What are tonsils

The tonsils that most of us are familiar with are actually known as the palatine tonsils to differentiate them from the lingual tonsils, which are tissue that can be found on the back portion of the tongue.  The tonsils are lymphoid tissue and therefore are part of the body’s surveillance system to identify and react to “foreign invasion” to maintain one’s health, whether it is forms of infection or abnormal cells in the body such as cancer.  Material that exists outside blood vessels (“lymph”) is collected into the lymphatics, a separate collection of small vessels that eventually feed into structures such as a lymph node -or a tonsil- where the material is assessed and any necessary response by the body is initiated.  Eventually, this fluid is collected and directed back into veins to ultimately be processed as waste.  In the head and neck area, the system has tremendous redundancy with not only the tonsil and adenoid tissue, but also hundreds of lymph nodes.

What is tonsillitis

Tonsillitis refers to inflammation of the tonsil tissue.  It is the most common infectious and can be caused by either bacteria or viruses.  Symptoms include a sore throat, which can be quite severe, difficulty swallowing or speaking, fever, lethargy, and painful lymph nodes in the neck.  Occasionally the infection can cause referred pain in the ear.  Accompanying these symptoms, examination of the throat will reveal swollen, red tonsils, which may have a white or yellow coating or “exudate” on the surface.

Types of tonsillitis

Bacterial tonsillitis

Bacterial tonsillitis is thought to be more commonly associated with a more severe sore throat and the presence of an exudate.  Although several different bacteria can cause tonsillitis, group A streptococcus or “group A strep” is the most commonly discussed and responsible for tonsillitis strep throat.  This infection is a contagious form of tonsillitis passed through close contact.  The reason for concern regarding strep throat is that children and teens risk developing rheumatic fever and subsequent damage to the heart and kidney if a health care provider does not properly treat the infection.

Due to this risk, a rapid strep test is commonly performed when the diagnosis is considered.  This involves a swab over the tonsils and back of the throat.  Although this may be slightly uncomfortable and cause the child to gag, there is no real risk associated with one’s health with this test.  It can provide the doctor with information very quickly as to whether group A strep is detected.  Since the test is approximately 95% sensitive, a negative test should be followed by culture by the doctor to rule out the 5% chance the rapid test was incorrect.

It should not be assumed, however, that a negative strep test confirms a viral cause.  The previously mentioned throat culture can be performed, but results can take a few days. While the medical doctor and patient should understand the risk of indiscriminate use of antibiotics, the presence of significant symptoms in a patient with a negative strep test may still warrant antibiotic treatment.

Peritonsillar abscess

Typically tonsillectomy affects both tonsils symmetrically.  However, the patient occasionally reports that the sore throat is more significant on one side.  There may even be ear pain on that side, a change in voice, and difficulty swallowing.  If these symptoms occur, the patient should be seen urgently by a medical doctor, preferably one trained in otolaryngology (ENT), as it may indicate the formation of a peritonsillar abscess.  This infection has progressed with the formation of an abscess around the tonsil.  If not treated urgently, it may spread and cause serious complications, even death.  Care involves antibiotics and commonly surgical drainage.  If surgical drainage is deemed necessary to treat the infection, it can be performed by the doctor either in the office or in the hospital, depending on the severity.

Viral tonsillitis

Viral tonsillitis is more common than bacterial, comprising 60-70% of all cases of child sore throat.  There are typically associated symptoms such as fever, cough, and fatigue.  The strep test and culture, if performed, would be negative.  Care is typically based on symptoms- normalizing fever, controlling discomfort, and decreasing congestion and cough.

Mononucleosis

A specific type of viral infection associated with tonsillitis is mononucleosis (mono), caused by the Epstein-Barr virus (EBV).   Mono typically is associated with systemic symptoms such as fatigue, swollen lymph nodes, and fever.  Enlargement of the liver and spleen may also occur.  Tonsillitis in mono can result in significant growth of the tonsils, making it difficult to swallow or even feeling as if it is difficult to breathe.  In these cases, treatment may include oral steroids to decrease the swelling.

