Introduction

Tonsillitis is when the two lymph nodes at the back of your throat called tonsils become inflamed causing your throat to become swollen and feel lumps in your neck. You may also see that the back of your throat has white patches filled with pus. As a result of this, you will generally have cold or flu-like symptoms and make it very difficult to speak, breathe and swallow.^1,2 You may also experience a decrease in your sleep quality and have trouble with bad breath due to the infection. 

Tonsillitis is caused by a viral or bacterial infection and it is important to distinguish between both of them since both require different treatments.¹ Treating tonsillitis caused by a virus with antibiotics will not cure it as antibiotics can only treat bacterial infections. Unnecessary use of antibiotics will eventually lead to antibiotic resistance which would be harder to treat. 

In recent decades, concerns about air quality and respiratory health have been growing significantly. As the air we breathe has been increasingly polluted overtime due to damage to the environment and household air pollution, there have been concerns about air quality possibly contributing to several diseases. 

According to the WHO, every year 3.2 million premature deaths occur due to household air pollution.  In this article, we will talk about how poor air quality could be a possible cause of tonsillitis. 

Tonsillitis Overview

The tonsils are the two large protruding tissues on each side at the back of your throat. They are lymph nodes which means that they contain a large amount of white blood cells and they are responsible for trapping germs and particles which prevent most of them from entering your lungs. 

When they are infected, they generally swell up and can form white pustules. This often affects children and young adults but can also affect anyone else too.^1,2 

The symptoms usually last for about a week and the infection often goes away on its own; however, you can still be reinfected months later.² 

If untreated, or the tonsillitis becomes more severe, a peritonsillar abscess (also known as quinsy) can form which can have severe complications.  

The two main causes are:

• Viruses such as the common cold and flu
• Bacteria such as streptococcus pyogenes

Symptoms include:

• Headaches
• Sore throat
• Difficulty swallowing
• High temperature
• Tiredness
• Swollen glands
• Bad breath
• Pus-filled patches on your tonsils

If you cannot swallow, have difficulty breathing or have a sore throat that has appeared rapidly with severe symptoms or if you see an abscess in the back of your throat. Consult a doctor immediately. 

The actual tonsillitis disease itself is not contagious, but the viral or bacterial infection is contagious and can be passed on to other individuals just like the common cold or flu.²

Treatments

Tonsillitis itself is very easy to treat as it is a self-limiting disease which means that the symptoms eventually go away on its own without any medication. You can also treat the symptoms yourself by doing the following:¹

• Gargling warm salty water
• Getting plenty of rest
• Taking ibuprofen and paracetamol
• Suck on Cough drops and cough sweets (lozenges)
• Drinking cool drinks

However, in more severe cases of tonsillitis where the symptoms last for more than a week, you may be prescribed antibiotics. In cases where tonsillitis occurs frequently, such as more than 5 episodes in a year, your tonsils may be partially or fully removed as they are not necessary to live a normal healthy life.^{1, 2}

Air Quality Overview

Since we all need air to breathe and provide our oxygen, it is important that the air we breathe has little to no pollutants. Sadly, due to our lack of concern for the environment, the air is getting more and more polluted as we speak. Millions of cars, thousands of industrial facilities, fossil fuels, forest fires and much more contribute to air pollution by releasing harmful gases and particles into the air. 

Here are some common air pollutants taken from the WHO:

• Particulate matter (PM)
• Nitrogen dioxide (NO₂) 
• Sulphur dioxide (SO₂)
• Ozone (O₃)
• Indoor pollutants like tobacco smoke and mould

Particulate matter less than sizes 2.5 and 10 microns (PM_2.5, PM₁₀) in diameter are small fine particles which have been shown to be small enough to be inhaled deeply into the lungs. Nitrogen dioxide and Sulphur dioxide can contribute to acid rain and increase the acidity of our soil. These gases are produced by burning fossil fuels. 

You may be wondering why ozone is classified as an air pollutant since we require ozone as it is needed for the ozone layer which protects us from the harmful UV rays from the sun. 

However, ozone at the ground level can be harmful to plants by harming their growth and have the ability to directly form oxidative free radicals by splitting apart.³ 

Indoor air pollutants are made of many different things. These things are contaminants that contaminate and pollute the air inside your home. For example, dust mites, mould, cleaning products, and even building materials.

Your level of air quality also differs depending on where you live. If you happen to live in a rural small town with little to no factories nearby, you will have a significantly better level of air quality than large urban cities with millions of people like London and Beijing. 

