The South African Society of Otorhinolaryngology Head and Neck Surgery

Patients

Throat Conditions

What is a Tonsillitis?

Tonsillitis is an infectious condition with symptoms characterized by inflamed tonsils, fever, painful swallowing, sore throat, and a slight voice change. Other tonsillitis symptoms include a white or yellow coating on the tonsils, swollen lymph nodes, headache and bad breath. Nausea, vomiting and abdominal pain may occur in younger children. Throat infection (pharyngitis) often occurs along with tonsillitis.

Tonsils are lymph glands or lymph nodes located at the back of the throat where they catch incoming germs before they enter the breathing passage. It is believed that tonsils fight infection in the body by filtering bacteria and other microorganisms. During this filtering process, however, the tonsils themselves may become infected.

Children are particularly vulnerable to this kind of infection. It may be difficult to determine if a child has tonsillitis, so you should visit your physician when your child suffers from the common symptoms of infected tonsils. If tonsillitis attacks are frequent or severe, your pediatrician may suggest a tonsillectomy.

Tonsillitis causes include viral infections such as the flu, the common cold, mononucleosis or herpes simplex. Streptococcus is the most common bacterial cause. Bacterial tonsillitis can be treated with antibiotics, but viral tonsillitis cannot.

All forms of tonsillitis are contagious and generally spread from person to person in coughs, sneezes, and nasal fluids.

FREQUENTLY ASKED QUESTIONS

Q. What are tonsils?
A. Tonsils are glands located on the right and left sides of the entrance to the throat.

Q. What do tonsils do?
A. The role of the tonsils is to guard against infection.

Q. What is tonsillitis?
A. Tonsillitis is an infectious condition of the tonsils.

Q. What are the symptoms of tonsillitis?
A. Symptoms of tonsillitis include frequent throat and ear infections or obstructed breathing.

Q. Who gets tonsillitis?
A. Though tonsillitis can occur at any age, seventy percent of the patients who have tonsillectomies are under 18.

Q. Can tonsillitis be treated with antibiotics?
A. Antibiotics are frequently effective in treating tonsillitis; however, your physician may suggest a tonsillectomy if antibiotics are no longer combating the illness.

Q. Is tonsillitis contagious?
A. Yes. All forms, bacterial or viral, are contagious. It usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.

Q. How can I avoid getting tonsillitis?
A. Wash your hands frequently and keep the infected person's eating utensils and drinking glasses away from yours.

Q. How many times do you have to get tonsillitis before considering a tonsillectomy?
A. It is not possible to give an exact number of infections needed before a tonsillectomy should be considered because each person is different. However, general guidelines suggest that individuals who have five or more throat infections in one year would probably benefit from a tonsillectomy.

Q. What is a tonsillectomy?
A. A tonsillectomy is the surgical removal of tonsils, most often due to chronic infection.

Q. Is the surgery painful?
A. The patient is under a general anesthetic during the surgical procedure.

Q. How long does the patient have to stay in the hospital following a tonsillectomy?
A. Tonsillectomies are usually performed on an outpatient basis (does not require an overnight hospital stay).
Q. Will a tonsillectomy eliminate sore throats?
A. Surgery will not eliminate throat infections, but will likely decrease the frequency of occurrence.

Q. Are tonsillectomies rare?
A. surgical removal of the tonsils is one of the most frequently performed procedures of the throat.

Q. When will my child be able to return to school?
A. Patients usually return to school after about one week, and vigorous physical activity may be resumed at that time also. However, you and your doctor should determine when your child is ready for normal activity.




GORD Perspective

What is GORD?

Once food leaves the mouth it travels via an active squeezing mechanism, (peristalsis), through the oesophagus (throat), to the stomach which lies just below the rib cage. A circle of muscle around the lower oesophagus just before the stomach which is known as the lower oesophageal sphincter, (LOS), keeps the stomach contents, including the acid made there, from squirting, (refluxing), back into the oesophagus. In GORD, the LOS does not close properly. GORD occurs when stomach contents, including the acid, reflux up into the oesophagus. The very young have especially immature LOS. Acid contact with the very sensitive lining of the oesophagus and throat causes burning - just like sunburn and the skin. As in sunburn and skin, reflux can and is most often silent, until a problem arises. Almost everyone has experienced some reflux in their life, but the disease (GORD) occurs when reflux happens on a frequent basis often over a long period of time (2). Reflux may reach the laryngopharynx, (voice box and throat) and is then referred to as Laryngopharyngeal Reflux (LPR).


