TONSILS AND ADENOID

ASKAROELLAH ABOET
 The word tonsil
- derives from latin, a mooring post
- it part of waldeyers ring of the lymphoid tissue
encircling the entrance from the mouth and nasal
passages to the pharynx
 Ring of waldeyer consist of:
Palatine (faicial) tonsil situated, one on
each side between the folds of the
palatopharyngeans and palato glossus
muscle
Lingual tonsil one each side between base
of tongue and vallecula
A single nasopharyngealtonsil (adenoid:
Greek aden, gland; eidos, form) in the
roof of the nasopharynx (epipharynx)
 Tonsil and adenoids are the major immunologic
organs of the upper aerodigestive tract. Tonsil
has 10 to 30 cryptlike invagination that branch
deep into the tonsil parenchyma and are lined
by the specialized antigen processing squamous
epithelium
This epithelium serves as the immune systems
acces route for both inhaled and ingested
antigens
 The tonsil are supplied by:
- ascending pharyngeal
- ascending palatine
- branches from the lingual and fascial arteries
- all branches of the external carotid artery
- the internal carotid artery lies approximately 2
cm posterolateral to the deep aspect of tonsil
 The lymphatic drainage from the tonsil is
primarily into the superior deep cervical
and jugular lymph node
Sensory innervation of the tonsil is from
the glassopharyngeal nerve and some
branches of the lessen palative nerve via
the sphenopalatine ganglion
Diseases of the tonsil and adenoid are some of the
most common problems seen in children.

Adenotonsillar disease can be broadly classified as

infectious, obstructive and miscellaneous.

The miscellaneous group includes unilateral tonsillar

hypertrophy and tonsilloliths.
 TONSILLITIS
Acute tonsillitis is defined as an acute
infection of the tonsil with symptoms of
sore throat, fever, odynophagia, and
general malaise.
Physical findings include tonsillar
hypertrophy and erythema and exudates
on the tonsillar surfaces.
 Tonsillitis may be associated with cervical
lymphadenopathy, skin rashes, and fever.

The disease is usually self-limited, lasting

from 7 to 14 days, but during this period
there may be significant loss of time from
school or work.
 Acute tonsillitis may progress to recurrent
acute tonsillitis, repeated episodes of
acute tonsillitis followed by periods in
which the patient is asymptomatic.

The patient may develop symptoms of

acute tonsillitis, during each acute episode
 Recurrent acute tonsillitis patients
developed enlarged tonsillar crypts that
accumulate debris, persistent erythema of
the tonsils, and dilated blood vessels on
the surface of the tonsils.
 Many pathogens may be cultured from the
surface and the core of the tonsils and
may cause acute tonsillitis.
The greatest concern is group A beta-
hemolytic streptococcus because it may
lead to the development of rheumatic
cardiac disease and glomerulonephritis.
 Group A beta-hemolytic streptococcus
maybe isolated on the tonsil surface
Up to 60% cases were found deep within
the tonsillar crypts
Cultures of the tonsil surface may not
detect group A beta-hemolytic
streptococcus as the cause of acute
tonsillitis
 Treatment of acute tonsillitis should be
based on clinical judgement
Consideration the entire clinical picture
rather than just cultures of the tonsil
surface
 Antimicrobial theraphy may be started
even in the absence of a positive culture
for group A beta-hemolytic streptococcus
In most cases, penicillin and amoxicillin
are the initial drugs of choise
 The responsible pathogens are likely to be
-lactamase-producing bacteria for
patients with history of treated reccurent
acute tonsillitis
Should be used -lactamase-stable
antibiotic such as amoxicillin clavulanate
 Some patients may be carriers of group A
beta-hemolytic streptococcus
No treatment is necessary for
asymptomatics patients
Patients who experience frequent episodes
of acute tonsillitis, infect other patients or
develop complications should be treated.
 An initial course of antibiotics may
eradicate the bacteria dan carrier state
Adenotonsillectomy is indicated for
treatment failure
 Childrenwho continue to experience reccurent
acute tonsillitis:
- Adequate antibiotic theraphy
- Considered for tonsillectomy and adenoidectomy
Over 70% cases, core tonsil and core adenoid tissue
harbor the same pathogens
Both tonsillectomy and adenoidectomy lead to their
eradication
 Candidates for tonsillectomy and
adenoidectomy are patients with > 3
episodes of acute tonsillitis within a year
It is important to document:
- dates of the two last infections
- degree of fever
- severity of disease
- results of any throat cultures
- response antibiotics
CHRONIC TONSILLITIS
 Defined as persistent tonsillar infection
occur in all age groups but more often n
adolescents and young adults
Patient complains:
- constant throat pain
- halitosis
- fatique
 Examination of tonsil reveals hypertrophy,
erythema, and enlarged crypts filled with
debris
Patient is treated with tonsillectomy if the
symptoms are severe or the persistent
infections interferes with normal activity
PERITONSILLAR INFECTION
 Defined as persistent tonsillar infection
occur in all age groups but more often in
adolescents and young adults
Most frequent head and neck space
infection
Most common complication of acute
tonsillitis
 Infections of the tonsillar capsule to
involve the peritonsillar space
Most infection occur in the superior pole of
the tonsil, but some involve the
midtonsillar area and inferior pole
The infection begins as a cellulitis and
progresses to an abscess
 Patients complain:
- fever
- unilateral sore throat
- odynophagia
- trismus
The examination may be difficult because
of the inabillity to open the mouth
 Classic signs include:
- a muffled voice
- drooling, unilateral swelling, an erythema of the
superior tonsillar pole
- deviation of the uvula to the opposite side
- bulging of the posterolateral part of the soft palate
 The oral airway may be compromised.
The diagnosis of a peritonsillar space
infection is usually made clinically, but it
may be difficult to distinguish between
cellulitis and an early abscess
 Patients with a suspected peritonsillar
infection should be hydrated and given
intravenous antibiotics and analgesics.
Drainage should be considered if there is
no improvement after 48 hours, airway
compromise, or definite abscess
formation.
 There is no consensus regardding the best
technique for drainage of the abscess
Options include needle aspiration, incision
and drainage, and immediate
tonsillectomy
Needle aspiration and incision and
drainage have success rates greater than
90%, but there is 10 to 15% risk of
abscess reccurent
 Immediate tonsillectomy is curative and
prevents reccurence
Tonsillectomy should be performed in
patients with a history of reccurent
infections or previous abscess
ADENOIDITIS
 The infected adenoid tissue during an
upper respiratory tract infection, causing
fever, nasal obstruction, purulent
rhinorrhea, postnasal discharge and cough
Signs and symptoms are nonspecific
 Examination with a mirror or telescope
may demonstrate inflamed, swollen
adenoid covered with exudates
 Treatment is with antibiotics
Antibiotics with activity against -
lactamase-producing microorganism are
recommended for patient with reccurent
condition
 The relationship between adenoid
infections and sinusitis has not been
clearly established
Adenoitis may be misdiagnosed as
sinusitis since the presentation ot these
two conditions is similiar
 Adenoitis may be a causal factor in
pediatric sinusitis
Child with chronic sinusitis, has been
suggested that an adenoidectomy be
performed a minimum of 3 months prior
to endoscopic sinus surgery
Sinus surgery may be avoided, if there is
significant improvement of symptoms