Correlation Between Age and Tonsil Size in Patients with Chronic Tonsillitis at Aek

Kanopan Regional General Hospital, North Sumatra

Heri Bastian Hutasoit1

Abstract
Background:Chronic tonsillitis is inflammation of the tonsils that persists as a result of
repeated acute or subclinical infections. The size of the tonsils in chronic tonsillitis is
enlarged due to parenchymal hyperplasia or fibrinoid degeneration with obstruction of the
tonsillar crypts. Based on data from the Indonesian Ministry of Health in 2012, the incidence
of tonsillitis in Indonesia is around 23%. Young age predominates in the characteristics of
tonsillitis patients.
ObjectiveThe research was to determine the correlation between age and tonsil size in
chronic tonsillitis at the Aek Kanopan Regional General Hospital, North Sumatra.
Method:This study uses secondary data, namely medical records at Aek Kanopan Hospital,
North Sumatra. Research and data collection were carried out in November 2022 - February
2023. This research is an analytical study. The population is chronic tonsillitis patients at the
ENT-KL installation at Aek Kanopan Hospital, North Sumatra, totaling 70 patients. Data
analysis was univariate presented in the form of a frequency distribution table and bivariate
analysis using a correlation testspearman rho by using SPSS version 24.0.
Results:Based on the study, as many as (57.6%) were women and (42.4%) were men, most
were aged <18 years, namely (72.7%), mostly with hypertrophic tonsil sizes, namely (65.2%)
and there were Correlation between age and tonsillitis size in chronic tonsillitis at Aek
Kanopan Regional General Hospital, North Sumatra, p=0.000 (p<0.05).
Conclusion:There is a correlation between age and tonsillitis size in chronic tonsillitis at the
Aek Kanopan Regional General Hospital, North Sumatra.
Keywords: Gender, Age, Tonsil Size
Introduction tonsils are >25% to <50% of the
Chronic tonsillitis is the most oropharyngeal diameter measured from the
common of all recurrent throat ailments. left and right anterior folds. The size of
Chronic tonsillitis generally occurs due to T3-T3 means that the tonsils are >50% to
complications of acute tonsillitis, <75% of the oropharyngeal diameter
especially those that do not receive measured from the left and right anterior
adequate therapy. Apart from inadequate folds. The size of T4-T4 means that the
treatment, other predisposing factors for tonsils are >75% of the oropharyngeal
chronic tonsillitis are poor oral hygiene, diameter measured from the left and right
physical fatigue and certain types of anterior folds.6
food.1-3 The many predisposing factors for
Common symptoms of chronic chronic tonsillitis also have an impact on
tonsillitis are sore throat, dysphagia and the high incidence of chronic tonsillitis. As
fever. Diseases of the tonsils affect other is the case with Khan's researchet al At
anatomically related structures such as the Khyber Hospital Peshawar Pakistan from
middle ear canal, paranasal sinuses, and April 2011 to May 2012, an analysis was
the junction of the upper respiratory tract carried out on the distribution of Ear Nose
with the digestive tract. Children who have Throat (ENT) disease and found that 8980
chronic tonsillitis have enlarged tonsils people suffered from chronic tonsillitis
and enlarged blood vessels on the surface (27.37%) from 32,800 total samples. In
of the tonsils.4 this study chronic tonsillitis is at the top of
Inflammation of the tonsils will the incidence of other ENT diseases.
result in enlargement which causes Tarasov and Morozov also conducted
difficulty swallowing or feels like there is health checks on children and adults,
a lump in the throat. In children, usually found a total of 190-230 ENT diseases per
this condition can also result in complaints 1,000 population, and 38.4% of them
in the form of snoring during sleep suffered from chronic tonsillitis.7,8
because the influence of the size of the World Health Organization In
tonsils interferes with breathing and even 2013, the number of cases of chronic
complaints of shortness of breath can also tonsillitis was estimated at 287,000
occur if the enlarged tonsils have closed children under 15 years.9 Research
the respiratory tract. If the inflammation conducted at Sarawak Hospital in
has been treated, it is possible that the Malaysia in the period July 2003 to June
tonsils will recover as before or may not 2004, out of 657 patients with chronic
even be able to return to health as before. tonsillitis, 342 men (52%) were found and
If there is no complete healing of the 315 women (48%).10
tonsils, recurrent infections can occur. If Based on data from the Indonesian
this condition persists, pathogenic bacteria Ministry of Health in 2012, the incidence
will nest in the tonsils and chronic of tonsillitis in Indonesia is around 23%.