GORD/LPR Symptoms and You

This is very variable - as stated above it may be silent. Symptoms may include persistent heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing (2). Some may experience such severe chest pain as to mimic a heart attack. GORD can also cause a dry cough and bad breath. Some people with LPR may feel as if they have food stuck in their throat, a bitter taste in the mouth on waking, or difficulty breathing although uncommon. In infants & children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep disorders, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnoea), apparent life threatening event (ALTE), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical (2). Symptoms twice a week or more mean you may have GORD or LPR. For proper diagnosis and treatment, you should be evaluated by your General Practitioner for GORD or an Otolaryngologist - (ENT Doctor).



GORD / LPR and your ENT Doctor

As stated, there are ear, nose, and throat problems either caused by or associated with GORD and LPR. An otolaryngologist - head and neck surgeon has the tools and expertise to diagnose GORD and LPR. They treat many of the complications of GORD/LPR, including: sinus and ear infections, throat and laryngeal inflammation and lesions. Often a Gastroenterologist is brought in to assist.



GORD / LPR - Diagnosis and Treatment 

Often there is very little to find on physical examination but the history and specialised evaluation by your ENT including being able to "scope" the patient immediately is most important. A rigid or flexible "scope" (a telescope that gives a clear view of the larynx) is passed through the nose or mouth with or without local anaesthetic. An empiric trial of treatment with a Proton Pump Inhibitor (PPI) drug (reduces the stomach's acid production) can often clinch the diagnosis. This is not recommended without adequate clinical evaluation.


Tests may be needed; Gastroscopy, biopsy, x-ray, 24 hour pH probe, acid reflux testing, oesophageal motility testing (manometry), emptying studies of the stomach, and oesophageal acid perfusion test. Endoscopic examination, biopsy, and x-ray may be performed as an outpatient or in a hospital setting.

Currently Health Care Funders may insist on specific tests, some perceived as unreliable by ENT surgeons. Most funders do not pay for GORD/LPR medications out of their chronic drug allocation. It is advisable that the patient negotiates directly with your medical aid fund manager. It is imperative to not stop GORD/LPR medications without consulting with your Doctor.


Some of the consequences of GORD/LPR include: bad breath, swallowing disorders, hoarseness, sinusitis, cough, chronic laryngitis, chronic oesophagitis, airway obstruction, nasal obstruction, cancer of the oesophagus and emphysema.

The goal of treatment is to keep stomach acid and other irritating substances out of the oesophagus and throat. Treatment allows healing of the damaged oesophagus and voice box as well as prevents further damage. Most will respond favourably to a combination of lifestyle changes and medication. Proton Pump Inhibitors (PPIs) are the drug treatment of choice in most. Other medications include antacids, histamine antagonists, pro-motility drugs, and foam barrier medications (2). Only occasionally is surgery recommended. The fundoplication operation is the operation of choice - stomach wraparound to tighten the LES, but if done in the wrong patient may cause more problems.

GORD / LPR - lifestyle changes
Adult (2)


  1. Avoid eating and drinking within two to three hours prior to bedtime.
  2. Limit alcohol consumption and loose weight if overweight.
  3. Eat slowly -small and more frequent meals,
  4. Limit problem foods: Caffeine, Carbonated drinks, Chocolate, Peppermint, Tomato and citrus foods, Fatty and fried foods
  5. Quit smoking
  6. Wear loose clothing


 

Children

  1. Avoid feeding at night – especially bottles
  2. Avoid bottle feeding – constant “full” stomach
  3. Feed upright


 

References

Pilot study of the oral omeprazole test for reflux laryngitis, Otolaryngology-Head and Neck Surgery. January 1997,116 No.1 DAVID C. METZ, MD, MARCIA L. CHILDS, RN, CESAR RUIZ, MA, GREGORY S. WEINSTEIN, MD

1. Otolaryngology Head Neck Surgery 1999;120:208-14. (2)

2. AAO-HNS Website