ADENOTONSILLAR

DISEASES

Dr.Sherif Bugnah
ENT Resident
Armed Forces Hospitals Southern Region
Khamis Mushayt - Saudi Arabia

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 ADENOTONSILLAR DISEAS

Outlines
• INTRODUCTION
• ANATOMY & PHYSIOLOGY (Adenoid & Tonsils)
• INFECTIONS : VIRAL INFECTIONS
• Epstein-Barr virus (EBV)
• Coxsackie virus
• FUNGAL INFECTIONS
• BACTERIAL INFECTIONS
• Group A -hemolytic streptococcus
• Corynebacterium diphtheriae
Recurrent Acute Tonsillitis
Chronic Tonsillitis
Complications of Acute Adenotonsillitis
• NONSUPPURATIVE COMPLICATIONS
• SUPPURATIVE COMPLICATIONS
• Chronic Adenotonsillar Hypertrophy
• TONSILLAR NEOPLASMS
 INTRODUCTION

 The tonsils and adenoids can be a source of

infection and obstruction for both adults and
children and are responsible for a significant
childhood illnesses.
 Tonsillectomy and adenoidectomy remain two
of the most commonly performed procedures
by otolaryngologists.
 ANATOMY & PHYSIOLOGY

 tonsils and the adenoids are both components

of Waldeyer tonsillar ring.
 The lymphoid tissue of Waldeyer tonsillar ring
contains B-cell lymphocytes, T-cell lymphocytes,
and a few mature plasma cells.

 Functions include secretory immunity &

regulating immunoglobulin production.
 ANATOMY & PHYSIOLOGY

 most active from the ages of 4 to 10 and tend to

supressed after puberty(secretory immune function
these tissues remains, but much less.
 The palatine tonsils are the largest component of the
ring and have the most specialized structures..
 A specialized portion of the pharyngobasilar fascia,
forming afibrous capsule, binds the deep surface of
the tonsil.
 ANATOMY & PHYSIOLOGY (Tonsils)

 tonsillar fossa consist of three muscles

form the. The palatoglossus muscle (the
anterior tonsillar pillar) , palatopharyngeal
muscle (posterior tonsillar pillar)

 tonsillar fossa Base formed by the

pharyngeal constrictors (primarily the
superior constrictor).
 ANATOMY & PHYSIOLOGY
(Tonsils)

Blood supply - Tonsils

Tonsillar branch Tonsil(main branch)

Facial Artery

Ascending palatine Tonsil

Lingual A. Dorsal lingual Tonsil

Ascending Pharyngeal Tonsil

Maxillary Lesser descending palatine Tonsil

 ANATOMY & PHYSIOLOGY (Tonsils)

enous Drainage peritonsillar plexus

lingual and pharyngeal veins IJV

ymphatic Drainage tonsillar lymph node

(behind angle of the mandible), jugulodigastric /upper
cervical lymph nodes.

erve Supply (tonsils): tonsillar branch of the

glossopharyngeal nerve, also descending
branches of the lesser palatine nerve.
 ANATOMY & PHYSIOLOGY (Adenoids)

he adenoids are located over the surface of the superior and

posterior wall of the nasoph

Blood supply – Adenoids

 Ascending palatine branch of facial a.

 Ascending pharyngeal a.

 Pharyngeal branch of IMAX.

 Ascending cervical branch of thyrocervical trunk

 Venous drainage pharyngeal plexus

 Lymphatic drain retropharyngeal or
pharyngomaxillary lymph nodes.
 INFECTIONS : VIRAL INFECTIONS

 Usually associated with viral pharyngitis, common

complaint: sore throat and difficulty swallowing.
 often fever and oropharyngeal erythema, usually
without a tonsillar exudate.
 Possible Viruses: adenovirus, rhinovirus, (RSV),
influenza and parainfluenza .
 Most of these infections are self-limited and require
only symptomatic treatment.
 INFECTIONS : VIRAL INFECTIONS

Epstein-Barr virus (EBV)

 Causes pharyngitis (infectious mononucleosis syndrome)

 Children and young adults, Presents as fever, malaise,
lymphadenopathy, hepatosplenomegaly
 Petechiae may present at the junction of the soft & hard
palates. Tonsils severely enlarged (may affect the
airway),covered with grayish-white exudate.
 Treatment: supportive, with IV fluids and rest.
 If progressive airway obstruction, short course of
systemic steroids can be helpful. Rarely, a
nasopharyngeal airway, nasotracheal intubation or
tracheotomy may needed.
 INFECTIONS : VIRAL INFECTIONS

Coxsackie virus
 ulcerative vesicles over the tonsils, posterior
pharynx, and palate
 Commonly in children under the age of 16.

 headache, high fever, anorexia, & odynophagia.

