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Definition: Almond shaped, ovoid mass of lymphoid

tissue situated bilaterally in the lateral wall of oropharynx


within the tonsilar recess or sinus bounded by
palatoglossal fold anteriorly i.e. anterior pillar and
palatopharyngeal fold posteriorly i.e. posterior pillar. They
belong to MALT (Mucosa Associated Lymphoid Tissue).
Size: Variable, 10-15 mm intransverse diameter and 20-25
mm in vertical dimension (larger in children)
Surface marking: An almond shaped area over the lower
part of masseter muscle, a little above and in front of the
angle of mandible marks the tonsil on the surface.
Parts:
A) 2 Surfaces:
1. Medial surface:
Lined by non-keratinizing stratified squamous
epithelium which is continuous with that of
palatoglossal fold and tongue
Mucosa invaginates into the substance of tonsil to
form 12-15 tonsillar crypts
Largest crypt known as crypta magna or intratonsillar
cleft opens near the upper part (represents ventral part
of 2nd pharyngeal pouch)
Crypts increase the surface area of tonsil
2. Lateral surface:
Covered by tonsillar hemicapsule formed by the
condensation of pharyngobasillar fascia which extend
into the tonsil to form septa that conduct nerves and
vessels
Tonsillar bed is separated from the capsule by loose
areolar tissue which formsperitonsillar space
Palatine/External palatine/Paratonsillar vein descends
from palate in the loose areolar tissue
Capsule is firmly attached anteroinferiorly to the side of
the tongue, just in front of the insertion of palatoglossus
and palatopharyngeus muscle
Tonsillar artery enters near this firm attachment

B) 2 Poles:
1. Upper pole:
Extends into soft palate
Plica semilunaris: Semilunar fold of mucous membrane
which extends from the anterior pillar to posterior pillar
and covers the medial part of upper pole
Supratonsillar fossa: Potential space enclosed by the
semilunar fold
2. Lower pole:
Attached to the tongue
Triangular fold: of mucous membrane extends from
anterior tonsillar pillar to the lower pole
Anterior tonsillar space: Potential space enclosed by
the triangular fold
Tonsillolingual sulcus: separates tongue from the lower
pole and is a seat of carcinoma
C) 2 Borders:
1. Anterior border: related to palatoglossal arch (anterior
tonsillar pillar)
2. Posterior border: related to palatopharyngeus arch
(posterior tonsillar pillar)
Bed of Tonsil:
From within outwards, tonsillar bed consists of:
1. Pharyngobasillar fascia
2. In upper and posterior part: Palatopharyngeus muscle
3. In postero-superior 2/3 rd: Superior constrictor muscle
4. In antero-inferior 1/3 rd: Styloglossus muscle
accompanied by glossopharyngeal nerve (CN IX)

Relations of tonsillar bed:


1. Arteries:
Facial artery and its ascending palatine branch
Ascending pharyngeal artery
Internal carotid artery (lies about 25 mm behind and
lateral to the tonsil)
2. Styloid process (if enlarged)
3. Submandibular salivary gland
4. Medial pterygoid muscle
5. Angle of mandible
Tonsils maintain its position:
1. By the suspensory ligament of the tonsils it is connected
with the tongue
2. The palatoglossus and palatopharyngeus muscles
attached to the fibrous capsules of the tonsils
3. By the perivascular stalks
Arterial supply: 5 arteries

1. Anterior tonsillar artery (1): from dorsal lingual branches


of lingual artery
2. Posterior tonsillar artery (2): from ascending palatine
branch of facial, and ascending pharyngeal arteries
3. Superior tonsillar artery (1): from greater palatine
branch of maxillary artery
4. Inferior tonsillar artery (1; main artery): from facial
artery
Venous drainage:
1. Tonsillar vein Common facial vein

2. Paratonsillar vein Pharyngeal venous plexus or


Common facial vein Internal Jugular Vein (IJV)
Lymphatic drainage:
Upper deep cervical lymph nodes: Also known as tonsillar
lymph nodes
Nerve supply:
1. Glossopharyngeal nerve (CN IX)
2. Greater and lesser palatine nerve (CN V)
Waldeyers ring:

This is a ring of lymphatic


tissue at the beginning of food and air passages (in the
nasopharynx and oropharynx). The ring is composed of
MALT which is characterized by the close approximation
of epithelium and lymphatic tissue. The components are:
1. Palatine tonsils (largest) on either side on lateral wall of
oropharynx
2. Nasopharyngeal tonsil (adenoids) on the posterior wall of
nasopharynx
3. Tubal tonsils on lateral walls of nasopharynx
4. Lingual tonsils on the dorsum of posterior 1/3 of tongue
in the floor of oropharynx
Embryology:
1. 2nd pharyngeal pouch endoderm: Mucosa and crypts
2. Surrounding mesenchyme tissue: Lymphoid tissue
Functions of tonsil:

The activity of this lymphatic organ is especially


pronounced during childhood, when immunologic
challenges from the environment induce hyperplasia of the
palatine tonsils. Following this active phase of immune
initiation, which lasts until about 810 years of age, the
lymphatic tonsillar tissue becomes less important as an
immune organ, and there is a corresponding decline in the
density of lymphocytes in all regions of the tonsils. While
the tonsils become less important immunologically with
ageing, the tonsillar tissue continues to perform
immune functions even at an advanced age, although
this should not alter the decision to remove the tonsils if
a valid indication for tonsillectomy exists.
Difference between Adenoid and Tonsil:
Adenoid
Tonsil
Non-keratinizing squamous
Ciliated columnar epithelium epithelium
No capsule
Hemicapsule
Has furrows
Has crypts
Peak growth: 6 years
8 years
Growth stops: 12 years
15 years
Disappears: 20 years
Partial regression: 18 years
Difference between Tonsil and Lymph node:
Tonsil
Lymph node
Subepithelial
Connective tissue
Hemicapsule
Fully encapsulated
Efferent only
Afferent and Efferent
Crypts present
Absent
Cortex or medulla absent
Present
Growth curve present
absent
Applied anatomy:
1. Accumulation of pus in in the peritonsillar space in
chronic tonsillitis gives rise toperitonsillar abscess or
quinsy. It is drained by an incision in the most prominent
part of the abscess where softening can be felt.
2. Jugulo-digastric lymph node is often enlarged in
tonsillitis.

3. Tonsils prevent infection but when these are infected,


acts as septic foci of the body which require surgical
removal.
4. Peritonsillar space is the plane of dissection during
tonsillectomy.
5. In tonsillectomy, the tonsil is dissected out along with its
capsule from its bed.
6. Internal carotid artery, although only 1 inch (2.5cm)
behind the tonsil, is never injured in this operation since it
lies safely freed from the pharynx by fatty tissue around
the carotid sheath.
7. Almost always in surgery, clots are not removed to
prevent hemorrhage, but this rule doesnt apply to tonsils
and uterus. After tonsillectomy, blood clots present in the
tonsillar fossa are removed. This is done to prevent postoperative hemorrhage because the clots in the tonsillar
fossa interfere with the retraction of vessel walls by
preventing the contraction of surrounding muscles i.e. the
muscles forming boundaries of the tonsillar fossa.
8. Ligature of the tonsillar arteries specially inferior
tonsillar artery is important during tonsillectomy.
9. During tonsillectomy, paratonsillar vein may be
damaged causing excessive hemorrhage.
10. Referred pain from the tonsils sometimes may radiate
into the middle ear due to common nerve supply (CN IX).
11. After tonsillectomy, glossopharyngeal nerve may be
affected which causes loss of taste sensation.