Pediatric Otolaryngology Quiz

Adenoids and Tonsils

• Adenoids are lymphoid tissue at the junction of the roof and posterior nasopharyngeal wall, related inferolaterally to the eustachian tube.
• The tonsils (palatine, tubal, and lingual) comprise a ring of lymphoid tissue guarding the entrance to the digestive and respiratory tracts.
• They play a crucial role in early recognition of pathogenic microorganisms and initiating an immune response.
• The palatine tonsils are a pair of lymphoid tissue masses on either side of the oropharynx.
• The tonsils are situated in the tonsillar fossa, with anterior and posterior pillars.
• The medial surface is covered by mucous membrane with 8-30 crypts (depressions).
• The largest crypt (crypta magna) separates the upper and lower poles of the tonsil.
• A fibrous capsule (part of pharyngobasilar fascia) separates the tonsil from the superior constrictor of the pharynx.
• The lateral (deep) surface is bordered by a fibrous tissue (capsule) that separates it from its bed, which includes the superior constrictor muscle, buccopharyngeal fascia, glossopharyngeal nerve, facial, lingual, and internal carotid arteries, and IJV.
• The inferior pole receives blood supply from the tonsillar branch of the facial artery, ascending palatine artery, and dorsal lingual artery.
• The superior pole receives blood supply from the ascending pharyngeal and descending palatine arteries.
• Venous drainage is through the peritonsillar plexus to the lingual and pharyngeal veins, then to the IJV.
• Nerve supply comes from the IX CN and descending branches of lesser palatine nerves.
• Lymphatic drainage is to the upper deep cervical lymph nodes (especially the jugulo-diagastric LN).

Diseases of Tonsils

• Inflammatory Diseases:
  • Acute conditions: acute tonsillitis and peritonsillar abscess.
  • Chronic conditions: chronic or recurrent tonsillitis, chronic specific tonsillitis (diphtheria, syphilitic, tubercular).
• Tumors: Benign and malignant tumors.

Acute Tonsillitis

• Common in children.
• Immunity to common organisms is not always established.
• Organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and viral infections.

Predisposing Factors for Tonsillitis

• Upper respiratory tract infections (URTI).
• Chronic sinusitis and chronic tonsillitis.
• Exposure to infectious diseases.
• Blood dyscrasias.
• Excessive cold drinks.
• Lowered body resistance.
• Excessive pollution.
• Foreign body impaction.

Clinical Features of Tonsillitis

• Symptoms: Fever, sore throat, odynophagia, thick and muffled voice, trismus (difficulty opening the jaw), pain referred to the ear, and foul breath.
• Signs: Markedly congested pillars, enlarged and hyperemic tonsils, crypts filled with purulent material, and enlarged and tender jugulodiagastric lymph nodes.

Investigations of Tonsillitis

• Complete blood count (FBC).
• Differential count.
• Throat swab for culture and sensitivity (C&S).
• Plain radiograph, CT, or MRI if malignancy is suspected.

Differentials for Tonsillitis

• Scarlet fever.
• Infectious mononucleosis.
• Diphtheria.
• Glandular fever.
• Thrush.

Treatment of Tonsillitis

• Broad-spectrum antibiotics.
• Anti-inflammatory/analgesics.
• Soft, warm diet or intravenous fluids.
• Bed rest.

Complications of Tonsillitis

• Nonsuppurative: Scarlet fever, acute rheumatic fever, poststreptococcal glomerulonephritis.
• Suppurative: Peritonsillar abscess (quinsy), parapharyngeal abscess, retropharyngeal space abscess, otitis media, and septicemia.