Chronic tonsillitis

In some patients, symptoms of tonsillitis seem to keep occurring over and over again.  A patient may be left with a chronic sore throat and even fatigue, despite the absence of the more severe symptoms of an acute attack. These chronic cases are thought to be because certain organisms can form biofilms.  Biofilms are a community of organisms that form an exterior coating which can allow them to exist in areas of the body- such as the tonsils-without the host being able to eliminate the organism.  Antibiotics also are not effective against biofilm protection.  This contained infection can then erupt into an acute episode, especially if the host’s immune system is weakened temporarily.

Tonsillectomy for tonsillitis

Indications for tonsillectomy

If a child has a single or only occasional episode of tonsillitis, medical management, as discussed previously, is usually adequate to maximize the patient’s health.  However, in the patient with recurrent acute tonsillitis-repeated episodes lasting days-or chronic tonsillitis- chronic low-grade symptoms such as sore throat- a more permanent solution may be indicated.

Guidelines for surgical treatment of tonsillitis have been established for those individuals in the pediatric age group with recurrent acute tonsillitis.  The most recent recommendations are for a child with seven or greater infections in the past year, five infections a year for the past two years or three infections a year for the past three years.  Although these recommendations are helpful, one must evaluate each child since tonsillectomy may be reasonable in those patients falling below those criteria but who have complicating factors such as the severity of the infections, duration of illness affecting work or school, or difficulty with repeated antibiotics.

Tonsillectomy may also be indicated in those patients who have chronic tonsillitis.  Chronic sore throat or the repeated formation of tonsil stones (tonsilliths), which can cause bad breath, can alter one’s quality of life such that a permanent solution is desired.

Tonsillectomy

Tonsillectomy involves the removal of the tonsil tissue.  There are records that the first such procedure was done over 2000 years ago.  Over the years, numerous techniques have been used.  These have included a traditional surgical scalpel, wire “snares,” and various forms of heat energy, including lasers.  Although each technique has its proponents, no single technique has been shown to be dramatically better than the others.  More recently, however, the performance of an intracapsular tonsillectomy which leaves a very thin layer of tonsil tissue behind, has demonstrated an improved recovery.

No matter which technique the otolaryngologist uses, the procedure is performed under general anesthesia in a hospital or surgery center.  A device keeps the mouth open, and each tonsil is carefully dissected from the bed in which it sits.  The numerous blood vessels that feed the tonsil are usually cauterized during removal to reduce the chance of bleeding.  Once the surgery is complete, the child is awakened from anesthesia and observed in the recovery room.  Most patients can be discharged home after an hour or so.

Recovery

The recovery from a tonsillectomy involves significant discomfort and can last 7-10 days.  Pediatric patients may need significant encouragement and support to eat and drink enough to sustain themselves.  Pain management can involve non-narcotic and narcotic pain medicines.

Overall, tonsillectomy is a very safe procedure. However, the one significant risk is postoperative bleeding which most commonly occurs 5-8 days after the surgery in 1-7% of cases.  Cauterization may be required in the doctor’s office or operating room under a brief anesthetic.  Once the child( recovers, the episodes of tonsillitis should end as the inflamed tissue has been removed.

The post Parents’ Guide to Tonsillitis in Children appeared first on Jerome Hester, MD.

The coronavirus is a conundrum in more ways than one. In addition to rapidly escalating to the most notable pandemic of our era, it is a mystery to healthcare providers. While some experience coronavirus as hardly anything at all, others find themselves in ICUs struggling to breathe and fighting for their lives.

And, while sore throat and coronavirus do go hand in hand, it is so important to realize that a sore throat is also a symptom of multiple other conditions, from common cold (yes – they still exist, too) to seasonal allergies or snoring at night. If you experience a sore throat, do not panic. Instead, take good care of yourself, get plenty of liquids and pay attention to other signs and symptoms.

IMPORTANT NOTE: There is so much misinformation floating around on the internet and social media channels, which makes it difficult to know what to believe. We highly recommend ignoring any and all information unless it comes from legitimate medical or health organization websites such as:

• Center for Disease Control (CDC)
• The World Health Organization (WHO)
• Reputable university websites such as Harvard.edu or Johns Hopkins.

As researchers at Harvard University write, “Just as the number of people and countries affected by this new virus has spread, so have conspiracy theories and unfounded claims about it. Social media sites, including Facebook, Twitter, YouTube, and TikTok, have seen a number of false and misleading posts…”

Do not fall victim to false information, and avoid being a part of the misinformation chain! Taking responsibility for where you get your information helps to protect you and the ones you love.

