Adenotonsilitis

Dr Benedict
 Outline
Introduction
Anatomy
Microbiology
Pathogenesis
adenoid
tonsils
reference
 Introduction
• Adenotonsillitis is inflammation of the palatine , lingual and
pharyngeal tonsils and most commonly caused by viral or
bacterial infection.

• They account for significant proportion of childhood illnesses

and pediatric health care expenditures.

• They are also among the most commonly encountered disease

in the general population.
• If not managed well can result into number complications
 Click icon to add picture
Anatomy
known as Waldeyer's
ring.

Which is ring of
lymphoid tissue is found
at the entrance of the
upper aerodigestive
tract.

are part of the mucosa-

associated lymphoid
tissue (MALT) system.
 Adenoids
• Adenoids are a triangular-shaped lymphoid tissue .
• located on the superiorposterior aspect of the nasopharynx .
• are present at birth and become colonized with bacteria during the
first few weeks of life.
• Non capsulated
• crypt formation, but less extensive compared to tonsils
 Blood supply
Anatomical relationships
of adenoids -mainly pharyngeal branches of the
external carotid artery
-minor contribution from internal
Laterally is related to maxillary and facial arteries.
opening of
eustachian tube in
 Nerve supply
the nasopharynx .
- glossopharyngeal and vagus nerves

anteriorly located
nose and paranasal
sinuses, and the
maxilla and
 Tonsils

• The (faucial or palatine) tonsils are paired, generally ovoid-shaped

lymphoid located on the lateral walls of the oropharynx .
• Capsulated with extensive crypt formation 10 to 30.
Anatomical relationships
of Tonsils
 Anteriorly bounded by
anterior pillar-
palatoglossus muscle
 posteriorly bounded by
posterior pillar-
palatopharyngeus muscle
 The internal carotid artery
lies approximately 2 cm
posterolateral to the
deep aspect of the tonsil
Blood supply
-ascending pharyngeal, ascending
palatine, and branches from the
lingual and facial arteries
 Lymph drainage
-The lymphatic drainage from the
tonsils is primarily into the superior
deep cervical and jugular lymph
nodes;
 Nerve supply
- glossopharyngeal nerve and some
branches of the lesser palatine nerve
Epidemiology
• Adenoiditis occurs mainly in childhood, often associated with acute
tonsillitis.
• Adenoiditis Incidence decreases with age, with adenoiditis being rare in
children over 15 years due to physiological atrophy of the adenoid tissue.
• Tonsillitis most often occurs in children; however, the condition rarely
occurs in children younger than 2 years.
• Tonsillitis caused by Streptococcus species typically occurs in children
aged 5-15 years, while viral tonsillitis is more common in younger
children.
 bacteria
-The bacteria encountered are remarkably similar
to those found in otitis media and sinusitis.
Microbiology
bacteria- aerobic and  Aerobics
anaerobic -Group A beta-hemolytic streptococci
(GABHS), Groups B, C, F, streptococcus,
Viruses and fungal Haemophilus influenza (type b and nontypeable),
Streptococcus pneumonia, Streptococcus
epidermidis, Moraxella
catarrhalis, Staphylococcus aureus, Hemophilus
parainfluenza, Neisseria sp., Mycobacteria sp.,
Lactobacillus sp., Diphtheroids sp., Eikenella
corrodens ,Pseudomonas aeruginosa ,Escherichia
coli,
Helicobacter pylori, Chlamydia pneumonia.
Anaerobic-
Viruses- Epstein-Barr, Adenovirus,
Bacteroides sp., Peptococcus Influenza A and B, Herpes
sp., Peptostreptococcus simplex, Respiratorysyncytial, Parainfluen
sp.,Actinomycosis za.
sp., Microaerophilic
streptococci, Veillonella Fungal- candida alibicans
parvula, Bifidobacterium
adolescences, Eubacterium
sp,Lactobacillus
sp., Fusobacterium
sp., Bacteroides
sp., Porphyromonas
asaccharolytica, Prevotella
sp.
sp.
 Pathogenesis of Adenotonsillitis
• Usually infectious/inflammatory disease in the tonsils and adenoids
commence with Viral infection then followed by secondary bacterial
invasion
• Inflammation and loss of integrity of the crypt epithelium result in
chronic cryptitis and crypt obstruction, leading to stasis of crypt
debris and persistence of antigen.
• Bacteria even infrequently found in normal tonsil crypts may
multiply and eventually establish chronic infection.
 • Infection/inflammation
Disease of the - Acute adenoiditis(nasopharyngitis)
adenoids aka common cold
- Recurrent acute adenoiditis
• Infection/inflammation - Chronic (persistent) adenoiditis
• Obstruction
• neoplastic • Obstruction
-chronic adenoid hypertrophy)
 Acute Adenoiditis
• This infection is characterized with Rhinorrhea (sometimes
purulent), nasal obstruction, fever, and often associated with
otitis media.
• Difficult to acute adenoiditis differentiate from viral-induced URI
or a true bacterial rhinosinusitis but the adenoiditis is associated
with snoring.
• A child also may have a lingering course and appear sicker than
when confronted with a typical viral URI.
 Recurrent Acute Adenoiditis
• Recurrent acute adenoiditis is defined as the presence of
four or greater discrete episodes of acute adenoiditis
during a 6-month period.
 Chronic Adenoiditis
• chronic adenoid infection presents Persistent nasal discharge,
malodorous breath, postnasal drip, and chronic congestion
• Most of these symptoms are often associated with chronic
sinusitis; thus, differentiating between the two is clinically
challenging.
 Obstructive disease of adenoids
Chronic Adenoid hypertrophy
• enlarged adenoids that cause nasopharyngeal obstruction will
present with The triad of symptoms, including chronic nasal
obstruction (associated with snoring and obligate mouth
breathing), rhinorrhea, and a hyponasal voice,
• Obstructive adenoid hyperplasia is best diagnosed by clinical
history and physical examination. triad of obligate mouth
breathing (both awake and asleep), snoring, and hyponasal
speech is seen.
 Complications of chronic adenoid
hypertrophy
1. Pediatric Sleep-Disordered Breathing
2. Attention Deficit–Hyperactivity Disorder
3. Neurocognitive Deficit
4. Enuresis
5. Failure to thrive
6. Cor- pulmonale and pulmonary vascular hypertension
7. Cranialfacial anomalies
8. Middle Ear Effusion
Cranialfacial
anomalies
Adenoid facies
characterized by
following features
• underdeveloped thin
nostrils
• short upper lip
• prominent upper teeth
• crowded teeth
• narrow upper alveolus
• high-arched palate
• hypoplastic maxilla
investigations
• lateral neck x-ray
• tympanometry
 Treatment
• Medical- Use of saline nasal drops in acute adenoiditis
-Recurrent or chronic adenoiditis due to
infection should be treated initially with an antimicrobial
effective against beta-lactamase-producing
microorganisms, particularly when associated with
persistent or recurrent otitis media or sinusitis.
• Surgery- Adenoidectomy
Indications for adenoidectomy
Infection
i. Recurrent/chronic adenoiditis
ii. Recurrent/chronic otitis media with effusion
iii. Chronic otitis media
iv. Chronic sinusitis
Obstruction
i. Obstructive adenoid hypertrophy
 • Infection/inflammation
Disease of the - Acute tonsillitis
tonsils -Recurrent acute tonsillitis
-Chronic (persistent) tonsillitis
• Infection/inflammation -Tonsillolithiasis
• Obstruction
• neoplastic • Obstruction
-chronic tonsillar hypertrophy
 Acute Tonsillitis
• Presents with Sore throat, fever, dysphagia, and tender cervical
nodes ,Tonsils are erythematous and have exudates .Not all
these signs and symptoms are present in every patient;
• In the ill patient with clearly inflamed tonsils, other bacterial
causes or EBV infection [infectious mononucleosis (IM)] also
should be considered and treated. There exists a wide range of
accuracy in the clinical diagnosis of acute tonsillitis.
Acute tonsillitis
 Classification:
 acute catarrhal or superficial
tonsillitis: Here tonsillitis is a part of
generalized pharyngitis and seen in
viral infections