 Treatment : mostly supportive, tonsils can have a

bacterial superinfection may benefit from
systemic antibiotics.
 FUNGAL INFECTIONS

 Oropharyngeal Candida (ie, thrush) mainly in

immunocompromised patients or patients who
have undergone prolonged treatment with
antibiotics.
 white plaques over the pharyngeal mucosa,
bleeds if removed with a tongue depressor.
 topical antifungal (e.g. nystatin or clotrimazole.)
 BACTERIAL INFECTIONS

 Acute Streptococcal Pharyngotonsillitis, Group A

-hemolytic streptococcus is the most common.

 children aged 5–6, Presents with fever, dry sore

throat, cervical adenopathy, dysphagia, and
odynophagia.
 Tonsils and pharyngeal mucosa erythematous
,may covered with purulent exudate;
("strawberry tongue")
 BACTERIAL INFECTIONS

 Major consideration is preventing complications

(acute rheumatic fever & poststreptococcal
glomerulonephritis. )

 Suspected pharyngitis, Daignosed by rapid strep

tests based on ELISA or latex agglutination, with
a throat culture.

 Treatment :Mainly Penicillin, if no response (48

hours), amoxicillin with clavulanate may be
helpful. Therapy should be for 10 days to
decrease recurrence.
 Other Acute Bacterial Infections

 Vincent angina is caused by Treponema vincentii

and Spirochaeta denticulata.

 Patients present with fever, unilateral pain

(swallowing), ipsilateral cervical
lymphadenopathy; unilateral deep ulcer on the
upper pole of the tonsil, covered by a white
exudative ulcer.

 Treatment usually with penicillin and oral

hygiene. heals in approximately 7–10 days
membrane
 Other Acute Bacterial Infections

Corynebacterium diphtheriae
 Usual symptoms of acute pharyngitis

 Gay, firmly adherent pseudomembrane (covers the

tonsils. 60% are localized to the pharynx; 8% spreads to
the larynx, compromising the airway.
 Diagnosis: Gram stain of the pseudomembrane reveals
gram-positive aerobic bacillus
 Treatment must started immediately, even before
confirmation with the culture. antitoxin (within 48 hours
of the onset of symptoms), high-dose penicillin.
 Recurrent Acute Tonsillitis

 Episodes of acute tonsillitis with complete recovery

between episodes.
 due to their location and numerous crypts and crevices,
seem to harbor bacteria.
 Tonsillectomy is indicated in patients with recurrent
acute tonsillitis involving 6–7 episodes of acute tonsillitis
in 1 year, 5 episodes/y for 2 consecutive years, or 3
episodes/y for 3 years
 Chronic Tonsillitis

 persistent sore throat, anorexia, dysphagia, and

pharyngotonsillar erythema.
 malodorous tonsillar concretions and the
enlargement of jugulodigastric lymph nodes.
 organisms involved are usually both aerobic and
anaerobic mixed flora, with a predominance of
streptococci.
 Chronic Tonsillitis

Tonsilloliths
 deep or stenotic crypts, food and secretions stagnate,
leading to bacterial overgrowth and a localized infection.

 In some patients, a sensation of a foreign body in the

throat, hard white material coming from the tonsils

 mouth care, which includes irrigation of the tonsils or

cleaning them with a cotton swab soaked in 3% hydrogen
peroxide.

 Tonsillar surgery and elimination of these cryptic structures

may be needed to control these infections.
Grading the Size of Tonsils

Grading system:
B. 0 – tonsils in fossa
C. +1 – tonsils less than 25%
D. +2 – tonsils less than 50%
E. +3 – tonsils less than 75%
F. +4 – tonsils greater than 75%
 Complications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONS
Scarlet Fever
 fever, severe dysphagia, diffuse erythematous rash,
pharyngeal symptoms.

 yellow membranous exudate covering the tonsils and

the pharynx, "strawberry tongue“, facial flush and
petechiae , (eruptions followed by desquamation occur
due to exotoxin produced by streptococcus. )

 Symptom identification and treatment planning are

important to prevent complications related to
streptococcal infection. The traditional treatment is
with penicillin.
 Complications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONS
Acute Rheumatic Fever
 18 days post infection (group A -hemolytic strept.),
when the throat culture is no longer positive.
Streptococcal infection results in production of cross-
reactive antibodies, leading to damage of the heart
tissues.
 Patients should be placed on a penicillin prophylaxis or
undergo tonsillectomy to eliminate the reservoir of
streptococcal infection
 Complications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONS
Post-Streptococcal Glomerulonephritis

 (12–25% incidence) typically 10 days after a

pharyngotonsillar infection or (10% incidence) as skin
infections with a nephrogenic strain caused by group
A-H.S.
 involves injury to the glomerulus by deposition of the
immune complexes & autoantibodies
 Antibiotic treatment has not been shown to affect the
incidence of the disease.
 Complications of Acute Adenotonsillitis

SUPPURATIVE COMPLICATIONS
Peritonsillar Abscess
 Lies in the potential space between the tonsillar
capsule and surrounding pharyngeal muscle bed.

