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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
What are 'Tonsils' ? The   tonsils   are   oval   collections   of   lymphatic   tissue located   in   the   back   of   the   throat   on   the   right   and left   sides.   The   uvula   hangs   down   from   the   middle of the soft palate, between the tonsils. The   primary   purpose   of   the   tonsils   is   to   trap   and destroy    viruses    and    bacteria.    Usually,    tonsils    do their   job   well.   But   sometimes   bacteria   or   viruses get    into    the    tonsils    and    infect    them.    When    this happens,    you    have    tonsillitis.    Some    children    and adults are prone to develop infections of the tonsils What is an acute tonsilitis ? Tonsillitis   is   an   inflammation   of   the   glands   of   the   throat,   which   results   in   a   sore   throat.   Acute tonsillitis   may   present   with   redder-than-normal   tonsils,   a   yellow   or   white   coating   on   the   tonsils,   a funny-sounding voice, swollen lymph nodes/glands in the neck, fever and bad breath. Most forms of tonsillitis are contagious and are spread by droplet transmission. Treatment   consists   of   antibiotics,   painkiller,   fever   medication,   gargle   and   taking   lots   of   fluids.   It will usually resolve after treatment. What problems can tonsil cause ? a.   Recurrent   sore   throats,   throat   infection.    If   these   acute   infections   are   especially   severe and   become   more   frequent,   the   tonsils   themselves   can   become   the   source   of   throat   infection. Abscess   (quinsy)   can   also   arise   around   the   tonsillar   space.   In   such   a   case,   it   may   be   best   to remove   the   tonsils   later   after   the   acute   episode   of   infection,   particularly   if   they   interfere   with everyday activities (i.e work, schooling). b.    Snoring    and    mouth    breathing.     Frequent    infection    makes    the    tonsils    grow    in    size (hypertrophy)   over   time.   Some   people   have   large   tonsils   despite   infrequent   infection   of   the throat   or   tonsils.   Large   tonsils   blocking   and   narrowing   the   airway   can   reult   in   constant   mouth breathing,    heavy    snoring    or    obstructive    sleep    apnea    OSA    (apnea    =    cessation    of breathing),   during   which   the   patient   stops   breathing   and   experiences   a   drop   in   the   oxygen content   in   the   bloodstream.   As   a   consequence,   they   may   feel   tired   and   sleepy   the   next   day due   to   the   poor   quality   of   sleep,   hence   affecting   their   concentration.   OSA   in   the   adults   can predispose to hight blood pressure (hypertension), and cardiovascular/heart problems. c.   Recurrent   ear   infections.   Frequent   infection   of   the   tonsils   can   also   lead   to   secondary infection of the middle ear, leading to severe pain in the ear, fever and hearing loss. d. Bad/foul-smelling breath (halitosis). This is due to bacteria in the oral cavity acting on the infected material in the tonsils and tiny stones containing high sulphur content, producing a foul smell. d. Altered voice quality. If the tonsils are extremely large they may cause a stuffy sounding, or muffled voice as narrowing of the throat interferes with voice production. What is 'Tonsillectomy'?  A   tonsillectomy   is   an   operation/surgery   which   removes   the   tonsils.   It   is   done   under   general anaesthesia    after    taking    into    consideration    patient's    symptoms    and    complications    from enlarged or chronically infected tonsils. What are the benefits of surgery ? a.   Fewer   sore   throats:    Once   the   tonsils   are   removed,   patients   are   much   less   likely   to   have bacterial   infections   in   the   back   of   the   throat.   However,   viral   infections   in   this   area   is   still possible.   Frequency   and   severity   of   infective   sore   throat   generally   reduces.   Removal   of   the tonsils will prevent tonsillitis and abscess collection around this area; however it cannot stop other illnesses with sore throats.  b.   Decreased   snoring   and   mouth   breathing:   Patients   who   snore,   or   mouth   breathe   because   of enlarged     tonsils,     often     have     a decrease   in   these   symptoms   after   surgery.   However,   if   other   problems   exist,   such   as   a   crooked nasal   passage,   a   long   soft   palate   or a thick tongue, these symptoms may continue after the procedure. c. Fewer ear infections: More significant improvement if any enlarged obstructive adenoid is removed during the surgery as well (see ‘Adenoids’ section below) d.   Fresher   breath:    If   halitosis   is   present   because   of   chronically   infected   tonsils,   this   may   improve after   surgery.   However,   bad   breath may   persist   if   it   is   caused   by   bacteria   in   other   areas   of   the   mouth.   Gum   disease,   failure   to   floss,   or other    medical    or    dental    problems can also contribute to bad breath. e. Improved voice quality: If the tonsils and adenoids are extremely large they may cause a stuffy sounding, or muffled voice. Removal of these tissues can help improve air flow and voice quality.
What are 'Adenoids' ? The     adenoids     are     lymphatic tissue    located    above    the    soft palate   on   the   back   wall   of   the throat     near     the     eustachian tubes   (ET).   The   ET   tubes   are small       air       passages       that connect    the    space    under    the eardrum   (middle   ear)   with   the back    of    the    nose    (also    called    nasopharynx).    When    you    clear    your    ears    on    an    airplane,    you    are equalizing air pressure through the ET. The primary purpose of the adenoids is to trap and destroy viruses and bacteria, just like your tonsils. Similarly,   the   adenoids   can   increase   in   size   due   to   frequent   infection   and/or   inflammation.   Enlarged adenoids   can   cause   nasal   blockage,   rhinosinusitis,   snoring,   frequent   ear   infection   (acute   otitis   media, middle ear effusion ) and foul breath. If problematic, it can be removed surgically.
