is weakened or the local immunity in the throat is weakened, the bacterial flora that already exist in the body, and the external bacteria and microorganisms, when they reach the throat, cause an infection of the tonsillar ring and pharynx.
Signs of tonsillar ring tissue differ depending on the disease. In acute diseases, the cardinal signs and symptoms of inflammation occur rapidly, but the pathological changes that occur are temporary. Pathologies that also occur in recurrent acute inflammation are temporary, the symptoms become apparent during the attacks. The color and characteristics of the tissue return to normal during the attacks. But when the disease becomes chronic after recurrent inflammation, pathological changes in the tissue begin to become permanent, and these tissues, which normally work for the body’s defense, begin to damage the body with their structures that contain inflammation or are hypertrophied. Hypertrophy occurs due to inflammation, as well as due to bacterial colonization and immune responses.
What is tonsillitis and tonsillar enlargement?
Tonsillar diseases are defined by two main concepts that interact with each other: tonsillitis and tonsillar enlargement. Tonsillar tissue can also become inflamed or grow on its own while fighting diseases. Doctors call inflammation of the tonsils, the tonsillitis, and its growth the hypertrophy. These and other lympho-epithelial tissue conditions in particular, occur in childhood, when the immune system, and therefore the tonsillar ring is very active.
Adenotonsillar disease is a common concept. The reason for this is that all tonsil tissues that make up the waldeyer’s tonsillar ring, especially the tonsils and adenoid, often become inflamed together, grow together, contain similar microorganisms, and operations on them are performed together. Again, for this reason, their inflammation is also defined by general concepts like adenotonsillitis or pharyngotonsillitis, and their hypertrophies as adenotonsillar hypertrophy. Common operations of these tissues are called adenotonsillectomy. However, it should be noted that these tissues can also become seperately inflamed, enlarge, and their operations can also be performed separately.
There is no consensus on the classification of tonsillitis. However, like in other diseases, it will be better to use a classification like acute, recurrent, chronic and inflammatory chronic. Among these forms, acute tonsillitis and chronic tonsillitis stand out with their clinical significance and sharp differences.
Acute tonsillitis, or acute angina, is a disease that occurs as a result of viral or bacterial infections, develops suddenly and lasts for 7-10 days. The concept is commonly used to refer to acute bacterial inflammations. Acute tonsillitis is a classic acute inflammation and creates the standard local symptoms of inflammation: sore throat, painful-difficult swallowing, redness of the tonsils, swelling, increased temperature. In addition, pus accumulation in the mouth of the crypts of the tonsils and painful growth of the lymph nodes of the upper neck can be observed. Fever, chills-trembling, malaise, weakness, joint pain, headache, ear pain, even abdominal pain in children and other similar symptoms make the patient weak. The most common cause of acute bacterial tonsillitis is microorganisms called beta hemolytic streptococci of Group A. These microorganisms, that is, beta hemolytic streptococci of Group A, are also the main factor behind the very significant suppurative and nonsuppurative complications of acute tonsillitis. In order to treat acute tonsillitis and prevent complications, especially acute rheumatic fever, 10-day antibiotic therapy, which must be effective against Group A beta hemolytic streptococci, is administered under the supervision of a doctor.
Chronic tonsillitis, or chronic angina, is a condition that occurs when pathological changes that develop with recurrent acute tonsillitis become permanent over time. Various microorganisms, especially anaerobes, settle in the tonsils. Because this process takes time, it does not occur in young children; it occurs in older children, adolescents and young adults. Chronic tonsillitis is clinically characterized by a scratching sore throat and bad breath that lasts for more than 3 months. A feeling of fatigue can accompany these symptoms. During the examination, the doctor will see shrunken tonsils with holes on them, and which rashes in the entry of their ducts, as well as enlarged, sensitized upper throat lymph nodes. It is difficult to achieve radical results with medical treatment in chronic tonsillitis. But if antibiotics are to be used, they must also be effective against anaerobes, be beta-lactamase-resistant and cefaclor, except for periods of exacerbation.
Tonsillolitis is a disease caused by the accumulation of dead tissue, microbial biofilm at the entry of the tonsillar channels and these turning into stone over time. The colors of tonsillolites range from white to yellow, while their size can vary from a few millimeters to a centimeter. In addition to the signs and symptoms of chronic angina, excessive bad breath, foreign body sensation in the throat may occur in these cases.
Tonsillar hypertrophy refers to the overgrowth of the throat tonsils. Tonsil hypertrophy leads to signs and symptoms such as muffled voice, difficulty in swallowing, snoring, open mouth sleep, sleep interruptions, stopping breathing during sleep, or even disorders of growth and development. Tonsillar hypertrophy may occur alone, but often, as in the case tonsillitis, may manifest itself as the enlargement of the entire tonsillar ring. Tonsillar ring hypertrophy is usually called adenotonsillar hypertrophy since tonsillar or adenoid enlargement is usually the problem. Tonsillar hypertrophy can develop due to overworking of the immune system, as a response to flora or due to infections inflammations. This overgrowth of the tonsils, especially the tonsils and adenoid, leads to many ailments, from snoring to stopping breathing during sleep, from speech disorders to difficulty swallowing, from tooth closing problems to craniofacial abnormalities. Excessive growth of adenoid also lays the foundation for diseases of the middle ear and sinuses.