inflammation occurs or what is known as Based on epidemiological data on ENT
chronic tonsillitis.5 disease in seven provinces in Indonesia in
The size of the tonsils is divided September 2012, the prevalence of chronic
into 5 starting from T0-T0, T1-T1, T2-T2, tonsillitis was 3.8%.11 According to
T3-T3, and T4-T4. Size T0-T0 means no Nurjannah in 2011, the distribution of the
tonsil enlargement or atrophy and no air proportion of chronic tonsillitis sufferers in
obstruction. The size of T1-T1 means a Medan in 2007 - 2010 based on age
little out where the size of the tonsils is occurred most in the age group 11-20
<25% of the diameter of the oropharynx years, namely 40%. Based on gender, the
measured from the left and right anterior most were men, namely 18 samples, 51.4
folds. The size of T2-T2 means that the % and the size of the T3 tonsil was
47.1%.12 analysischisquare a p-value of 0.000 was
Based on medical record data in obtained.13 The same thing was also
2010 at dr. M. Djamil Padang, ENT-KL obtained from Amalia's research which
Polyclinic, sub-section of the larynx and obtained p= 0.001
pharynx found tonsillitis in 465 of 1110 which shows that there is a significant
visits. The incidence of chronic tonsillitis relationship between age and tonsil size in
is increasing from year to year. The patients with chronic tonsillitis.16
incidence of chronic tonsillitis is common Based on the explanation above,
in children.13 Research conducted by the researcher is interested in conducting
Shalihat in 2013 found 149 patients with research on the correlation of age and
chronic tonsillitis from the medical records tonsil size with the incidence of chronic
of Dr. M. Djamil Padang. The highest tonsillitis at Aek Kanopan Hospital, North
frequency distribution of chronic tonsillitis Sumatra.
patients based on age in the age group
11-20 years 70 patients (47.0%), female Method
sex 84 patients (56.4%), tonsil size T3-T3 This study uses secondary data,
82 patients (55%).14 namely medical records at Aek Kanopan
The relationship between age and Hospital, North Sumatra. This study is
tonsil size can be seen from the limited to the variables of gender, age and
immunological activity of the tonsils. The tonsil size in chronic tonsillitis. Research
cellular immune response in chronic and data collection were carried out in
tonsillitis shows an increase in antigen November 2022 - February 2023. The
deposition in the tonsillar tissue. This leads research was carried out at the ENT-KL
to a continuous upregulation of installation at Aek Kanopan Hospital,
immunocompetent cells. This is evidenced North Sumatra. This research is a form of
by the increased incidence of cells analytical study. This research is used to
expressing IL-ip, TNF-a, IL-6, IL-8, find the relationship between the
IL-2,INF-Y, IL-10 and IL-4. Most are independent variable and the dependent
found between the ages of 3 and 10 years, variable by taking a momentary
consequently the tonsils are more measurement. The reachable population is
prominent during this period and then chronic tonsillitis patients at Aek Kanopan
show age-dependent involution. One or General Hospital, North Sumatra in
more attacks of acute tonsillitis per year is November 2022 - February 2023. The
common in children of primary school inclusion criteria in this study were
age.4 patients diagnosed with chronic tonsillitis
Some researchers suspect that the and the exclusion criteria were patients
tonsils and adenoids enlarge in childhood. diagnosed with chronic tonsillitis with
Research using Magnetic Resonance complications. The sample in this study
Imagine (MRI) shows the tonsils and was selected using the probability method,
adenoids develop in proportion to the namelysimple random sampling. The
organ structures during the normal number of samples obtained was 70
development of the child.4 The relationship people.
