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

The pharyngeal tonsils are thus often blamed for symptoms that they really play no part in. I cite a common example, which is parents bringing their child in for treatment of “tonsillitis”, based solely on what appears to be big tonsils, when in fact to my well-practised eyes, the tonsils are perfectly healthy and normal.

So what are the tonsils?

They are the round lumps peeking from the wings of the theatrical stage that one can imagine the tongue and soft palate to be. The tonsils are situated on both sides behind the bulk of the tongue, and when enlarged, or hypertrophied as doctors call it, are easily seen. The surface is often covered by crypts, or in plain English, pits. The size is variable, most commonly peanut sized, and most impressively ping-pong ball sized and in contact with each other. There may be an acceptable slight difference is 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.

I shall describe the more significant and common problems derived from and directly attributable to the tonsils. There are only a handful, and fairly straightforward to describe. It is then easier to contrast from the symptoms which the tonsils are often mistakenly blamed for.

Acute Bacterial Tonsillitis

Firstly, acute bacterial tonsillitis. The commonest bacterial infection is by Group A Streptococcus, hence in North America, the infection is known as Strep Throat. The symptoms are fever, pain in the throat often impeding eating and drinking, and body aches. Pus typically covers the surface or in the pits, giving the descriptive terms of exudative or follicular tonsillitis. Painkillers and antifever medication like Paracetamol is the least that should be given. It is preferable to give antibiotics but some parents may opt not to give. 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.

Tonsillar Enlargement

Secondly, tonsillar enlargement to the point of obstructing the upper airway. The upper airway is the part including the nose, mouth and throat. Anything lower than the larynx is arguably the lower airway. The tonsil enlarges often 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 adenoid are large is that in children the immune system is only just getting acquainted with new germs, and so is still very busy, hence the large size. With age, and having met a large proportion, maturity means smaller size with less activity. Narrowing of the upper airway would lead to more strenuous breathing, but this is seldom a problem during waking hours. It is only during the deepest 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 its upper airway totally blocked off with deep sleep, ie apoea. The child will not stop breathing permanently,but will spend much of the sleep hours in light sleep, making the child sleepy and fatigued during waking hours. This condition is 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.

Gross Asymmetry of the Size of the Tonsils

Thirdly, gross asymmetry of the size of the tonsils that suggests cancer. As I have said before, a slight difference in the size of the tonsils is normal. However, when one side is about three to four times the size of the other, then suspicion is raised of usually lymphoma, the lymph gland tumour. Squamous cell cancer is in smokers and in adults. Suspicion is confirmed or ruled out by tonsillectomy and histopathology tests.

Tonsil Stones

Fourthly, 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 multiply. 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.

Wrongly Assigned to Tonsils

This brings me to the symptoms which in my experience of seeing patients that have been wrongly assigned to tonsils. Most commonly, in the minds of some people, all pain in the throat is due to tonsil infection, which is so far from the truth. Most cases of sore throat is due to viral infections, which affects 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 is due to tonsillitis.

Other symptoms like voice hoarseness and cough I have seen patients attribute to 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, cough is an action by the respiratory system to expel mucus from postnasal drip or from the lower airways, hardly involving the tonsils.

The Final Note

The tonsils are there to serve a function, but if a genuine reason does exist, as expounded above, bacterial tonsillitis, obstructive sleep apnoea or suspected cancer, then tonsillectomy can be justified. But try not to blame the poor tonsils for all sore throats, coughs or voice hoarseness.