CHAPTER II

LITERATURE REVIEW

A. ANATOMY
A ring of lymphoid tissue surrounds the nasopharynx and
oropharynx. These lymphoid tissue are collectively known as the
Waldeyers Ring. It consists of pharyngeal tonsil (adenoid), palatine tonsil
(faucial), lingual tonsil, and tubal tonsil (Gerlachs tonsil) (Soepardi, et al.,
2012).
Palatine tonsil is a huge lymphoid mass that lodge in the tonsillary
fossa on either side of oropharynx. The tonsillar fossa lies between two
pillars, anterior and posterior pillars. The anterior pillar is formed by
palatoglossus muscle, while the posterior pillar is formed by
palatopharyngeus muscle. It is almond-shaped with 2-5 cm in length. Each
tonsil has 10-30 crypts that expands into the tonsillar tissue. This
lymphoid tissue, however, does not fill all the space between the arches.
So, a small depression, also known as supratonsillar fossa occupies this
region (Moore and Dalley, 2007). Palatine tonsil is confined by superior
pharyngeal constrictor muscle laterally, palatoglossus muscle anteriorly,
palatopharyngeal muscle posteriorly, palatum molle superiorly, and lingual
tonsil inferiorly. Microscopically, the tonsil consists of three components:
connective tissue, germinative follicle (lymphoid cell), and interfollicle
tissue (consists of lymphoid tissue) (HTA, 2004).
The tonsillar fossa is composed of three muscle: palatoglossus
muscle that forms the anterior pillar, palatopharyngeal muscle that forms
the posterior pillar, and superior constrictor muscle that formsthe tonsillar
bed (Campisi & Twfik, 2003). Anterior pillar is fan-shaped structure located
inside oral cavity, starting from soft palate to lateral side of tongue.
Posterior pillar is a vertical muscle that reach soft palate, Eustachius tube
and cranial base, and extend downward to lateral esophageal wall,
furthermore extra caution must be taken during tonsillectomy as to not
injuring the posterior pillar (HTA, 2004).
Lateral surface of the tonsil is covered by connective tissue
membrane called capsule. Althought the anatomist deny the existence of
this capsule, the clinicans state that this capsule is a white connective
tissue that cover 4/5 part of the tonsil (HTA,2004).
The medial surface of the tonsil is free and faces the oropharynx. It
is covered by non keratizing stratified squamous epithelium which is
continous with that of the lining of the oropharynx. A triangular fold of
mucous membrane extends back from the palatoglossal fold to cover the
anterior inferior part of the tonsil. This fold is known as plica triangularis.
In childhood, this fold is usually invaded by lymphoid tissue and becames
incorporated into the tonsil. The mucous plica that passes throught the
supratonsillar fossa, between the two arches, is called plica semilunaris,
and the continuation of this plica is called plica triangularis (Jacomo et al,
2010).

The main artery of the tonsil is tonsillar artery, branch from the
external maxillary which enter the tonsil near its lower pole by piercing the
superior constrictor muscle just above the styloglossus muscle. Other
arteries supplying the tonsil are lingual artery through its dorsal lingual
branches, ascending palatine branch of facial artery and tonsillar branch
of ascending pharyngeal artery (Jacomo et al, 2010). Anterior part of the
lower pole of tonsil is vascularized by dorsal lingual artery, while the
posterior part is vascularized by ascending palatine artery. Between two of
those area is vascularized by tonsillaris artery. Upper pole of tonsil is
vascularized by ascending pharyngeal artery and descending palatine
artery (HTA, 2004).
Venous drainage from the tonsil occurs mainly by the external
palatine vein which directs to the pharyngeal plexus (Jacomo et al, 2010).
Venous drainage occurs through the paratonsillar vein, and the vessels
also pass through the pharyngeal plexus or facial vein after piercing the
superior constrictor pharynx muscle, which in turn drain into internal
jugular vein (HTA, 2004; Campisi & Tewfik, 2003).
Lymphatic vessel of the palatine tonsil usually 3-5 in number,
emerge from the pharyngeal wall pierce through the buccopharyngeal
fascia and pass to the upper deep cervical group of nodes (mostly
jugulodigastricus lymph nodes) under the sternocleidomastoid muscle
which then drain into thoracic duct (Rouviere, 1981). Tonsil has only
efferent lymphatic vessel with no afferent vessel (HTA, 2004).
The nerve supply of the tonsillar region is through the tonsillar
branches of the glossopharyngeal nerve and the descending branches of
the lesser palatine nerve. The cause of referred otalgia with tonsillitis is
through the tymphanic branch of the plossopharyngeal nerve (Campisi &
Tewfik, 2003).
Tonsil is a secondary limphatic organ which is need for
differentiation and proliferation of semsitized lymphocyte. It has two main
function, (1) trap and collect foreign material effectively, (2) main organ
that produce antibody and sensitize T lymhocyte with specific antigen
(HTA, 2004)
The adenoid also known as the pharyngeal tonsil are a part of
lymphatic system located in the superior and posterior wall of the
nasopharynx. It is made up of folded lymphatic tissue lined with epithelial
cells, mucosal glands, and are covered in cillia and mucous. Adenoid is
unencapsulated, lack of crypts and includes afferent and efferent
lymphatics. Adenoid will reach full size at some point during early
childhood (3-7 years old) and then diminish again in size prior to
adulthood (14 years old) (HTA, 2004; Soepardi et al, 2012).
B. CHRONIC TONSILITIS