Adenoids and Tonsils- UMST PDF

ADENOIDS AND TONSILS Dr Rajab MUGABO Senior Consultant ENT-Head & Neck Surgeon Assistant Professor of ENT, UMST. Anatomy  Waldeyer’s Ring  Ring of Lymphoid tissue guarding entrance to the digestive & respiratory tracts.  It plays an important rol...

ADENOIDS AND TONSILS Dr Rajab MUGABO Senior Consultant ENT-Head & Neck Surgeon Assistant Professor of ENT, UMST. Anatomy  Waldeyer’s Ring  Ring of Lymphoid tissue guarding entrance to the digestive & respiratory tracts.  It plays an important role in early recognition of pathogenic microorganisms & initiation of an immune response. Pharyngeal Tonsil (Adenoid). Tubal Tonsils. Palatine Tonsils (Tonsil) Lingual Tonsils. Waldeyer’s ring Palatine tonsil  A pair of lymphoid tissue masses lying on either side of the oropharynx  Tonsillar fossa- anterior & posterior pillars  Medial surface is covered by mucous membrane showing 8-30 depressions (crypts)  The largest crypt (crypta magna) separates the upper pole from lower pole of the tonsil  Capsule (part of pharyngobasilar fascia)- separates the tonsil from superior constrictor of the pharynx Tonsil … Tonsil …  Its lateral (deep) surface is bounded by a fibrous tissue (capsule), which separates the tonsil from its bed that is made up of:  Superior constrictor muscle  Buccopharyngeal fascia.  Glossopharyngeal nerve.  Facial, lingual and internal carotid arteries  IJV  The lower pole may extend to the BOT & become continuous with the lingual tonsil Blood Supply  Inferior pole  Tonsillar branch of facial artery  Ascending palatine artery  Dorsal lingual artery  Superior pole  Ascending pharyngeal Artery  Descending palatine artery Tonsil …  Venous drainage  peritonsillar plexus- lingual & pharyngeal veins-IJV  Nerve supply  IX CN & descending branches of lesser palatine nerves Lymphatics  Lymphatic drainage:  Upper deep cervical LNs (esp. the Jugulo- diagastric LN) Adenoids  At the junction of the roof & posterior nasopharyngeal wall  Related inferolaterally to the eustachian tube Adenoids …  Blood supply  ascending pharyngeal artery  ascending palatine artery  ascending branch of maxillary artery  artery of pterygoid canal  contributing branches from tonsillar branch of facial artery  Venous  pharyngeal plexus- pterygoid plexus- IJV Adenoids …  Nerve supply  pharyngeal plexus  Lymphatics  retropharyngealspace ) nodes  pharyngomaxillary ) nodes Diseases of tonsils 1. Inflammatory diseases: Acute conditions Acute tonsillitis Peritonsillar abscess Chronic conditions: Chronic or recurrent tonsillitis Chronic specific tonsillitis- diphtheria, syphilitic, tubercular 2. Tumors Benign Malignant Acute tonsillitis  Common in children  immunity to common orgs has not been established  Organisms  Strep pneumoniae  H. influenzae  Moraxella catarrharis  Staph 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  Symptoms:  Fever  Sore throat  Odynophagia  Thick and muffled voice  Trismus and pain referred to ear  Foul breath Clinical features …  Signs  Fever  Markedly congested pillars  Enlarged & hyperemic tonsils  Crypts filled with purulent material  Enlarged & tender jugulodiagastric nodes Investigations  FBC  Total  Differential  Throat swab for C & S  Plain radiograph, CT & MRI if malignancy suspected Differentials  Scarlet fever  Infectious mononucleosis  Diphtheria  Glandular fever  Thrush Treatment  Broad spectrum antibiotics  Anti-inflammatory/analgesics  Soft, warm and simple diet  Bed rest Complications  Nonsuppurative  Scarlet fever  Acute rheumatic fever  Poststreptococcal glomerulonephritis  Suppurative complications:  Peritonsillar abscess (Quinsy)  Parapharyngeal space abscess  Retropharyngeal space abscess  Otitis media  Septicemia Quinsy  A collection of pus between the fibrous capsule of the tonsil, usually at its upper pole, and the superior constrictor muscle of the pharynx  Usually occurs as a complication of acute tonsillitis  Usually unilateral & common in young adult males Quinsy …  Clinical features  Toxic  Febrile  Odynophagia/severe pain  Dribbling saliva  Trismus  Muffled voice  Otalgia Quinsy …  Examination findings  Affected side is congested & bulging  Tonsil is pushed downward & medially  Asymmetry with edema & hyperemia of the soft palate and enlargement  Pillars are congested  Halitosis  Severe trismus  Tender & enlarged jugulodiagastric nodes Quinsy …  Complications  Pharyngeal & laryngeal edema with respiratory obstruction  Parapharyngeal abscess  Retropharyngeal abscess  Jugular vein thrombosis  Septicemia  Aspiration of pus into respiratory passage Quinsy …  Differentials  Abscess related to upper molar tooth  Acute tonsillitis  Malignancy of tonsil  Parapharyngeal abscess Management  Medical  broad spectrum antibiotics  anti-inflammatory/analgesics  Soft, warm diet or IV Fluids  Surgical I &D  Tonsillectomy(hot/interval) Tonsillectomy  Indications  Absolute Chronic/recurrent acute tonsillitis Sleep apnea syndrome Malignancy Brachial fistula Chronic otitis media 2º to TH Surgical approach- glossoph nv, styloid process Tonsillectomy  Relative indications  Quinsy  Diphtheria  RHD  GN  Benign tumors or cysts  Tonsillar foreign body  Halitosis  Voice changes Chronic Adenotonsillar hypertrophy  Typically, the tonsils and adenoids are very small at birth and progressively enlarge over the first to fourth years of life  Etiology:  increased immunologic activity  chronic infection  Second-hand smoke exposure Grading of tonsil  Gr I- medial surface of tonsil hidden behind anterior pillar  Gr II- medial surface of tonsil just at the level of anterior pillar  Gr III- size in between Gr II and Gr IV  Gr IV- tonsils touching each other (kissing tonsils) Complications of chronic ATH  Common cause of upper-airway obstruction in children  Severe cases my result into cor pulmonale, pulmonary vascular hypertension and alveolar hypoventilation  Treatment- adenoidectomy or tonsillectomy or both Clinical features  Symptoms of AH are not due to increased size of adenoid mass but due to disproportion in the size of nasopharynx & adenoids. CFS …  Obstructive sleep apnea(OSA)  Apneic attacks  Excessive loud snoring  Frequent awakening during night  Hypersomnolonce  Enuresis  Nightmares  Poor school perfomance CFS …  Chronic mouth breathing & drooling of saliva  Hyponasal voice  Nasal discharge  Conductive hearing loss due to secretory or purulent otitis media  Poor feeding/Failue to thrive  Chronic mouth breathing has been shown to affect craniofacial growth patterns in children- Adenoid facies CFS …  General symptoms:  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  Raiological assessment- lateral postnasal space soft tissue x-ray  Flexible endoscopic nasopharyngoscopy Preop assessment  Coagulation abnormalities  CXR  ECG In patients with  Cardiology review severe upper airway  Pulmonary evaluation obstruction Complications adenotonsillectomy  Hemorrhage - intraoperative - reactionary - secondary  Pain  Airway obstruction- edema more common in patients < 3 years  Post-op pulmonary edema  Nasopharyngeal stenosis  VPI  Cervical spine complications- atlantoaxial sublaxation (Grisel’s syndrome) common in pts with Down’s syndrome Assignment  Discuss the presentation and management of adenoiditis