between age and tonsil size can be seen
from Shalihat's study where hypertrophic Results
tonsils were found more in patients with In table 1, we will introduce the
chronic tonsillitis aged <18 years, namely research characteristics which consist of
89 patients (84.8%), while information about the participants
non-hypertrophic tonsils were found in covering the age and sex ranges. By
those aged> 18 years, namely 21 ( 47.7%). understanding the characteristics of this
After doing statistical tests with study, readers will gain a better
understanding of the research context and Table 3. Correlation between age and
the results we present. Based on table 1, tonsil size
the results obtained from 70 chronic
tonsillitis patients show that most of them     Tonsil Size
were aged 11-20 years (50%), and as many non-hype hypertro p
as 57.6% of patients were women and rtropics phy value
42.4% were men.
    n(%) n(%)
Table 1. Characteristics of study patients < 18 <0,00
22(31,42) 28(40)
n=70 % years 1
variable age
>18
Age category 3(4,28) 17(24,28)
Years
0-10 Years 23 32,86 Total 25(35,71) 45(64,28)  
11-20 Years 35 50,00
21-30 Years 7 10,00
31-40 Years 2 2,86 Discussion
41-50 Years 2 2,86 Based on the research, the results
>50 Years 1 1,43 obtained from 66 patients with chronic
Gender tonsillitis, mostly aged 11-20 years (50%)
Man 31 44,29 at Aek Kanopan Hospital, North Sumatra.
Women 39 55,71 The results of this study support previous
research conducted by Sapitri at Raden
Based on table 2, the results obtained from Mattaher Hospital Jambi in 2013, the most
70 patients with chronic tonsillitis, mostly Chronic Tonsillitis patients were in the age
with tonsis T3/T3 size of 40%. range of 5 - 14 years (50%). Hasanov's
researchet al In Russia, regarding the
prevalence of chronic tonsillitis in
Table 2. Distribution of tonsil sizes in families, 335 children aged 1-15 years
study patients from 321 families had chronic tonsillitis.17
In Sembiring researchet alin 2013 at the
Tonsilliti BLU ENT polyclinic at Prof dr. R. D.
n=70 %
s Size Kandou found that the most age that
T1/T1 10 14,29 suffers from Chronic Tonsillitis is age <12
T2/T2 15 21,43 years.
T3/T3 28 40,00 At school age, starting from the age
T4/T4 17 24,29 of 5, children are more susceptible to viral
and bacterial infections from the
Based on table 3, it was found that at the surrounding environment. One of the
age < 18 years, the most common tonsil predisposing factors for chronic tonsillitis
size was in the hypertrophic group, and at is the influence of several types of food.
the age > 18 years, the most common This is because children consume foods
tonsil size was hypertrophy. These results such as foods with artificial sweeteners,
have been carried out by merging cells and contain lots of preservatives and poor oral
using the Spearman correlation test care.3
obtained a value of p <0.001 (p <0.05), it Tonsil immunological function is
can be concluded that there is a correlation very active between the ages of 3-10 years.
between age and tonsillitis size in chronic Tonsil function will increase at the age of
tonsillitis at the Aek Kanopan Regional 5 years and then decrease and will increase
General Hospital, North Sumatra. again at the age of 10 years, then will
decrease at the age of 15 years because the
tonsils begin to involute at puberty so that portion of food that is recommended to
antibody production decreases which make their posture look perfect. This can
makes them more susceptible to infection. cause malnutrition and the body's
Children and adolescents aged 5-15 years, resistance to various diseases becomes
who spend most of their time in the school very low so that more health problems
environment and outdoors, often suffer occur.22
from ARI. 18 Akcayet al states that male sex is a
The high incidence of chronic risk factor for tonsillar hypertrophy.23 This
tonsillitis in children and adolescents is is due to chronic irritation factors, smoking
because they often suffer from ARI or habits and eating habits, which cause
acute tonsillitis which are not treated recurrent infections of the tonsils resulting
adequately or left alone without treatment. in enlargement of the tonsils.24
Tonsillitis can be spread by hand or air Based on the research, the results
contact so that children and adolescents obtained from 70 chronic tonsillitis
aged 5-15 years are most likely to suffer patients, mostly with tonsis T3/T3 in Aek
