Among singers, tonsils must be among the best known but least understood structures in the throat. What are those two pitted almond-shaped things sitting in the back of your mouth? Why are they there? Do we need them? And why are they at times covered with little white bumps?
Tonsils (the correct name is “palatine tonsils”) are part of the body’s defense mechanism. They contain lymphoid cells, similar to the lymph glands sometimes palpable in the neck, armpits or groin. The lymphoid cells make antibodies against bacteria and viruses, and constantly add information to the vast database that allows the immune system to recognize potential invaders. However, the role of the tonsils is not primarily to stop bacteria from entering the body. More importantly, they trap bacteria long enough for the lymph cells to study them, and to make antibodies (mostly IgA) against them. Then, when the same bacteria enter the mouth the next time, the body is ready for battle, with a host of prefabricated antibodies. In addition to the tonsils, there is also lymphoid tissue along the back of the tongue, the oropharynx, and the nasopharynx (called adenoids). This physiologic Maginot line (called Waldeyer’s ring) is set up in a way that nothing can enter either through the nose or the mouth without coming in contact with lymphoid tissue and setting off the alarm.
The tonsils are particularly good at the “hold-and-release” technique. Facing the middle of the throat are deep pockets called crypts, which trap bacteria and other debris for a while. As we swallow, the palate lifts, and slips of muscle in front and behind the tonsil (the “tonsillar pillars”) contract, squeezing out the crypts like a wet sponge. The debris is cleared, and the tonsils are ready for their next mission.
If tonsils are so terrific, why take them out? Most of the work tonsils do to strengthen the immune system is done by the age of 4. After this time, tonsils normally slowly shrink, to almost disappear by young adulthood. On occasion, however, the tonsils themselves become infected. Pockets of bacteria persist within the crypts. The pockets become walled off, as the body tries to contain the invader. This walling off (or fibrosis), however is self-defeating: neither the body’s immune cells nor antibiotics can cross the barrier effectively enough to kill off the infection. A Mexican standoff develops: the infection is contained, but ready to strike whenever your immune system is weakened. Such patients with chronic tonsillitis are usually well, but whenever they get sick or weakened the tonsils flare up. This causes a sore throat and difficulty in swallowing, and may progress down the upper respiratory tract. The immune defenses may be temporarily weakened by many things: viral illness, work-related stress, too many late nights, money worries, a fight with the significant other, etc. Chronically infected tonsils probably need to be removed for a definitive cure.
Another version of chronic tonsillitis is one where there is no pain, but recurrent white spots on the tonsils (cryptic tonsillitis). These spots are bits of debris, infected cheesy material trapped in the crypts. Bad breath is a cardinal symptom. At times, the tonsils are simply too large, and actually can obstruct the airway at night, causing sleep apnea (see last month’s column).
Medical treatment for tonsillitis can include antibiotics, which are best based on a throat culture. Remember, there are many bacteria beside strep that can cause tonsillitis. As mentioned above, however, for chronic tonsillitis, antibiotics can help but seldom cure. Local treatment of the area may include warm saline gargles, hot ginger tea, swabbing the tonsils with antiseptic solutions, and cleaning out the crypts with Q tips or a water pic.
Just because you sing does not mean that you cannot have your tonsils out, but you must have this done in a way that will not scar or injure the palate. If the problem is primarily recurrent cryptic debris, the crypts can be opened with a laser, without full removal of the tonsils. If the infection involves the whole tonsil, it should be removed with great care, preserving the pillars and minimally traumatizing the surrounding structures. This is best done by a laryngologist who is familiar with technical aspects of singing.
After tonsillectomy, anticipate not singing normally for four weeks. The most important post-operative exercises are those that work on palate movement and flexibility. As after any general anaesthetic, there is some edema of the vocal folds, so vocal rest, plenty of hydration and patience are important.
What about the voice after tonsillectomy? Most patients tell me that they feel they have more room in the back of the throat, and a better voice, although they can not define how it is better. As with other conditions, the key steps to managing your tonsils is to identify the problem, exhaust all medical treatment, and, if surgery is necessary, have it done with expertise and a respect for the vocal apparatus.
DISCLAIMER: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific medical advice, or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
