Inflammation of the tonsils and adenoids

Interview with a specialist in the field of diseases of the ear, nose and throat, Professor of the New York Eye and Infirmary IGOR BRANOVAN

Perhaps, one of the most frequent reasons for referring to otolaryngologists are inflammatory diseases of the lymphatic glands of the nasopharynx in children. These diseases are also addressed to pediatricians, who usually advise treatment by an ear, nose and throat specialist. These diseases, and this is primarily inflammation of the tonsils and adenoids, often take a chronic course, which can lead to complications from the ears, lungs, and other organs of the child. That is why we decided to ask Professor Igor Branovan, a well-known specialist in diseases of the ear, throat and nose, to acquaint readers of the newspaper with the issues of recognition, prevention and treatment of these diseases.

IGOR BRANOVAN: The nasopharynx is, as it were, the internal continuation of the nose and mouth of a person. Here are several small paired lymphatic glands, which play an important protective role in protecting people from the invasion of many infectious “agents.” In the upper part of the nasopharynx on both sides of the back of the tongue are the tonsils. Below, in the back of the nasopharynx are the adenoids. Unfortunately, these names are well known to most parents, because almost all of them have to go to the doctor about the inflammation of these glands in their children - tonsillitis and adenoiditis.

As a result of the response to the infection of the child’s body, the inflammation of these lymph glands occurs. Tonsils and adenoids swell, increase in size, pain occurs when swallowing, the child’s breathing becomes difficult, because the access of the air flow to the lungs is difficult. Due to the fact that the adenoids are located near the openings of the auditory (Eustachian) tubes connecting the nasopharynx with the middle ear, the infection can penetrate into its cavity, leading to a complication - otitis and, consequently, hearing impairment.

— What contributes to the occurrence of inflammatory diseases of the nasopharynx in children? Why does the disease occur so often?

- This is a very important question. I will name the main reasons contributing to this. Medical experience shows that children often get sick literally a few days after a change of environment - after they have changed their home “greenhouse” conditions to stay in a kindergarten or school. At home they were, as it were, in “sterile” conditions. In public places, they find themselves surrounded by many different types of bacteria and viruses, leading to the development of the disease. More often this occurs in weakened children whose immune defenses are reduced. In addition, the place of residence of the children also plays a certain role. In urban environments, where air pollution is more pronounced, these diseases are also more common.

By themselves, these diseases are not so terrible. A relatively short antibacterial course of treatment within 7 - 10 days is usually sufficient. Worse in cases where, despite the treatment, the disease becomes chronic. At the same time, frequent - up to 5 - 7 once a year - exacerbations of the disease occur. This suggests that the infection in the tonsils and adenoids is not eliminated. The presence of frequent exacerbations indicates a weakened immune response of the child’s body. In such cases, to suppress the bacterial flora, it is necessary to conduct a longer course of treatment with properly selected antibiotics. In our institute, which is one of the head hospitals in the field of fighting infections of the ear, throat and nose in children, for several years a comparison was made of the effectiveness of treatment using various methods. It turned out that in the chronic course of inflammation of the tonsils and adenoids, the most effective was a monthly course of antibiotic treatment. This allowed 1 / 3 to reduce surgical interventions in such cases. We know that some parents are wary of taking antibiotics for a long time. Indeed, antibiotics, like the way any drugs, have some side effects. But with their proper application, they can be avoided or minimized. But most importantly, you need to remember that a number of complications in the ineffective treatment of tonsillitis and inflammation of the adenoids can lead to the development of severe complications from many internal organs (lungs, heart, etc.). Unfortunately, some parents do not always know about this. Therefore, the treatment of a child with chronic inflammation of the nasopharynx should be carried out by an otolaryngologist or by a pediatrician, since it is they who can provide the most qualified help to a sick child.

What else do I want to emphasize. In addition to the presence of infection, the size of the tonsils and adenoids is important. Their increase makes it difficult to breathe, and also prevents normal swallow food.

— Do children with significantly enlarged adenoids even change the sound of their voice and facial expression (“adenoid face”)?