Sometimes,    adenoids    can    mimick    cancerous    lesions    in    the    nasopharynx    (eg.    nasopharyngeal carcinoma    or   commonly   called   NPC)   or   vice   versa,   making   biopsy   necessary   to   exclude   the   more sinister counterpart.
Tonsils & Adenoids
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Surgery of the Tonsils & Adenoids
TONSILLECTOMY refers to removal of the tonsils. ADENOIDECTOMY refers to the removal of the adenoids. Both the surgeries can be done concurrently (called ADENOTONSILLECTOMY) or independently. For more details on surgical care after the operation, please kindly click this link.
PATIENT’S HEAD END PATIENT’S HEAD END A Tonsillectomy in progress while the patient is under general anaesthesia PATIENT’S MOUTH PATIENT’S  MOUTH © Vincent Tan ENT Right: A close-up view of the oral cavity and oropharynx (upper throat) Left: Throat examination revealing large tonsils (red lines). Compare the narrowed airway with the above picture (without enlarged tonsils) © Vincent Tan ENT uvula
Right picture : Acute tonsillitis with exudates on both tonsils. Left picture : Stones (red arrow) in the right tonsils
A cross section top view of the upper airway. Oval blue line represents the tonsils, the black line represents the epiglottis (part of your voice box structure). Tongue The same view in a real patient where the left tonsil (red line) is enlarged while the right tonsil is not (blue line). The black line represents the epiglottis. Now... imagine if the right tonsil is enlarged (green line) as well - how narrow can the airway be !? © Vincent Tan ENT © Vincent Tan ENT Right  Left
Notice   the   tonsil   crypts   in   the   resected   tonsil   on   the   left. On    cross    section    (right    picture),    these    crypts    (white arrows)   from   small   ‘tunnels’   into   the   core   of   the   tonsil. Food   debris   can   get   stuck   here,   causing   bacterial   infection or   foul   smell   in   the   mouth   or   forming   ‘stones’   (tonsillolith). Picture on the right -source: Dhingra Diseases of ENT 3rd edition textbook
What are the complications of tonsils removal surgery ? Most   are   in   the   immediate   or   early   postoperative   period.   They   include bleeding   from   the   operative   site,   infection,   local   trauma   to   the   oral   cavity region. But   these   are   rare   incidences   (less   than   3%)   and   generally,   tonsil   surgery is very safe. Scientific   researches   over   the   years   had   also   shown   that   removing   the tonsils   does   not   cause   any   significant   problems   with   the   immune   system in long term. It   should   be   emphasized   that   all   decisions   for   or   against   surgery   are dependent   upon   the   individual   patient's   particular   situation.   Patients   will be thoroughly counselled before any decision for surgery made.
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
Last update:  3/1/16 
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For more details on surgical care after the operation, please kindly click this link.
Postoperative  Care
There   are   many   ways   to   remove   the   adenoids   and   tonsils   depending   on   the   surgeon   and   instruments available. Here,   the   tonsils   are   removed   under   direct   vision   using   different   instruments   and   different   techniques (   e   v   e   n     using   the   same instrument), including: Cold steel instruments Monopolar and bipolar Diathermy Radiofrequency ablation Harmonic scalpel Carbon dioxide (CO2) laser Adenoidal   removal   performed   with   microdebrider   (a   special   rotating   blade)   under   endoscopic   guidance also        has t       h       e         following advantages: faster, more accurate, and complete removal of adenoidal tissue less   risk   of   injury   to   important   structure   eg   the   Eustachian   Tube   opening,   therefore   reducing   risk of scarring, pharyngeal stenosis less postoperative pain
© Vincent Tan ENT Endoscopic view in the nose showing adenoids removed using microdebrider  Microdebrider adenoids
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Left picture: An enlarged adenoids (green arrow) encroaching onto the left Eustachian Tube (ET) opening (white arrow). Right picture: An endoscopic view of the right ear showing Middle Ear Effusion as a result of ET blockage. Notice the bubbles (red arrows) behind the ear drum.  © Vincent Tan ENT adenoids purulent mucus © Vincent Tan ENT Inflammed and infected adenoids (adenoiditis) as a potential source of infection to the ear and sinuses pus enlarged adenoids
Occasionally, a tonsil can be enlarged only on one side (note the dotted line). It is important to exclude growth within a tonsil. Lower picture showing lymphoma (red arrow), a type of cancer, arising in the right tonsil   © Vincent Tan ENT © Vincent Tan ENT
© Vincent Tan ENT
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Pic A & B: Endoscopic view of the nasopharynx (back portion of the nose): Compare the normal  and large adenoids on the right. The nasal cavity has very narrowed airway,contributing to snoring, nasal blockage © Vincent Tan ENT A B C
Talks about TONSILS on 14/2/14 ((for educational purposes)
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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