Podcast
Questions and Answers
Which of the following structures does not directly contribute to the bed of the palatine tonsil?
Which of the following structures does not directly contribute to the bed of the palatine tonsil?
The crypta magna is best described as:
The crypta magna is best described as:
Which artery does not supply the palatine tonsil's inferior pole?
Which artery does not supply the palatine tonsil's inferior pole?
The palatine tonsil's venous drainage primarily flows into the:
The palatine tonsil's venous drainage primarily flows into the:
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Which cranial nerve provides the main sensory nerve supply to the palatine tonsil?
Which cranial nerve provides the main sensory nerve supply to the palatine tonsil?
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Which of the following is least likely to be observed in a child experiencing chronic mouth breathing due to adenoid hypertrophy?
Which of the following is least likely to be observed in a child experiencing chronic mouth breathing due to adenoid hypertrophy?
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A patient with suspected significant adenoidal enlargement presents with severe upper airway obstruction. Which pre-operative assessment is MOST critical in this specific situation?
A patient with suspected significant adenoidal enlargement presents with severe upper airway obstruction. Which pre-operative assessment is MOST critical in this specific situation?
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Which physical characteristic is NOT typically associated with adenoid facies?
Which physical characteristic is NOT typically associated with adenoid facies?
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A child who underwent adenotonsillectomy develops signs of atlantoaxial subluxation. This complication is MOST likely to occur in patients with which pre-existing condition?
A child who underwent adenotonsillectomy develops signs of atlantoaxial subluxation. This complication is MOST likely to occur in patients with which pre-existing condition?
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Which symptom is LEAST likely to be a direct consequence of adenoiditis itself, rather than a secondary complication or associated condition?
Which symptom is LEAST likely to be a direct consequence of adenoiditis itself, rather than a secondary complication or associated condition?
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Which artery does not directly contribute to the blood supply of the adenoids?
Which artery does not directly contribute to the blood supply of the adenoids?
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Which of these is the least common etiological agents of acute tonsillitis?
Which of these is the least common etiological agents of acute tonsillitis?
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Which of the following is LEAST likely to be a predisposing factor for acute tonsillitis?
Which of the following is LEAST likely to be a predisposing factor for acute tonsillitis?
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A patient presents with severe dysphagia, trismus, and a 'hot potato' voice. Which of the following is the MOST likely diagnosis?
A patient presents with severe dysphagia, trismus, and a 'hot potato' voice. Which of the following is the MOST likely diagnosis?
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During the examination of a patient with suspected Quinsy, which of these findings is UNLIKELY?
During the examination of a patient with suspected Quinsy, which of these findings is UNLIKELY?
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A patient with Quinsy develops a high fever, tachycardia, and altered mental status. Which of the following is the MOST concerning immediate complication?
A patient with Quinsy develops a high fever, tachycardia, and altered mental status. Which of the following is the MOST concerning immediate complication?
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Which of the following is NOT a typical absolute indication for a tonsillectomy?
Which of the following is NOT a typical absolute indication for a tonsillectomy?
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Which description best describes a grade II tonsil?
Which description best describes a grade II tonsil?
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Which of the following best describes the pathophysiology of the symptoms seen in chronic adenotonsillar hypertrophy?
Which of the following best describes the pathophysiology of the symptoms seen in chronic adenotonsillar hypertrophy?
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Which of the following best describes the typical venous drainage of the adenoids?
Which of the following best describes the typical venous drainage of the adenoids?
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What is the primary nerve supply to the adenoids?
What is the primary nerve supply to the adenoids?
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Which of the following is NOT a typical symptom of acute tonsillitis?
Which of the following is NOT a typical symptom of acute tonsillitis?
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Which of the following is a possible non-suppurative complication of acute tonsillitis?
Which of the following is a possible non-suppurative complication of acute tonsillitis?
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Which of the following is a relative indication for tonsillectomy?
Which of the following is a relative indication for tonsillectomy?
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A young child presents with chronic adenotonsillar hypertrophy. What treatment should be considered?
A young child presents with chronic adenotonsillar hypertrophy. What treatment should be considered?
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Study Notes
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.
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Description
Explore the anatomy and function of adenoids and tonsils in this quiz. Learn about their significance in the immune system and the specific types of tonsils, as well as the vascular supply related to them. Test your knowledge on this essential lymphoid tissue located in the oropharynx.