Tonsils Anatomy and Function

Adenoids and Tonsils

• Adenoids and tonsils are lymphoid tissue, part of Waldeyer's ring
• Located at the entrance to the digestive and respiratory tracts
• They play a crucial role in recognizing pathogenic microorganisms and initiating an immune response.
• Types of Tonsils:
  • Pharyngeal Tonsil (Adenoid)
  • Tubal Tonsils
  • Palatine Tonsils
  • Lingual Tonsils

Palatine Tonsil Anatomy

• A pair of lymphoid tissue masses on either side of the oropharynx
• Tonsillar fossa: anterior and posterior pillars
• Medial surface covered by mucous membrane with 8-30 crypts (depressions)
• Largest crypt: crypta magna, separates the upper and lower poles of the tonsil.
• Capsule (part of pharyngobasilar fascia) separates the tonsil and superior constrictor of the pharynx

Tonsil Blood Supply

• Inferior pole: Tonsillar branch of facial artery, ascending palatine artery, and dorsal lingual artery.
• Superior pole: Ascending pharyngeal artery, facial artery, and descending palatine artery.

Tonsil Venous Drainage and Nerve Supply

• Venous drainage: peritonsillar plexus, lingual, and pharyngeal veins (IJV)
• Nerve supply: IX CN and descending branches of lesser palatine nerves.

Lymphatics

• Lymphatic drainage: Upper deep cervical LNs (especially the jugulo-digastric LN)

Adenoids

• Located at the junction of the nasopharyngeal wall roof and posterior nasopharynx
• Located inferolaterally to the eustachian tube.

Adenoid Blood Supply

• Ascending pharyngeal artery
• Ascending palatine artery
• Ascending branch of maxillary artery
• Artery of pterygoid canal
• Branches from the tonsillar branch of facial artery

Adenoid Venous Drainage and Nerve Supply

• Venous drainage: pharyngeal plexus-pterygopid plexus - IJV.
• Nerve supply: pharyngeal plexus

Adenoid Lymphatics

• Retropharyngeal space nodes
• Pharyngomaxillary space nodes

Diseases of Tonsils

• Inflammatory diseases:
  • Acute tonsillitis
  • Peritonsillar abscess
  • Chronic or recurrent tonsillitis
  • Chronic specific tonsillitis (diphtheria, syphilitic, tubercular)
• Tumors:
  • Benign
  • Malignant

Acute Tonsillitis

• Common in children
• Immunity to common organisms is not always established.
• Organisms include:
  • Streptococcus pneumoniae
  • H. influenzae
  • Moraxella catarrhalis
  • Staphylococcus aureus
  • Viral infections

Predisposing Factors

• URTI
• Chronic sinusitis
• Chronic tonsillitis
• Exposure to contagious infection
• Blood dyscrasias
• Excessive use of cold drinks
• Lowered body resistance
• Excessive pollution
• Foreign body impaction

Clinical Features (Tonsils and Adenoids)

• Symptoms:
  • Fever
  • Sore throat
  • Odynophagia
  • Thick and muffled voice
  • Trismus and referred ear pain
  • Foul breath
• Signs:
  • Markedly congested pillars
  • Enlarged and hyperemic tonsils
  • Crypts filled with purulent material
  • Enlarged and tender jugulodiagastric nodes

Investigations

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

Differentials

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

Treatment

• Broad-spectrum antibiotics
• Analgesics and anti-inflammatory medications
• Soft and warm diet
• Bed rest

Complications (Tonsils and Adenoids)

• Nonsuppurative:
  • Scarlet fever
  • Acute rheumatic fever
  • Poststreptococcal glomerulonephritis.
• Suppurative:
  • Peritonsillar abscess (Quinsy)

Quinsy (Peritonsillar Abscess)

• Collection of pus between the tonsil's fibrous capsule and superior constrictor muscle of the pharynx.
• Often a complication of acute tonsillitis.
• Usually unilateral and common in young adult males.
• Clinical Features:
  • Toxic appearance
  • Fever
  • Odynophagia/severe pain
  • Dribbling saliva
  • Trismus
  • Muffled voice
  • Otalgia
• Examination Findings:
  • Congested and bulging affected side of tonsil.
  • Tonsil pushed downward and medially.
  • Soft palate edema and hyperemia.
  • Congested pillars.
  • Halitosis
  • Severe trismus
  • Tender and enlarged jugulodiagastric nodes
• Complications:
  • Pharyngeal and laryngeal edema with respiratory obstruction
  • Parapharyngeal abscess
  • Retropharyngeal abscess
  • Jugular vein thrombosis
  • Septicemia
  • Pus aspiration into the respiratory tract
• Differentials:
  • Abscess related to upper molar tooth
  • Acute tonsillitis
  • Tonsillar malignancy
  • Parapharyngeal abscess

Management

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

Tonsillectomy

• Indications:
  • Chronic/recurrent acute tonsillitis
  • Sleep apnea syndrome
  • Malignancy
  • Brachial fistula
  • Chronic otitis media (2ndary)
  • Surgical approach involving glossopharyngeal nerve, styloid process
• Relative indications:
  • Quinsy
  • Diphtheria
  • Rheumatic Heart Disease (RHD)
  • Generalized infection (GN)
  • Benign tumors/cysts
  • Foreign body
  • Halitosis
  • Voice change

Chronic Adenotonsillar Hypertrophy (ATH)

• Gradual enlargement of tonsils and adenoids after birth, usually in the first 4 years of life.
• Etiology:
  • Increased immunologic activity
  • Chronic infection
  • Second-hand smoke exposure
• Complications:
  • Upper airway obstruction
  • Cor pulmonale
  • Pulmonary vascular hypertension
  • Alveolar hypoventilation
• Treatment: Adenoidectomy, tonsillectomy (or both).
• Clinical features: Symptoms are not related to increased size of adenoids but rather disproportion with regard to the nasopharynx
• Clinical presentation (CFS): Obstructive sleep apnea (OSA) - apnea attacks, loud snoring, frequent awakenings, hypersomnolence, enuresis, nightmares, poor school performance , chronic mouth breathing, hyponasal voice, nasal discharge, conductive hearing loss, poor feeding/failure to thrive, craniofacial growth patterns in children
• General symptoms (CFS): Failure to thrive, pigeon chest, flat voice, protruding abdomen, halitosis

Adenoid Facies

• Open mouth
• Loss of nasolabial groove
• Pinched & narrow nose
• Vacant expression
• High arched palate
• Malocclusion
• Drooling of saliva
• Elongated face

Diagnostic Assessment

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

Pre-operative Assessment

• Coagulation abnormalities
• Chest x-ray
• ECG
• Cardiology review
• Pulmonary evaluation

Complications of Adenotonsillectomy

• Hemorrhage (intraoperative/reactionary/secondary)
• Pain
• Airway obstruction (edema more common in patients <3 years)
• Post-operative pulmonary edema
• Nasopharyngeal stenosis
• Velopharyngeal insufficiency (VPI)
• Cervical spine complications (atlantoaxial subluxation- Grisel's syndrome: common in patients with Down's syndrome)

Adenoiditis Assignment Summary

• Students should discuss the presentation and management of adenoiditis.