What is COVID-19? Its  Signs and Symptoms

As we mentioned above, the current coronavirus pandemic is caused by a version of the virus (which is covered with crown-like spikes on its surface) is called COVID-19 and is a version of the SARS virus.

Without an actual test, COVID-19 is impossible to accurately diagnose because it replicates other versions of common colds and cases of flu. To complicate matters, the only way to be tested is to visit a local healthcare provider, which means potentially exposing yourself to the real coronavirus if all you have is a common cold.

This is why healthcare providers recommend staying at home and calling them via office lines or their 24-hour nurse line. By describing your symptoms and their severity, healthcare professionals can provide a tremendous amount of support while allowing you to stay safely at home. That way, only those in the greatest need occupy medical facility space, and the rest of us with potential coronavirus cases remain quarantined at home, preventing further spread of the virus.

If symptoms are severe enough, your healthcare provider will give you explicit instructions on how to safely travel to and enter their facility for testing and treatment.

First and Most Common Symptoms

Symptoms of COVID-19 typically appear within two to five days after exposure. In almost all but the most severe cases, the virus runs its course within 14 days.

The first and most common symptoms of coronavirus are:

• Fatigue
• Headache
• Sore throat
• Low-grade fever

Additional symptoms

As with any cold or flu, the symptoms vary from person to person, and they tend to get worse after the initial two to three day onset. Additional symptoms of COVID-19 include:

• Muscle aches
• Difficulty smelling or tasting (a common side effect of viruses because they attack the cells that our noses and brains use to detect scent, which enhances our sense of taste)
• Headache
• More elevated fever
• Diarrhea and/or stomach upset

Severe symptoms of COVID-19

Some of the most severe symptoms are most likely to result in hospital admission and testing. These are:

• Persistent pain or pressure in the chest
• Difficulty breathing
• Bluish lips or face
• Inability to rouse from sleep or a resting state or mental confusion

Any of these symptoms should result in a phone call to a 24-hour nurse hotline or 9-1-1, when you will be given explicit instructions on how to proceed.

Soothing a Sore Throat – Coronavirus or Otherwise

The very good news is that the large majority of those who catch COVID-19 never experience severe symptoms. In fact, some never have any symptoms at all, or a sore throat may be the only coronavirus they experience.

Again, the best thing you can do for yourself if you experience any of the potential coronavirus symptoms (headache, sore throat, fever, fatigue, aches, etc.) is the same thing you would do for any other flu – hydrate, eat soft, nourishing foods, and get plenty of rest. Fortunately, sheltering-in-place mandates make it easier than ever to take good care of yourself.

Drink plenty of fluids – preferably water and herbal teas

Your sore throat is inflamed and the body produces mucous to drain viruses or bacteria out of your system. Mucous drainage from the nose, which travels and can linger in the throat, is also a cause of sore throats. Drinking fluids flushes those out of the throat and soft palate area, which minimizes irritation. Remaining hydrated also boosts your body’s natural immune boosting response.

If you have a sore throat, try:

• Sipping on room temperature or cool (rather than ice-cold) water to keep the throat moist and lubricated. Sometimes drinking ice water causes throat spasms, which can lead to coughing and further throat irritation.
• Warming or heating water and adding a squeeze of lemon and a teaspoon of honey, which is a known throat-soother
• Sip decaf teas or herbal teas that advertise throat-soothing properties
• Suck on ice chips or 100% juice ice popsicles if your throat is really sore. This helps your body absorb fluids through the mouth while minimizing painful swallowing

DO NOT: Consume alcohol. Alcohol irritates inflamed throat tissues. Plus, as the CDC states on their Coronavirus Myth Busters page, “Frequent or excessive alcohol consumption can increase your risk of health problems…Drinking alcohol does not protect you from against COVID-19…” Plus, alcohol is dehydrating, which is counterproductive when focusing on hydration.

Try to avoid…

You may also want to avoid sports drinks and fruit juice. While they may seem like a good idea, they are loaded with sugar and the acid content in most fruit juices often irritate inflamed throats. Coffee is also high in acid and the caffeine may prevent you from getting the rest you need.