What Is Tonsillectomy-What Are The Reasons For Tonsillectomy?
Tonsil surgery, more strictly defined, partial or complete removal of tonsils by surgery, is called tonsillectomy. Tonsil surgery can be performed alone. But often, the removal of adenoid, called adenoidectomy, is also performed together.
The decision of tonsil surgery requires the consent of the patient-family and physician. From time to time, various international groups establish absolute and relative indications for tonsil surgery. But there is no strict international and inter-branch consensus on these concepts. In addition, the established indications can be changed over time. It should be noted that these are general concepts, and according to the general principles of medicine, there are no diseases, there are patients. Patients should be reasonably evaluated by physicians on a case-by-case basis and final decisions should be made with the patient and family, taking into account medical and surgical treatment options. Issues that play a role in decisions about tonsil surgery can be cited as infectious, occlusive, functional and tumor-related reasons. In cases other than those related to tumors, especially in children, surgery is usually performed in the form of adenotonsillectomy, which means that the tonsils and adenoid are removed together. Tonsillectomy alone, that is, isolated tonsillectomy, is performed more rarely, mostly in adults. In children, there are also indications for adenoidectomy, that is the removal of adenoid alone. The reasons for tonsillectomy and adenotonsillectomy are:
Infection-related reasons are repetition of acute tonsillitis attacks in the last 2-3 years more than the set numbers, the existence of peritonsillary abscess, tonsillitis cardiac disease or tonsillitis febrile convulsions.
Blocking reasons are cases of stopping of breathing during sleep, snoring and sleep disorders, severe difficulty in swallowing, severe speech disorder, cranio-facial development disorder, occlusion disorder problems accompanied by adenotonsillary growth.
Functional reasons are the presence of constant bad breath or tonsillitis symptoms.
Tumor-related reasons are the detection of unilateral growth that causes suspicion of the presence of a tumor or other signs that cause suspicion of a tumor.
Tonsillectomy techniques are not very varied. Tonsillectomy is performed using two separate techniques; classical total tonsillectomy and subtotal tonsillectomy. In classical tonsillectomy, the entire tonsil capsule is removed by means of tools such as scissors, electrocautery, scalpel etc. In subtotal tonsillectomy, not all of the tonsil tissue, but most of is removed or destroyed with tools such as microdebrider, radiofrequency, and the capsule is left in place. Classical tonsillectomy provides the advantage of complete removal of patient tissue, while subtotal tonsillectomy aims to shorten the duration of intervention, reduce pain, and reduce the risk of bleeding.
Tonsillectomy methods vary. In addition to the use of classical scalpel-scissors, diathermy, radiofrequency, microdebrider, coblator and similar methods are used. These are differences in the use of tools and methods that the surgeon chooses from, but their differences do not change the outcome. Multiple tools and methods can be used together according to the needs.
How does one feel during and after tonsillectomy?
The sensations during and after the operation on tonsils and adenoid can be summarized as follows: following the surgery, patients are discharged after 4-5 hours or the next day, depending on the situation. In order not to disrupt the anatomy of the throat, all around the world, operations on the tonsils and adenoid are performed without stitches. For this reason, in all techniques, wounds are left to a self-healing process called secondary wound healing. The process is similar to healing of a skin injury with a brown-black scab when it is left on its own. But open wounds on the throat heal by being covered by a white surface consisting of fibrin and other substances. Patients experience symptoms such as sore throat, ear pain, difficulty swallowing for 5-6 days, which getter better everyday. In children, there is less pain than in adults, since tonsillitis is not yet chronic and there are no joining muscles yet around the tonsils. With the use of analgesics, these pains are kept to a minimum. Patients are fed liquid foods for the first two days and soft foods for the next few days. Although there is a sore throat, regular intake of liquid and soft food should not be neglected to prevent dehydration of the body and to prevent late bleeding by removing the scab in the throat as food passes.
The passing of duty: the patient and their families should not be worried about the removal of the adenoid and related tissue as their duties will be assumed by other lymphoepithelial tissues, in other words, other smaller parts of the tonsillar ring. In this way, the immune system of the body is not impaired. It should be noted that when a need arises to remove the tonsils and adenoid, they no longer work in favor of the body.
The process following tonsillectomy and adenoidectomy should be known to patients: the throat tonsils, which are completely removed with the capsule, do not grow again in later years. The long-term results of partial tonsil operations in which the capsule was left in place are not yet clear. On the other hand, the mini tonsils at the base of the tongue, which are not surgically removed, may grow slightly over time, as their body defense tasks will increase. Adenoid can also show, exceptionally, partial growth over time, as it is a tissue without capsules and of which remains can be left behind. But these functional growths in the tongue base and adenoid are rarely clinical problems. Tonsillectomy and adenoidectomy operations are evaluated as a whole in terms of gain-risk-loss concepts; in case of need, they are initiatives that prevent various functional and vital risks and greatly improve the patient’s quality of life.
Kindest regards,
Surgeon Dr. Cemal Yazıcıoğlu
Ear, Nose, and Throat Specialist
FSM Medical Center Kavacık
