Don’t just blame the tonsils

040113-N-4614W-005Northern Arabian Sea (Jan. 13, 2004) -- Capt. Wan Mun Chin examines a patient suffering from a sore throat and high fever. Capt. Wan is assigned to the Republic of Singapore tank landing ship RSS Endurance (L 207). Endurance is participating in a 15-nation coalition exercise Sea Saber 2004. Endurance will participate as both a compliant and non-compliant vessel for boarding teams. Sea Saber will provide a multi-tiered training scenario in locating weapons of mass destruction aboard suspect ships operating in waters currently patrolled by coalition forces in support of Operations Enduring Freedom and Iraqi Freedom. U.S. Navy photo by Journalist 1st Class Jeremy L. Wood. (RELEASED)

The throat and mouth are the only parts of the inner body that a person can naturally see with his own eyes, either in front of a mirror or looking directly into another person’s mouth.

Other internal parts of the body would need the assistance of an endoscopic instrument.

Commonly, people attribute some symptoms to what can be most easily seen, sometimes mistakenly so. Hence, the pharyngeal tonsils are often blamed for symptoms that they really play no part in.

A common example is parents bringing their child in for treatment of “tonsillitis”, based solely on what appears to be big tonsils, when in fact, the tonsils are perfectly healthy and normal.

So, what are the tonsils? They are round lumps peeking from the wings of the “theatrical stage” that is the tongue and soft palate.

The tonsils are situated on both sides of the tongue, and when enlarged (or hypertrophied as doctors call it), they are easily seen. The surface is often covered by crypts, or in plain English, pits.

Their size is variable and is most commonly peanut-sized. There are slight differences in size between the two sides. The colour of the tonsils is the same as the rest of the healthy pink pharyngeal mucosa.

The tonsils contain lymphoid tissue, which is involved in immunity and fighting infection, very much like the lymph glands in the neck, armpits and groin.

There are only a handful of significant and common problems derived from, and directly attributable, to the tonsils.

Bacterial infection

First, there’s acute bacterial tonsillitis. The commonest infection is by Group A Streptococcus, hence, in North America, the infection is known as a strep throat. The symptoms are fever, pain in the throat that often impedes eating and drinking, and body aches.

Pus typically covers the surface or pits of the tonsils, giving rise to the descriptive terms of exudative or follicular tonsillitis.

Painkillers, antifever medications and antibiotics should be given. Tonsillectomy is a common ultimate outcome of bacterial tonsillitis, but not necessarily so.

Surgery does give everlasting relief to recurrence of infection, but the child who has undergone tonsillectomy does suffer much pain, which will mean the parents have to suffer along with the child – sleepless nights, crying, etc.

V0036368ET Sore throat and ulcerated right tonsil in a 47-year old womaCredit: Wellcome Library, London. Wellcome throat and ulcerated right tonsil in a 47-year old woman with herpes labialis and hypoplastic anaemia. Watercolour by Barbara E. Nicholson, 1949.1949 By: Barbara E. Nicholsonafter: Norman Murdoch MathesonPublished: 1949Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0
Sore throat and ulcerated right tonsil. Photo: Wellcome Library, London. Wellcome

Enlargement of the tonsils

The tonsils can enlarge to the point of obstructing the upper airway.

The upper airway encompasses the nose, mouth and throat.

Anything lower than the larynx is arguably the lower airway. The tonsil often enlarges along with the adenoid, the tonsil-like lump that sits in the nasopharynx, the part of the throat that is behind the nasal cavity.

The only real reason the tonsils and adenoids are large in children is that their immune system is only just getting acquainted with new germs, and so, is still very “busy”, resulting in the large size.

Age and maturity lead to smaller-sized (due to less activity) tonsils.

Narrowing of the upper airway could lead to more strenuous breathing, but this is seldom a problem during waking hours. It is only during the deepest part of sleep – rapid eye movement (REM) sleep – that the throat muscles are sufficiently relaxed to cause inward collapse of the throat muscle walls. This could lead to snoring during the slightly narrowed phase and cessation of breathing during total obstruction, until the child exits REM sleep to lighter sleep.

One can imagine then that a child with adenoid and tonsillar enlargement would have his upper airway totally blocked off with deep sleep (apnoea). The child will not stop breathing permanently, but will spend much of his sleep hours in light sleep, making him sleepy and fatigued during waking hours.

This condition is called obstructive sleep apnoea, and is a separate topic in itself. Suffice to say that if severe enough, this condition warrants the removal of the adenoid and tonsils.

Different-sized tonsils

Gross asymmetry of the size of the tonsils might suggest cancer.

Usually, a slight difference in the size of the tonsils is normal. How-ever, when one side is about three to four times the size of the other, then suspicion is raised of a lymph gland tumour, usually lymphoma.

Squamous cell cancer is suspected in smokers and adults.

Suspicion is confirmed or ruled out by tonsillectomy and histopathology tests.

Tonsil stones

These are little whitish specks on tonsils called tonsilloliths, or tonsil stones. These are clumps of food matter and secretions from glands that collect within the pits of the tonsil.

It may occur singly or in groups. These clumps can have a foul odour and this motivates patients to try and remove them. These will, however, recur.

Tonsillectomy is rarely, if ever, done for tonsil stones.

Common misconceptions

Usually, most people attribute pain in the throat to tonsil infection, which is far from the truth.

Most cases of sore throats are due to viral infections, which affect the throat, nose, middle ears and lower airways to some degree.

Put another way, all cases of tonsillitis have sore throat, but not all cases of sore throat are due to tonsillitis.

Other symptoms like voice hoarseness and cough are also often blamed on the tonsils, either because the tonsils are enlarged, or they look “inflamed”. Many people seem to see enlarged and inflamed tonsils even when the tonsils are normal in size and colour.

“Inflamed” is a conclusion made when people see red, but the healthy tonsil can be a reddish-pink, so in theory, all tonsils can look inflamed!

Voice hoarseness is due to abnormalities of the larynx or voice box, and never to the tonsils, which do not serve any vocal function.

Likewise, a cough is an action by the respiratory system to expel mucous from a postnasal drip or from the lower airways, hardly involving the tonsils.

The tonsils are there to serve a function, but if a genuine reason does exist – bacterial tonsillitis, obstructive sleep apnoea or suspected cancer – then a tonsillectomy can be justified.

But try not to blame the poor tonsils for all sore throats, coughs or voice hoarseness.

Dr Lim Wye Keat is a ENT surgeon. This article is courtesy of the Malaysian Association of Paediatric Surgery. For further information, e-mail The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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