Get lots of rest

Your body does its best healing when you are at rest. Sleeping and lying low allows your body to divert as much energy as possible towards fighting off the invader, whether that be a bacterial infection, a virus, or COVID-19.

In fact, multiple studies have proven that sleep really is the best medicine against the flu. A study conducted by the University of Washington found that when we have a flu virus, our bodies produce an extra amounts of the protein AcPb. While we sleep, this protein interacts with immune system signaling chemical called interleukin-1. Together, they catalyze more sleep and expedited healing.

Eat nourishing foods

Typically a sore throat and flu include that aforementioned lack of smell and taste. Altogether, it can diminish your appetite. However, healthy and nourishing foods will help to boost your immune system can help you feel better at the same time.

The post Your Sore Throat and Coronavirus: Care & Treatment appeared first on Jerome Hester, MD.

The following is transcript of the video for your convenience:

If an individual has recurrent sinus infections or a sinus infection that just doesn’t go away, surgery is one option for treatment. If you look at the goal of sinus surgery it is basically to reestablish the normal ventilation and drainage of the sinuses. Originally this was done with very aggressive surgery, where incisions were made sometimes on the face itself, and actually the goal was to destroy some of the sinuses, so they would not bother the patient. This was at times very successful, however, as one may imagine by the scope of such a surgery, were painful and had a prolonged recovery.

A little over 30 years ago there was in introduction of endoscopes, which are small telescopic cameras that allow the surgeon to actually enter the nose and find the natural openings of the sinuses, where very small instruments can be used to provide access to the openings and create larger openings and removal of infection. This improved the recovery time dramatically from the original surgeries, but still left the patient with a five to seven day recovery.

In addition, recently, there have been advances made with packing materials. Packing is a substance that’s generally placed in the nasal cavity after surgery, to hold pressure on that area to reduce bleeding and maintain the openings. Not only was it painful to have the packing in place for sometimes three to seven days, but it’s removal was also sometimes described by the patient as the worst part of the whole surgery. Newer devices have been manufactured, which allowed us to avoid the use of packing, many times because these devices just self absorb and do not need to be removed and put much less pressure on the system.

Within the last decade, advances have been made further to eliminate the need for cutting or removal of tissue and instead, simply, dilating the sinus openings. This can be accomplished either by a higher pressure balloon system or by a lower pressure osmotic system, where fluid is drawn from the sinus cavity into a device, which then expands. Placement of these devices carefully into the sinus openings can then allow for these openings to be dilated, the device is removed, and the patient many times can return to normal activity either the same day or at the worse the very next day. This allows a marked improvement over the last several decades in the recovery time and the uncomfortable period following sinus surgery.

The post Is Sinus Surgery Painful? appeared first on Jerome Hester, MD.

A generation or two ago, many times tonsils were removed for somewhat vague reasons, either just based on appearance, in general, or some mild symptoms. Subsequent to that, with increased study, decisions were made to markedly reduce the number of tonsillectomies performed. Many times, individuals who were truly suffering from those issues were told that they should not have their tonsils out.

Within approximately the last decade, more concise and, I believe, more accurate recommendations for tonsillectomy have evolved. They basically come down to two reasons. The first is recurrent infection. There are definite parameters over how many infections in one year or how many infections over two to three years and individual would have before removal of the tonsils appeared to be indicated.

However, also something must be taken into consideration regarding the severity of these attacks. In other words, how sick is the patient during the attacks? How much school or work are they missing during these, which may prompt an earlier removal of the tonsil.

It is also important to know that although a Strep test, which is a test done commonly to measure a certain type of bacteria in a tonsil, may or may not be positive even in those individuals where the Strep test is negative. Removal may be indicated due to the presence of other organisms causing the infection.

Interestingly, over the last several years, however, the more common reason to remove tonsils is due to obstruction. This is not to say the tonsils are removed simply due to their size. However, we do know that large tonsils, especially in the young child or adult, can lead to obstruction of the airway, causing disruption of breathing during sleep. It has become the most common reason for tonsil removal, even in the individuals who never have tonsil infections.

The post Why Are Tonsils Removed? appeared first on Jerome Hester, MD.