Enlarged Tonsils: Did You Want That to Go?

Enlarged Tonsils: Did You Want That to Go?

Consider the tonsil.  Poor, misunderstood things, they are ugly even on good days, looking like a pair of pitted meatballs, tacked up to the throat wall and painted the same color as the back of the mouth. On bad, inflamed days? Ecch! Two of them sit at the entrance to the throat, flanking that portal like poorly paid security guards. And what do they do, exactly? Do they have a point, aside from being a sort of ‘appendix of the oral cavity,’ an item to be removed so that you can eat ice cream for a week, post op? Turns out, in the last several years, tonsils have gone from disposable items—perhaps removed as a favor during an operation for something else—to something worth having, if possible. Weird, huh?

 Tonsils are the part of the first line of defense for that tube within a tube called your aerodigestive tract (aka the plumbing you eat and excrete with, and/or use to breathe, belch, etc). Working in relative obscurity, tonsils toil to produce protective white blood cells and manufacture antibody type proteins to protect against infection. Tonsils work in tandem with the adenoids, which live upstairs in the back of the nasal cavity, out of view, and have a similar, immune protective role.  When all these glands work well, they keep you healthier by surveilling the food you eat, and the air you breathe. Nice. Yet, like the adenoids, tonsils work like quirky old appliances, prone to breaking down or causing trouble. Most people, in fact don’t even think about their tonsils til they become infected or inflamed or if they poorly fit their space.

While infection fighters, tonsils themselves can be prone to bacterial or viral attack. Amongst the medical set, the ‘tonsillitidies” are described in four flavors: acute, chronic, recurrent, and peritonsillar abscess.  Let’s be clear: any tonsillitis can be a drag. Children may suffer fever, sore throat,  enlarged lymph nodes on their neck and have pain with swallowing. Some kids even drool and talk in an aptly termed ‘hot potato voice.’(Literally, they sound as if they are talking around a hot french fry on their tongue). Sufficiently swollen tonsils can block the back of the throat causing a need to mouth breathe, or to spit all secretions. Yuck again.

In children under two, acute tonsillar infections almost invariably are relatively short lived, viral affairs, which may run with fevers, and some combination of cough, rashes, runny noses, and inflammation of the nose and back of the mouth. Some of these are quite painful, and can cause sores on the tonsils due to infections by such viruses as herpes, EBV or coxsackie. Checking with your primary care doctor on comfort measures and supportive care can be important here, especially for the  little ones, who may get dehydrated due to the pain associated with swallowing.

As children enter school age, the rates of tonsillar infections by bacteria rise to about a 20-30%, and the dreaded Group A strep species of bacteria cause  more and more infections in this age group. Easily identified by rapid tests and throat culture, strep throats customarily respond to antibiotics and get better. And, as noted elsewhere, strep throats need to be treated to avoid the complications of rheumatic fever.  Symptoms usually resolve in a few days, but can take up to a week or more.

 As part of a full exam, the tonsillar assessment is all about why we have the children say “aah.” By protruding the tongue, and pronouncing that vowel sound, the floor of the mouth muscles drop, and we get a view of the teeth, lining of the mouth and the ‘posterior pharynx,’ where the tonsils live. We are trained to describe what we see (or not).  We do well to note the presence or absence of sores or redness on the lining of the mouth or gums. As for the tonsils, we peek and note for changes in color (redness?), exudates (goop covering them, such as pus), asymmetry (is one side worse than the other?) and for enlargement.  For this latter part of the exam, we even use a scale. 0+ tonsils are normal size, ranging up to 4+ where tonsils ‘kiss’ and meet at the midline.   

Of course, life is messy, and things don’t always go according to plan.  Some children may suffer recurrent tonsillitis. In these repeated rounds of strep throats, a child may be colonized by the bacteria and/or become repeatedly vulnerable to infection from those who have it. For these families, the school year can be a nightmare, with frequent absences and days lost to illness and discomfort. Chronic tonsillitis is where the infection moves in and doesn’t respond to treatment. Essentially, these beatup, unrelentingly infected tonsils don’t work so well,  and serve as a persistent source of pain, inflammation, and bad breath; their owners are pretty miserable.  Peritonsillar abscesses are a true bummer, and involve pockets of bacterial infection in the deep, complex spaces of the neck . These require urgent, often surgical consultation.   

More is not always better.