from tonsillitis, but it can affect anyone, so Kanopan Hospital, North Sumatra. The
this study also found patients aged <5 results of this study are in line with
years and >15 years.19 previous research conducted by Amalia in
Based on the research, the results 2011 from 812 patients who received
obtained from 70 tonsillitis patients, the tonsillectomy.16 341 (42%) with tonsil size
majority were women at Aek Kanopan T3 and a study conducted by Fakh 2013
Hospital, North Sumatra. The results of also obtained tonsil size results in children
this study are in line with previous which were most commonly found in this
research conducted by Fakh, in the study, namely T3 - T3 sizes (68%).20 One
ENT-KL Section of RSUP Dr. M. Djamil of the factors for enlargement of the tonsils
Padang also found that most of the sexes is due to the influence of infection in the
of patients with tonsillitis were women tonsils. Enlarged tonsils due to
(56%).20 Research conducted by Kishveet parenchymal hyperplasia or fibrinoid
al conduct researchcase series in India, out degeneration with obstruction of the
of 203 tonsillitis patients with the majority tonsillar crypts. Recurrent infections and
aged 5-14 years, more were female, obstruction of the tonsillar crypts result in
namely 105 (51.72%), while men were increased debris and antigen stasis in the
98 (48.28%).21 This is in accordance with crypts, as well as a decrease in the
data from the prevalence of chronic integrity of the crypt epithelium, making it
diseases in the United States, it was found easier for bacteria to enter the tonsillar
that the average number of chronic parenchyma. Bacteria that enter the
tonsillitis sufferers each year is more in the tonsillar parenchyma will result in tonsillar
female sex, namely 13.7/1,000 population infection. In chronic tonsillitis can be
while men are as much as 9/1,000 found multiplying bacteria. Bacteria that
population.1-3 settle in the tonsillar crypts become a
Factors predisposing to chronic source of recurrent infection of the
tonsillitis include chronic irritation (due to tonsils.25
smoking and food), nutrition or low body Tonsils are lymphoid tissue that
resistance, the influence of weather and plays a role in helping the immune system.
poor oral hygiene. During puberty when In chronic tonsillitis infection persists or
the need for calories and protein increases, recurs. Tonsils that are repeatedly infected
women, especially teenagers, are more at one time cannot kill all the germs, as a
concerned with body shape and result the germs become lodged in the
appearance so that many of them delay tonsils (focal infection). The presence of
their meal schedule and even reduce the recurrent infections and focal infections
causes the tonsils to work hard against at the age of children. The tonsils begin to
germs by producing lots of immune cells gradually involute at puberty.13 Akcay
so that the size of the tonsils will grow Researchet alfound in school children with
rapidly beyond normal size.24 In chronic tonsil sizes T2 and T3 showed a decrease
tonsillitis lymphocyte infiltration occurs in number as they got older.23 Crombie and
into the epithelium of the tonsillar surface. Barr in Shalihat, 2013 stated that there is a
An increase in the number of plasma cells tendency for the size of the tonsils to be
in the subepithelium and in the relatively small at the age of <7 years and
interfollicular tissue. Hyperplasia and to enlarge at the age of 7-15 years, while
fibrotic formation of parenchymal those in old age have small tonsil sizes.14
connective tissue and lymphoid tissue In a study of tonsil size in the age
result in tonsillar hypertrophy.26 range of 3-10 years, T3-T3 sizes were
Tonsil hypertrophy in size can obtained. However, this size increases with
cause various complaints and symptoms increasing age which is contrary to the
such as discomfort or a lump in the throat, immune activity of the tonsils. The results
difficulty swallowing and especially can showed that adults also experience
cause airway obstruction characterized by enlarged tonsils with sizes T3-T3 and
snoring, frequent drowsiness, anxiety, lack T4-T4.
of attention and decreased learning The cellular immune response in
achievement. This is what usually chronic tonsillitis shows an increase in
encourages patients to seek treatment.24 antigen deposition in the tonsillar tissue.
