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AFFECTIONS OF THE TONSILS                       121

the child turned on to the affected side. The abscess is opened as recovery
from the anaesthetic takes place, and the child is turned face down and suction
employed to evacuate the pus. The returning cough reflex will prevent aspira-
tion of the pus. Rapid improvement follows but penicillin should be continued

until resolution is complete. The tgnsfla <frrm|if]......bMmna^fcS.....ffigbJgV^v-

ing a quinsy^

Intratonsillar Abscess. This is uncommon and implies an abscess within the

tonsil following retention of pus within a follicle to give pain and dysphagia.

The tonsil is swollen and inflamed, but the soft palate does not bulge. It is

treated on the same lines as a quinsy.

Lingual Tonsil Abscess. This is a rare condition causing extreme dysphagia and

profound pain behind the tongue. It may give rise to laryngeal oedema. The

abscess follows a lingual tonsillitis and is only seen with the aid of a laryngeal

mirror. The abscess is treated as for a quinsy, but restricted access makes

incision a matter of difficulty.


Chronic Enlargement of the tonsils. The physiological enlargement of the
tonsils in childhood between the ages of 3 and 6 years has already been
described. It probably represents the development of active unmunity when
children begin to play with others and to attend nursery or primary schools.
If this hypertrophy is unassociated with tonsillitis no action need be taken and
swelling will settle down without constitutional upset.

Chronic inflammatory enlargement may follow acute tonsillitis or one of
the infectious diseases such as measles or scarlet fever, and may be found
between the ages of 4 and 15 years. There is a sequence of attacks of acute
tonsillitis, and speech may be affected, the child talking as if his mouth were
full. An irritating cough is frequently complained of, and there may be
choking attacks during meals or at night. The tonsils are seen to protrude
towards the midline and may actually meet. The pharyngeal mucosa is red,
particularly on the anterior faucial pillars, and the cervical lymph nodes may
be persistently enlarged.

The treatment may be expectant in the first instance, and if there is no
constitutional upset an adequate diet of vitamins and sufficient fresh air and
exercise may be all that is required. In the inflammatory state this regime may
be followed initially but should exacerbations persist removal of the tonsils
should be considered.

Chronic tonsillitis results from repeated acute attacks when infected material
remains in the crypts. Cheesy food particles may collect in the follicles and
present on the surface of the tonsils, or they may be squeezed out of the
crypts as small white or yellow solid particles with an offensive smell and
taste. This gives an unpleasant smell to the breath to the embarrassment of
the patient, and often to the misery of a child whose schoolmates are not slow
to comment. On occasion one of the crypts becomes distended owing to the
blocking of its mouth, and a smooth yellow swelling, containing creamy fluid
and debris, appears on the surface. This is called a retention cyst and may be
easily opened and drained.

SYMPTOMS. The patient suffers from repeated sore throats, an unpleasant
smell and taste in the mouth, and systemic upsets. Toxic effects in children are