Tonsils, Mono, and Chronic Fatigue

December 2, 2009

As I was taking out enormous tonsils from a young child yesterday, I was reminded of a young female college student that I treated many years ago who came to see me with severe tonsillitis. She had severe throat pain, difficulty swallowing, diffuse and tender swollen neck glands, and couldn’t sleep at all. Due to the severity of her "infection," I prescribed a course of oral antibiotics, as well as a short course of anti-inflammatory steroids, to get rid of the swelling in her throat. The next day, she reported that she was feeling dramatically better and sleeping better as well. When I saw her three days later, her tonsils were not touching in the midline anymore, and her neck glands were much smaller. Upon further questioning, she did state that she’s always had large tonsils, but they became much bigger with this infection.

You may think that the antibiotics helped to fight the infection, but typically, it takes 2-3 days for antibiotics to reach significant concentrations to begin to work. What actually helped her feel better, faster, was the steroids, which begins to work within a few hours.

In retrospect, she probably had mono. But because it resolved rather quickly, it would be classified as a routine throat infection that resolved with antibiotics. However, since mononucleosis is a viral infection (the Epstein-Barr virus), antibiotics won’t really make a difference. Had she not been given oral steroids, her symptoms probably would have continued for weeks to months, despite being given multiple rounds of antibiotics. Most of these patients eventually start to feel better after some time, but some never feel better. This is the classic mono condition that you hear about. Some are later diagnosed with chronic fatigue syndrome.

The reason for these persistent symptoms is that the Epstein-Barr virus preferentially infects the lymphoid tissues in your body. Since your tonsils are lymphoid tissues, they will swell up. Having larger tonsils all of a sudden will narrow your upper airway, causing frequent obstructions and arousals when in deep sleep due to muscle relaxation.

Frequent obstructions also causes stomach juices to be suctioned into the throat, which causes more swelling and inflammation of the tonsils, leading to a vicious cycle.

You may be thinking that it’s a good idea to take out your large tonsils, since it’ll prevent this situation from happening the next time you get a cold. For the most part, it should help, but don’t think of it as a cure. Studies performed in children who undergo tonsillectomies showed that only about 2/3 improve significantly. Many of these non-responders will go on to have obstructive sleep apnea later in life. Even the "responders" will have a slightly increased risk of obstructive sleep apnea, since their jaw structures are more narrowed, which lead to enlarged tonsils.

Do you have large tonsils and have severe or recurrent throat problems every time you get a cold? If so, please enter your experiences below in the comments box.

Written by Steven Park · Filed Under Blog
Tagged: ,chronic fatigue, epstein-barr, large tonsils, mononucleosis, reflux, sleep apnea, tonsilltis

7 Responses to “Tonsils, Mono, and Chronic Fatigue”

Marie on December 9th, 2009 8:49 pm

I do not have enlarged tonsils but have read many posts by people who developed sleeping and fatigue problems after contracting mono. Here are some selected posts.

http://www.talkaboutsleep.com/message-boards/viewtopic.php?t=20998&highlight=mono

http://www.talkaboutsleep.com/message-boards/viewtopic.php?t=24931&highlight=mono

http://www.medhelp.org/posts/Respiratory-Disorders/Horrible-Sleep-Disorder-Nocturnal-Asthma-Please-Help/show/283307

http://www.talkaboutsleep.com/message-boards/viewtopic.php?t=25525&highlight=mono
Karen on March 23rd, 2010 11:30 am

I'd swear we'd met before with the history you just gave! I had mono when I was a junior in college. They told me that there was really nothing that they could do about it and I'd just have to ride it out. Talk about miserable. My tonsills got so big at one point that my uvula was stuck to one. I felt truly awful. But I did get better. Mostly.
My tonsills are not as big as they were then, but they're definately above average. And every time I get the slightest infection or cold, they get even bigger. (I even have a lymph node in my neck that tends to enlarge right before I get sick!) I get a LOT of tonsil stones, and seem to be more prone to infection than ever in the past. I never had strep prior to the mono, have had it three times since. I get more sinus infections. Maybe some day I'll have to get the buggers out.
Victor on February 25th, 2011 7:26 am

I had my tonsils and adenoids removed when I was 12. I did have bad complications — severe bleeding from both sites days after the surgery. Had to be hospitalized for 4 days with nose packing. However, almost every time I get a cold, I do get throat symptoms — often lasting for months. I also used to get chronic middle ear infections — as an adult, which only cleared up after I had my deviated septum repaired.
Ivory on July 15th, 2011 12:18 am

When I was in grade 12 last year I was very active and got sick quite often after a sports practice my neck and back were so sore and stiff I couldn’t stop crying. I went to the hospital and he was about to send me off thinking I was just complaining when he lifted my shirt to check my heart beat there was a rash. He then took my blood and found out I had mono. I left and from then on I would randomly get hives for no reason id sleep for hours and constantly get severely sick. After that my lymphnodes were constantly swollen and I was still tired so they took my blood again and said I had chronic fatigue syndrome that went on for months and id still constantly get sick. After that went away almost every other week until now I seem to have tonsillitis and have been medicated for it over 38 times. I saw a specialist last month and he let me choose if I wanted to get them out. Im now on the waiting list. Altogether this experience has left me beyond frusterated and run down. Im hoping my health improves soon.
KW on November 6th, 2011 3:17 pm

Ivory and whoever else may read this, so I first had mono when I was 12. I got it again when I was 16. Then more recently, I was diagnosed with it a few weeks ago. My first onset of symptoms were over 5 weeks ago. After about 3 weeks I finally started to feel better, I went a little over a week with no sore throat or swollen neck glands, I would just get tired easily. Something happened during that week because one morning I woke up with mono symptoms again. I was very achy, chills, and my tonsils and neck glands were very swollen. After a couple days of feeling this way I took a good look at my tonsils, they are covered in white patches. This morning I woke up, the chills are gone and the achiness is better, but now my throat is very sore again, along with the white patches and they are almost touching so swollen. I have no idea what my doctor will say this week, but should I request to have my tonsils out?? I have no idea what to think about all this. What if I get mono again? What this throat issue never clears up and I continue to battle with tonsilitis?
amber on December 18th, 2011 6:37 pm

My tonsils have been swollen since I was diagnosed in having mono when I was 13. They are prone to tonsil stones, they get larger when I’m sick, and I often have a sore throat and post nasal drip. My neck is very tender and causes me a lot of pain but I’m not sure if it is due to the lymph nodes being swollen. I am always tired and never really feel well. I was told I have CFS and now that I’m 29 and getting married and looking to start a family, it really saddens me to think that I have to live in a state of exhaustion and pain and won’t have the energy I would like to raise children. I’m a little confused about this article, however. Dr. Park, are you stating that you would recommend that I take steroids to help my tonsils to go down? I’m only in the first chapter of your book, so I’m still unaware of how I can go about getting more restful sleep. Any input is much appreciated…I am so frustrated with feeling so yucky. :(
Steven Park on December 18th, 2011 7:14 pm

Amber,

Taking steroids is only a short-term fix. I bring up this example to show that anything that significantly shrinks the tonsils can help you breathe better and sleep better. It can be either short-term or long-term, determined by which option you choose. But the tonsils are usually not the only reason for narrowed breathing passageways that interrupts your sleep. You’ll see what I mean as you continue reading the book.