- Yes. American doctors also use this terminology. When the adenoids are enlarged, the child's mouth is open, he sniffles, and often snores at night. An experienced specialist will make the correct diagnosis just by looking at such a child. But, of course, this is the first impression. A serious examination involves a traditional examination of the nasopharynx. It is more difficult to see the adenoids with a mirror. Then inspection with a special probe comes to the rescue. If there is difficulty breathing, notice a significant enlargement of the adenoids, although the inflammation will be minimal or may even be absent altogether. Only in some cases is it necessary to use a lateral x-ray for diagnosis.

— What causes adenoids to enlarge?

“Often this is based on an inadequate reaction of the child’s immune system. We explain this to the parents of a sick child. They are usually concerned about how the removal of enlarged tonsils or adenoids may affect the immune system. Fortunately, this issue has been well studied. It has been proven in a large number of cases that in children suffering from chronic inflammation of the tonsils and adenoids, the protective response of the immune system to infection is significantly weakened. The lymph nodes of the protective “shaft” of the nasopharynx have lost their original meaning. Therefore, their removal will not only not weaken the immune defense of the child’s body, but, on the contrary, will contribute to its restoration.

— In what cases do you have to use a surgical method of treatment, i.e., remove tonsils and adenoids?

In all those cases where, despite the ongoing drug antibacterial treatment, it did not produce the desired effect and exacerbation of chronic infection in the nasopharynx occurs at least 5 - 7 once during one year, or 3 - 4 once a year during 2 - 3 years contract. These are now the recommendations of the American Association of Otolaryngologists. But the final decision is made directly by the attending physician of the sick child. The second important criterion for such a decision with enlarged adenoids and their chronic inflammation is the patient's hearing condition. The fact is that chronic infection in adenoids and their increase contribute to the ingress of bacterial flora into the middle ear, which leads to the development of inflammation there - otitis. The result of this is often a child's hearing impairment, his speech development slows down, he begins to lag behind in general development, learning. In order to prevent these negative processes, according to the current situation, along with removal of the adenoids, a surgical method of hearing restoration is recommended, if hearing loss remains for at least 6 months. In such cases, through a miniature incision of the eardrum, we remove fluid accumulated there from the cavity of the middle ear. If it has become too thick and is poorly sucked away, we leave a small tube in the eardrum, through which the fluid gradually goes away, and then after a few months the tube itself drops out, leaving no traces of its presence there.

In a child with a significant increase in adenoids, in some cases they interfere so much with breathing that they can interrupt him for a few seconds. Often it happens at night and this condition causes a feeling of fear for the life of the child in mothers who do not sleep at night, afraid to lose the child. In such cases, we remove the adenoids without delay. Unlike the methods of removing the tonsils and adenoids in Russia and other CIS countries, in the United States the removal is carried out not under local but under general anesthesia (under general anesthesia). Due to this, the child easily, without any torment, transfers the procedure of removal. Of the complications, postoperative bleeding is observed in a small percentage of cases. Such bleeding does not occur immediately, but about a week later, when a crust formed on the surface of the postoperative wound and it disappeared too early and a blood vessel began to bleed beneath it. If a similar situation has arisen in an adult patient, then it is easy for him to stop the bleeding in the conditions of almost any medical office. It is more difficult for the child to stop the bleeding, since this should be done only in the hospital, because the child needs anesthesia for this. This kind of complication occurs after surgery is not often (less than 2% of cases), but you need to remember this and with the slightest signs of bleeding a child must be immediately taken to the hospital. Then qualified assistance will be provided quickly and the child will not be in danger.

— Why, in your opinion, are there many times fewer patients with rheumatic (acquired) heart defects in the USA compared to many other countries, in particular, compared to Russia and other CIS countries?

— Diseases of the nasopharynx and, above all, chronic tonsillitis are the “entry gate” of infection and, above all, streptococcus, which was and still is the infectious basis for the occurrence of rheumatism and its complications in the form of valvular heart defects. Until the mid-twentieth century, the United States was not much different from other countries in this regard. However, after the treatment of pharyngitis and tonsillitis in children with penicillin began to be actively carried out here in the 40-50s, the number of diseases of rheumatism began to decline and now this disease in the United States seems, fortunately, to be very rare. And this is a huge merit of the scientists who created penicillin and other antibiotics. That is why I want to once again remind parents of the need to consult a doctor in a timely manner if their child begins to develop “innocent”, at first glance, diseases of the nasopharynx. They are fraught with a number of serious complications that we are able to prevent.

Interview conducted by MD

Leonid Lozinsky