 Symptoms include malaise, severe odynophagia

leads to dehydration & trismus.

 O/E a bulging palate with the corresponding tonsil

displaced to the midline or beyond.
 Complications of Acute Adenotonsillitis

SUPPURATIVE COMPLICATIONS
Peritonsillar Abscess
 Needle aspiration confirms
diagnosis and ocate the abscess.

 Definitive Treatment incision and drainage

 recurrence rate for peritonsillar abscess indicate
tonsillectomy. some surgeons favor a "Quincy
tonsillectomy”, most surgeons prefer either to surgery
after all the acute infection has resolved or to perform
an interval tonsillectomy.
 Complications of Acute Adenotonsillitis

SUPPURATIVE COMPLICATIONS
Deep Neck Infections
 common cause of parapharyngeal abscesses is
bacterial pharyngitis or tonsillitis.
 odynophagia, trismus, and shortness of breath.
 asymmetric pharyngeal swelling, including the palate,
extends more inferiorly than the tonsil, into the
hypopharynx.
 Ultrasound may be helpful, a definitive diagnosis
requires (CT) scan of the neck.
 management includes control of the airway,
intravenous antibiotics, I&D of the abscess.
 Chronic Adenotonsillar Hypertrophy

 Hypertrophy occurs in response to colonization with

normal flora, pathogenic microorganisms & Second-
hand smoke .
 Symptoms: (adenoid hypertrophy) Nasal obstruction,
rhinorrhea, hyponasal voice. (tonsillar enlargement)
snoring, dysphagia, and hypernasal or a muffled
voice.
 Chronic adenotonsillar hypertrophy is the most
common cause of sleep-disordered breathing in
children
 Chronic Adenotonsillar Hypertrophy

 Adenotonsillar hypertrophy and chronic mouth

breathing due to nasal obstruction is associated with
craniofacial growth abnormalities (increased anterior
facial height and a retrognathic mandible, with
subsequent malocclusion.)
 Flexible endoscopy is helpful in diagnosing adenoid
hypertrophy and forruling out other causes of nasal
obstruction.
 Lateral neck soft-tissue radiography can be helpful if
endoscopy is not performed.
 TONSILLAR NEOPLASMS

 Asymmetric tonsillar hypertrophy, if accompanied by a

suspicious clinical course or history, a tonsillectomy
should be performed for biopsy.
 Lymphoma and squamous cell carcinoma are the most
common primary tonsillar neoplasms.
 Many primary malignant neoplasms metastasize to
tonsils (eg, melanoma, renal, lung, breast, gastric and colon ca)
 Benign tumors are rare, include lipomas, fibromas and
schwannomas.
 TONSILLAR NEOPLASMS
 Parapharyngeal space tumors are important to consider,
may present with similar signs and symptoms.

 Risk Factors for Malignanency include tonsillar

asymmetry associated with rapid enlargement,
constitutional symptoms, atypical tonsillar appearance,
ipsilateral cervical lymphadenopathy, and Hx of previous
tumers.

 Unilateral tonsillar enlargement in asymptomatic children

is rarely of neoplastic , However, the diagnosis of
tonsillar lymphoma should be considered when unilateral
tonsillar enlargement is present either in an
immunocompromised child or when acute tonsillitis is
asymmetric and unresponsive to medical therapy.
 ADENOTONSILLAR DISEASES : Refrences

 Current Diagnosis & Treatment in Otolaryngology—Head & Neck

Surgery, 2nd Edition Copyright © 2008
 Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg. 2002;128(7):767.
(Prospective controlled study of the implication of pediatric tonsillar asymmetry.) [PMID:
12117331]
 Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry.
Laryngoscope. 2000;110(11):1807. (Retrospective review examining the incidence of malignant
neoplasms in incidentally discovered unilateral tonsillar enlargement.) [PMID: 11081589
 Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope.
2002;112:6. (A thorough review of the indications for tonsillectomy and adenoidectomy based on
evidence in the medical literature.) [PMID: 12172229]
 Krisha P, Lee D. Post-tonsillectomy bleeding: A meta-analysis, Laryngoscope. 2001;111:1358. (A
review of reports on post-tonsillectomy bleeding, the major complication of tonsillectomy.) [PMID:
11568568]
 ADENOTONSILLAR
DISEASES

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