What is tonsillitis?

Also known as infected tonsils, tonsillitis is a viral or bacteria infection that occurs frequently in children and younger adults. Most children will have at least episode of tonsillitis in their life. About 15-30% of tonsillitis is due to bacteria, most commonly due to streptococcus species (strep throat).

How do I know if I have a tonsil infection?

In acute tonsillitis patients often have fever, a fairly severe sore throat, foul breath, painful swallowing, tender lymph nodes in the upper neck and generally feel ill. The infected tonsils can also enlarged when infected and obstruct breathing particularly at night. This may last days to weeks. When this occurs multiple times a year it is called recurrent tonsillitis and when it becomes persistent it is called chronic tonsillitis. It is important to differentiate between bacterial and viral causes of a sore throat since antibiotics do not help for viral infections. Often a swab is taken of the tonsils to see if they are infected by bacteria.

Do I need my tonsils taken out?

Tonsils are generally removed for chronic/recurrent infections or more often for obstructive breathing at night. For obstructive symptoms usually a sleep study is recommended to determine whether you would benefit from tonsil surgery (see obstructive sleep apnea link). For recurrent infections antibiotics are the mainstay of treatment. Usually this is given by your primary doctor for suspected or confirmed bacterial tonsil infections. For those with frequent sore throats due tonsil infections, tonsillectomy (removal of the tonsils) significantly decreases, but does not always eliminate, the number and severity of infections. Tonsillectomy is an elective surgery that has risks of bleeding and a very sore throat for about 2 weeks after surgery. Therefore a significant number of infections every year are needed to benefit overall from removing the tonsils. Many years ago 90% tonsils were removed due to fear of serious complications due to chronic tonsil infections which are now fortunately very rare due to increased antibiotic during infections. Today only 20% of tonsillectomies are done for recurrent infections and 80% are done for obstructive breathing.

What causes hoarseness?

Also called dysphonia, hoarseness is an abnormal change in the voice. Voice is produced when air is expelled by the lungs and resonates via the voice box (larynx) and vocal cords similar to a musical instrument. Any sort of irritation, infection, or mass can affect the voice. In general, hoarseness that is not improving or worsening after 3 months should be evaluated by an Otolaryngologist (ENT). Some of the most common causes of hoarseness are:

  1. Acute laryngitis: The most common cause is during a viral upper respiratory tract infection (common cold). This can also occur during voice strain or misuse. Symptoms typically resolve on their own within a few weeks.
  2. Benign vocal cord lesions: Nodules, polyps and cysts can occur on the vocal cords and alter the voice. Some of these can occur in with vocal misuse. Depending on the type of lesion, your doctor may recommend voice therapy or surgery.
  3. Acid reflux: If stomach acid reaches the esophagus it typically causes heartburn. If acid reaches all the way to the throat it can cause hoarseness, sticky mucous, chronic throat clearing, and a lump in the throat.
  4. Laryngeal cancer: The most common first symptom of cancer of the voicebox (larynx) is hoarseness. Fortunately if caught early the survival rate is very good. Smokers are at significantly higher risk of developing laryngeal cancer.
  5. Vocal hemorrhage: If you suddenly lose your voice after a yell or strenuous vocal use, you may have bleeding into the vocal cord. This should be seen urgently by an otolaryngologist and if a vocal hemorrhage is seen absolute voice rest is needed.

When should I see and otolaryngologist (ENT) for my voice problem?

  1. If your hoarseness last for over 3 months
  2. If your hoarseness is present for under 3 months and you smoke or have other concerning symptoms
  3. If you have coughed up blood
  4. If you have difficulty swallowing
  5. If you have noticed a lump in your neck
  6. If you have pain with speaking
  7. If you also have difficulty breathing
  8. If you hoarseness is significantly affecting your life

What is Laryngopharyngeal Reflux (LPR)?

Normally stomach acid stays in the stomach. A muscular ring called the lower esophageal sphincter keeps stomach acid from entering the esophagus. If this does not work properly stomach acid enters the esophagus, called gastroesophageal reflux (GERD) and typically causes heartburn. There is another muscular ring at the top of the esophagus called the upper esophageal sphincter which keeps acid from entering the throat and larynx (voicebox). When you are awake this can sometimes give you the bitter taste of regurgitation. Although the esophagus can handle a certain amount of acid exposure, even a small amount of acid (along with the stomach enzyme pepsin) in the throat can be very irritating. Many people with LPR do not experience heartburn. Even an occasional reflux episode can perpetuate symptoms long after the acid is gone, unlike heartburn. This occurs more often at night because when laying flat gravity does not help keep stomach acid down.

What are the symptoms of Laryngopharyngeal Reflux (LPR)?

Most commonly adults with LPR complain of a feeling that something is stuck in the throat. They may want to clear their throat frequently but are unable to bring much up. This may be associated with trouble swallowing (usually worse with dry solid foods), hoarseness, chronic cough, and throat pain or irritation.

In infants and children, LPR may cause cough, stridor (noisy breathing), difficulty feeding (spitting up), croup, asthma and rarely cyanosis (turning blue) or apparent life-threatening events. Your doctor will determine if these symptoms are likely caused or worsened by reflux.

How do I prevent and treat reflux?

Usually a trial of acid suppressing medication is given to see if your symptoms improve with treatment. These are also the mainstay of treatment. If it is unclear if your symptoms are due to reflux and the symptoms are severe, other studies may be done to confirm the diagnosis. Additionally there are several lifestyle changes which can significantly improve the amount and frequency of reflux including:

  1. Avoid eating or drinking 2-3 hours prior to bedtime
  2. Elevate the head of your bed as much as you can tolerate
  3. Eat small meals
  4. Lose weight
  5. Limit problem foods like
    • caffeine
    • alcohol
    • chocolate
    • spicy foods
    • acidic foods (citrus, tomato etc.)