However, if you happen to live near an area with many forest fires and volcanoes, air quality can decrease extremely quickly as they happen to spread and erupt in a small amount of time. You can view your level of air quality in your area here. (World's Air Pollution: Real-time Air Quality Index)

How poor air quality affects respiratory health

Several studies have shown that air pollution has some association to upper respiratory diseases.^3,4,5,6  Inhaling excessive nitrous oxide can lead to constriction of the bronchioles and decreased function of the lungs. 

This is because NO₂ is naturally very reactive and can form free radicals which cause oxidative stress in the affected areas.

This can also increase your levels of inflammation resulting in a response from your immune system.³ If your immune system is overactive, it can lead to the development of autoimmune diseases. 

Particulate matter (PMs) can also affect your respiratory health in a variety of ways. Firstly, PMs are mutagenic, meaning that they have the ability to cause a mutation in your DNA. This means that it may increase your chances of lung cancer if you breathe them in. PMs can do this by increasing levels of oxidative stress, inflammation, and tissue damage. Damage to your lung tissues will increase your chances of a respiratory infection.⁴  

According to the Department of Environment, Food and Rural Affairs O₃ and SO₂ can have an affect on your overall respiratory health by irritating and constricting the airways and they both contribute to the production of NO.^3,8 It has also been mentioned that O₃ and SO₂ have the ability to create PMs too by reacting with chemicals in the air. SO₂ does this by reacting with NO₂ and ammonia whilst O₃ can react with almost anything in the air. 

According to Asthma+Lung UK, indoor air pollution over a long period of time can cause asthma, COPD and lung cancer.¹⁴ It can also cause dizziness and headaches. Building materials such as asbestos form small sharp silicon fibres that can break off and be breathed in and remain in the lungs for a very long-time causing scarring leading to potential infections. Another thing that you should be aware of is damp and mould which can build up and spread further. Mould can grow on the back of wallpaper, tiles, and carpet as a result of damp and moist surfaces. Gas cooking can also be affecting your air quality by releasing PMs into the air.

Link between poor air quality and tonsillitis

When air quality is poor for long periods of time there is an increased risk of tonsillitis in people. The reason for this is because PMs can be trapped within the tonsils and trigger an immune response by irritating the mucous membrane and weakening it which is one of the first lines of defence against pathogens which can make it easier for bacteria and viruses to infect you.^3,4 NO₂, as stated before, is very reactive which means it can break into reactive particles called reactive nitrogen species such as nitric oxide (NO)  that are associated with peritonsillar abscess formation.⁴ In people that have had recurrent tonsillitis, it is found that they exhale a significantly more amount of NO than normal people which could be a strong indicator of NO₂ affecting the frequency of tonsillitis episodes.⁹ Vulnerable children with tonsillitis are more likely to be affected by PM_2.5.⁶ O₃ and SO₂ actually have no significant association with tonsillitis according to this paper.⁴

How can we improve our air quality?

There are many ways to improve our air quality:

• Buy an air purifier

There is significant evidence that an air purifier can reduce the amount of PM_2.5 and PM₁₀ particles in the air efficiently.⁹ 

• Treat damp and mould

As mentioned before, a build-up of dampness can cause mould to grow which can float in the air and be breathed in as they spread throughout the house.⁷

• Use extractor fans and keep windows open whilst cooking with a gas cooker

Ensure to also clean the extractor fan from grease and also clean grease off of the cooker.⁷

• Consistently open your windows on a regular basis

This ensures that there is ventilation allowing the air to flow consistently around the house which prevents a build up of harmful pathogens.

• Remove any known harmful building materials such as asbestos and lead paint

Lead has been proven to have devastatingly negative effects on children such as lowering their IQ, anaemia and slowed growth.

Summary 

Whilst tonsillitis isn’t directly caused by poor air quality, there is some evidence to conclude that it can contribute to the development of tonsillitis overtime. If you have had tonsillitis and or have had other upper respiratory diseases before, poor air quality has been shown to be associated to exacerbate the disease and can increase the frequency of tonsillitis episodes. 

Poor air quality can contribute to other respiratory diseases too, which can eventually cause tonsillitis overtime and can lead to quinsy. 

Ensure that you are consistently taking care of your indoor air quality as this can contribute to your household respiratory health. This is a very simplified article on the link between air quality and tonsillitis and I advise that you as the reader should read more on this issue.