Tonsils may respond to inflammation by revving up immunologically and actually becoming larger. Tonsillar hypertrophy, as this is called, is expected during an acute infection. And, the tonsils will typically revert to their baseline size after a few weeks.  As long as this cycle of inflammation and gland growth and shrinkage follows this trajectory, without creating pain or stress for the child, no problem.   In fact, it is a relatively newer idea that the tonsils are providing some immune protective function.  Some children, though, have tonsils that remain enlarged due to recurrent or persistent infections. Other kids have tonsils without a known history of illness, but appear inexplicably enlarged. For children with chronically big (hypertrophic) tonsils, the majority are asymptomatic and are not at risk.  Parents can work with their doctors to figure out if their kid’s large tonsils are a worry, or are just a cool party trick (“Hey, Grandma, check out my 3+ oral lymphoid tissue!”)…and if those tonsils need to come out.  

And therein lies the rub: in days of old, tonsils were removed much more readily. Nowadays, the procedure is done after a bit more consideration.

In terms of who needs to get those tonsils out, it boils down to two groups. The children who are adversely affected by seriously or persistently infected tonsils, and/or the children whose tonsils are becoming too big for their britches, are interfering with breathing, and are wreaking havoc on a life or little one’s biology.

Children with three or more bacterial tonsil infections a year, in spite of appropriate therapy with antibiotics may be candidates for tonsillectomy. Beyond these kids, children with a chronic or recurrent tonsil infections that are unresponsive to medications may be considered for surgery.  Children with individuals who have chronic bad breath or a foul taste in their mouth due to their afflicted glands, or those who have difficult to treat peritonsillar abscesses may get a ticket to the OR.

Large tonsils can cause large problems for kids. Parents may come in specifically concerned about the symptoms they can cause, and other times, I have stumbled upon the diagnosis after I have a look in a mouth and see a child with meatball-like glands in the back of this throat.  In those children who are symptomatic, tonsillar hypertrophy can create a host of problems, including difficulty feeding, noisy and snorkelly breathing sounds, chronic mouth breathing, restless sleeping and buzzsaw snoring. The irregular, gasping respirations, known as obstructive sleep apnea , stress a child’s cardiovascular system, and may cause high blood pressure and abnormal growth of the heart muscle. In turn, such children may also show a host of behavior changes, including excessive daytime sleepiness, hyperactivity, irritability, and difficulties in school.  I gladly ham up a snoring version of obstructive sleep apnea breathing for my patients when I am taking a history. Any word that a child has gasping or choking breathing that continues for weeks after a cold or sore throat has resolved merits careful review.

But it doesn’t end there.  For the more severely and chronically affected, longstanding large or inflamed tonsils can predispose kids to ear and sinus infections. They can affect anatomy: these children may actually develop an elongation of their lower face and jaw from continually opening their mouth to breathe. And, long term, it is likely that some of these children may suffer a dent to their cognitive development, if their brains are growing in an oxygen depleted state.  Fortunately, the majority of children are identified and treated long before these problems arise.

And, with all this worst case scenario stuff, let us not act like second year med students, and conclude that all of our life’s problems (or our children’s issues) are due to tonsillar hypertrophy. Not hardly. Let’s take a step back and take heart.  In fact, the news is good, and most kids do just fine (and get to keep their tonsils).  Primary care docs and parents are now operating with much more information, clearer guidelines, and I think, a more balanced perspective about what tonsils do and when they need to come out. Parents and health care providers can tap into the expertise of our surgical colleagues when medicine treatments don’t appear to be  having the desired effect, or when in fact, those tonsils need to come out.

Tonsillar surgery is still quite common. Over 650,000 tonsillectomies (some with, some without adenoidectomies) were done in 2006 alone, making it one of the most common surgical procedures done on children.  History and examinations may confirm surgery is necessary, other times imaging studies or even sleep studies will be done to determine if the tonsils are problematic. Unlike years past, these operations are now an outpatient procedure, allowing the child to be home in her own bed that evening. Even still, I counsel families to plan on at least a week  (maybe even two for some children) for recovery.  And remember, for this rocky road, rocky road flavored ice cream works (and tastes) great!

And so, the next time you or your child feel a twinge of discomfort at the back of your throat when you swallow, brew up some Throat Coat tea, and respect the tonsil. There, in the slimy dark, they are fighting the good immune fight, even if they don’t always do it so well.

And, keep an eye on them as best you can. And, if necessary, talk with your child’s doc to see if those tonsils should stay…or, should they go?


(photo above from http://www.kkkmedicine.blogspot.com/2009/07/tonsil-paint.html; cartoon below by me)

 Enlarged Tonsils: Did You Want That to Go?



Jack Maypole, MD has plenty of material to work from. He is director of Pediatrics at the South End Community Health Center and he is director of the Comprehensive Care Program at Boston Medical Cent ...read more


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