Based on this study, it was found This leads to a continuous upregulation of
that at the age < 18 years, the most immunocompetent cells. This is evidenced
common tonsil size was Hypertrophy and by the increased incidence of cells
at the age > 18 years, the most common expressing IL-ip, TNF-a, IL-6, IL-8,
tonsil size was Hypertrophy. These results IL-2,INF-Y, IL-10 and IL-4, which are
have been carried out by merging cells and mostly found between the ages of 3 and 10
using the Spearman rho test obtained a years. During this period the tonsils are
value of p <0.001 (p <0.05), it can be consequently more prominent and then
concluded that there is a correlation show age dependent involution. One or
between age and tonsillitis size in chronic more attacks of acute tonsillitis per year is
tonsillitis at the Aek Kanopan Regional common in children of primary school
General Hospital, North Sumatra. age.7
The results of this study are in Tonsils undergo involution at
accordance with previous research puberty, but this can be hampered if the
conducted by Amalia, 2011 which tonsillar tissues and cells are not
obtained p= 0.001 which shows that there permanently damaged. Children who
is a significant relationship between age experience acute tonsillitis with adequate
and tonsil size,16 and the research by treatment are at lower risk of experiencing
Shalihat, 2013 which also obtained the enlarged tonsils compared to patients who
results of a significant relationship experience recurrent tonsillitis or chronic
between age and tonsil size. The difference tonsillitis. Damage to tonsillar cells and
in the results of the research is in the tissues in chronic tonsillitis can be
positive significance relationship. In this temporary or permanent. Tonsil tissue that
study, it was found that the higher the age, is permanently damaged will be replaced
the greater the size of the tonsils with a with scar tissue so that not all of the
significant relationship p = 0.000 tonsillar tissue experiences involution.27
Tonsil immune activity is maximal Tonsil action decreases with
between the ages of 3 and 10 years, increasing age. The aging process results
therefore the size of the tonsils is greatest in decreased organ work and the sensitivity
of the immune system, one of which is the dosed can fail therapy and can also cause
tonsils. Decreased sensitivity causes the resistance.5,12 Resistance in question is a
components of the immune system to be condition in which microbial life is not
unable to distinguish normal cells from disturbed at all by the presence of
abnormal cells which results in the tonsils antibiotics, as a result the bacteria continue
not being able to carry out its function to multiply and cause chronic hypertrophic
optimally to capture and collect foreign tonsillitis caused by repeated infections.
bodies effectively and as an organ for the
production of antibodies and the sensitivity Conclusions and recommendations
of T lymphocyte cells to specific Based on the results of research on the
antigens.28 This decrease in sensitivity correlation of age with tonsillitis size in
causes bacteria to easily infect the tonsil chronic tonsillitis at the Aek Kanopan
organs which will lead to an inflammatory Regional General Hospital, North
reaction of the tonsils which is Sumatra, it can be concluded that the most
characterized by an abnormal enlargement chronic tonsillitis sufferers are women
of the tonsil size. (57.6%). Most people who experience
Ni made Putri et al stated that long tonsillitis are at the age of 11-20 years
agoexposure tonsillitis patients against risk (50%). Most have tonsil size T3/T3,
factors causing enlarged tonsils.Oral namely (40.9%). There is a relationship
hygine A poor diet is one of the risk between age and tonsillitis size in chronic
factors for enlarged tonsils.Oral hygine A tonsillitis at the Aek Kanopan Regional
bad diet can increase the risk of General Hospital, North Sumatra, p=0.000
developing tonsillitis regardless of age and (p<0.05). Suggestions from researchers are
gender. Coupled with a decrease in the that it is hoped that the community can
body's immunity with age, it also has an increase awareness about the importance
effect on enlarged tonsils. The of oral hygiene and knowledge about how
combination of these two things can give to use antibiotics according to doctor's
an overview of enlarged T3-T4 tonsils in directions.
adults and the elderly.29 Smoking also For future researchers, it is hoped that the
causes a decrease in antibodies in the results of the research will serve as a
tonsils, the function of the tonsils is that scientific source of information and it is
when a pathogen penetrates the epithelial hoped that future research can conduct
layer, the mononuclear phagocytosic cells research to look for risk factors for
will recognize and eliminate antigens, enlarged tonsils in adulthood.
resulting in impaired function of the body's
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