 acute follicular tonsillitis: In which

tonsillar crypts become filled with
purulent materials
acute parenchymatous tonsillitis:
Here tonsils are uniformly
enlarged and red

acute membranous tonsillitis:

The exudates in the crypts
coalesces to form membrane on
the surface
Acute Membranous Tonsillitis
Acute Follicular Tonsillitis
Acute Parenchymatous Tonsillitis
Acute catarrhal tonsillitis
 Recurrent Acute Tonsillitis
• Recurrent acute infection has been variably defined as from four
to seven episodes of acute tonsillitis in 1 year, five episodes for 2
consecutive years, or three episodes per year for 3 consecutive
years
 Chronic (Persistent) Tonsillitis
• Presents with Chronic sore throat, malodorous breath, excessive
tonsillar debris (tonsilloliths), peritonsillar erythema, and
persistent, tender cervical adenopathy.
 Obstructive disease of tonsils
Chronic tonsillar hypertrophy

• Presents with Enlarged tonsils grade 3 and 4 ,snoring, obstructive

disturbances (asleep and awake), dysphagia, changes in the
craniofacial skeleton, and voice changes (muffling or
hypernasality).
• Chronic tonsillar hypertrophy has same complications as chronic
adenoid hypertrophy
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examination

• Throat examination
using spatula

• Grading of tonsil
hypertrophy base
the ratio of the
tonsils to the
oropharynx.
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investigations
• Throat culture
not done in our
setting
 Treatment
• Medical- Penicillin continues to be the first-line antibiotic
used in acute tonsillitis due to GABHS.
• Prophylaxis reserved for unfit candidate for surgery or
refusal to underwent surgery.

• Surgery-tonsillectomy
 Indications for tonsillectomy
Infection obstructive
i. Recurrent/chronic tonsillitis I. Obstructive tonsillitis
ii. Tonsillitis with:
-Abscessed cervical nodes
-Acute airway obstruction
-Cardiac valve disease
iii. Persistent tonsillitis with:
-Persistent sore throat
-Tender cervical nodes
-Halitosis
iv. Tonsillolithiasis
v. Peritonsillar abscess unresponsive
to medical therapy or in a patient
with recurrent tonsillitis or recurrent
abscess
 Complication of Tonsillitis
• Nonsuppurative complications
include scarlet fever, acute rheumatic fever, and post streptococcal
Glomerulonephritis
• Suppurative complications are the result of abscess
formation and include peritonsillar and parapharyngeal abscess
development.
 Gaps in management of Adenotonsillitis
Knowledge – community-uvulectomy
- primary physician, pediatrician-??when to refer
to otorhinolaryngologist

Scarcity of otorhinolaryngologist
 reference

1. Bailey head and neck surgery

2. Cummings head and neck surgery
3. medscape