Quinsy

• A collection of pus between the tonsil's fibrous capsule and the superior constrictor muscle of the pharynx, usually at the tonsil's upper pole.
• Commonly a complication of acute tonsillitis.
• Typically unilateral and more common in young adult males.
• Clinical Features: Toxic appearance, fever, severe odynophagia (painful swallowing), dribbling saliva, trismus, muffled voice, and otalgia (ear pain).
• Physical Examination Findings: Affected side is congested and bulging, tonsil is pushed downward and medially, asymmetry with edema and hyperemia of the soft palate, congested pillars, halitosis, severe trismus, and enlarged and tender jugulodiagastric lymph nodes.
• Complications: Pharyngeal and laryngeal edema with respiratory obstruction, parapharyngeal abscess, retropharyngeal abscess, jugular vein thrombosis, septicemia, and aspiration of pus into the respiratory passage.
• Differentials: Abscess related to an upper molar tooth, acute tonsillitis, malignancy of the tonsil, and parapharyngeal abscess.

Treatment of Quinsy

• Medical: Broad-spectrum antibiotics, anti-inflammatory/analgesics, soft, warm diet, or intravenous fluids.
• Surgical: Incision and drainage (I&D) or tonsillectomy (hot or interval).

Tonsillectomy

• Indications: Chronic/recurrent acute tonsillitis, sleep apnea syndrome, malignancy, brachial fistula, chronic otitis media secondary to tonsillitis.
• Relative Indications: Quinsy, diphtheria, rheumatic fever (RHD), glandular fever (GN), benign tumors or cysts, tonsillar foreign body, halitosis, and voice changes.

Chronic Adenotonsillar Hypertrophy (ATH)

• Typically, tonsils and adenoids are small at birth and progressively enlarge in the first to fourth years of life.
• Etiology: Increased immunologic activity, chronic infection, and secondhand smoke exposure.
• Complications: Common cause of upper airway obstruction in children, severe cases can lead to cor pulmonale, pulmonary vascular hypertension, and alveolar hypoventilation.
• Treatment: Adenoidectomy or tonsillectomy, or both.
• Clinical Features: Symptoms of ATH are not due to the increased size of the adenoid mass itself, but rather to a disproportion in size between the nasopharynx and the adenoids.

Grade of Tonsil

• Graded based on visibility of the tonsils' medial surface relative to visible anterior pillars. The grading system involves Gr I, Gr II, Gr III, and Gr IV (kissing tonsils).

Complications of Chronic ATH

• Common cause of airway obstruction in children.
• Severe cases can result in: cor pulmonale, pulmonary vascular hypertension, and alveolar hypoventilation.
• Treatment involves adenoidectomy, tonsillectomy or both.

CFS (Chronic Tonsillitis) Presentation Issues

• Clinical Features: Symptoms like chronic mouth breathing and drooling saliva, hyponasal voice, nasal discharge, conductive hearing loss due to otitis media, poor feeding/failure to thrive, and craniofacial growth pattern issues in children (adenoid facies).
• General Symptoms with chronic adenotonsillar hypertrophy can include failure to thrive, pigeon chest, flat voice, protruding abdomen and halitosis.
• Adenoid facies include open mouth, loss of nasolabial groove, pinched and narrow nose, vacant expression, high arched palate, malocclusion, drooling saliva and elongated face.

Diagnostic Assessment of Tonsils

• Historical assessment.
• Physical examination.
• Radiological assessment (lateral postnasal space soft tissue x-ray).
• Flexible endoscopic nasopharyngoscopy.

Preoperative Assessment

• Coagulation abnormalities.
• Chest X-ray (CXR).
• Electrocardiogram (ECG).
• Cardiology review.
• Pulmonary evaluation - only in patients with severe upper airway obstruction.

Complications of Adenotonsillectomy

• Hemorrhage (intraoperative, reactionary, secondary).
• Pain.
• Airway obstruction (edema, more common in patients <3 years).
• Postoperative pulmonary edema.
• Nasopharyngeal stenosis.
• Vocal cord paralysis (VPI).
• Cervical spine complications (atlantoaxial subluxation, Grisel's syndrome, common in patients with Down syndrome).

Assignment: Adenoiditis Presentation and Management

• Students should discuss the presentation and management of adenoiditis. This will include the symptoms, diagnoses, and treatment options for this condition.