TONSILS/PERITONSILLAR ABSCESS/TONSILLECTOMY

Waldeyer’s Ring
 Lingual tonsils, palatine tonsils, pharyngeal tonsils

Palatine tonsils
 Largest accumulation of lymphoid tissue in Waldeyer’s ring
 Compact body with a thin capsule on deep surface (capsule = portion of
pharygobasilar fascia)
 Tonsillar crypts are lined with squamous epithelium (10 – 30 per tonsil)
 Capsule is loosely adherent to the pharyngeal muscles by loose connective issue
 Tonsillar fossa: palatoglossus, palatopharyngeus, superior constrictor
o Glossopharyngeal nerve sits immediately against the outer wall of the
superior constrictor (referred otalagia via tympanic br and temporary loss
of taste over posterior 1/3 tongue)
o Arterial supply:
 Superior pole
 Ascending pharyngeal a
 Lesser palatine a
 Inferior pole
 Tonsillar br of lingual
 Ascending palatine a (br of facial)
 Tonsillar br of facial
o Nerve supply:
 Tonsillar br of glossopharyngeal n
 Descending br of lesser palatine nerves
o Lymphatic drainage
 Deep cervical lymph nodes
 Jugulodigastric/tonsillar node

Adenoids
 Pharyngeal tonsils; composed of lymphoid tissue with apex toward the nasal
septum and base toward the roof and posterior wall of the nasopharynx
 Covered by psuedostratified ciliated columnar epithelium; plicated to form
surface folds
 Become fully developed by seventh month of gestation; grow until 5th year of life;
thereafter, atrophies
o Blood supply
 Ascending pharyngeal artery
 Ascending palatine artery
 Pharyngeal br. of maxillary artery
 Artery of the pterygoid cancal
 Contributing br of the tonsillar br of the facial artery
o Venous drainage
 Pharyngeal plexus  pterygoid plexus  IJV and facial veins
 o Nerve supply
 Pharyngeal plexus
o Lymphatic drainage
 Retropharyngeal and pharyngomaxillary space lymph nodes
 Fossa of Rosenmeuller/Gerlach’s tonsil are lateral; Passavants ridge is the most
inferior aspect of the adenoid

Immuologic Function
 Adenoids and tonsils are predominantly B-cell organs
o 50 – 65% are B cells, 40% T cells, 3% mature plasma cells
o Immune-reactive lymphoid cells are found in 4 areas:
 Reticular cell epithelium
 Extrafollicular area
 Mantle zone
 Germinal centre
o Secretory immunity and regulating secretory Ig production
 Immunologically active between ages 4 to 10
 Specialized endothelium for antigen uptake
 Transport of foreign material from the exterior to the lymphoid
cells
 Produces IgA, IgG, IgM, and IgD, antibodies and B cells
 No major immunologic consequences of tonsillectomy and
adenoidecomty

Normal flora
 Actinomycoses, Fusobacterium, Nocardia, Bacteroides, Leptotrichia,
Prionibacteria, Candida
 Significant proportion of children also colonized with H. influenza, GAS,
Moraxella catarrhalis

Infections of the Waldeyer’s Ring

 Common viral: rhinovirus, influenzavirus, adenovirus, parainfluenza virus,
adenovirus, coxsackievirus, echovirus, reovirus, RSV
 EBV/mononucleosis
 Candidiasis: particularly in immunocompromised or pts already on antibiotics
 Neisseria – gonoccal pharyngitis
 Vincent’s angina – secondary to Spirochaeta denticulata and Barrelia vincentii
 Syphillis – primary and secondary syphilis (oral chancres or superificial mucous
membrane patches)
 Corynebacterium diphtheriae (diptheria)
 GAS (Streptococcus pyogenes)
o Most common cause of bacterial cause of acute pharyngitis
o Disease of childhood with peak incidence of 5 to 6 years of age
 o SS: dry throat, malaise, fever, fullness of the throat, odynophagia,
dysphagia, otaliga, headache, limb and back pain, anterior cervical
adenopathy
 Absence of cough
 Fever
Tonsilloliths
 Tonsillar concretions; arise from retained material and bacterial growth in the
tonsillar or adenoid crypts
 Halitosis, sore throat, with white, expressible foul-tasting cheesy lumps
o Use water to rinse pockets of debris
o Topical silver nitrate to tonsillar crypts
o May remove surgical removal of the tonsil

Complications of Tonsillitis
 Non-suppurative
o Scarlet fever
o Acute rheumatic fever
o Post-streptococcal glomerulonephritis
 Suppurative complications
o Peritonsillar infections
o See section on PTAs

PERITONSILLAR ABSCESS

Quick Facts:
 AKA Quinsy
 30/100,000 (4 – 5000 case in Canada/yr); most common in age 15 – 30; rare in
<12
 No sex differences
 Smoking may be a risk factor
 Almost always the consequence of acute tonsillitis
 Early recurrence rate is 10 – 15%

Pathophysiology
 Usually progress form tonsillitis to cellulitis and then to abscess formation
o GABHS is the most common bacterial cause of acute tonsillitis
 Weber’s glands (mucous salivary glands) become inflamed; local cellulites
develops; tissue necrosis and pus formation
 SS:
o Fever, malaise, headache, neck pain, throat pain, dysphagia, change in
voice, otalgia, odynophagia
 O/E
o Fever, tachycardia, dehydration
o Drooling, salivation
o Trismus
 o Hot potato/muffled voice
o Rancid or fetor breath
o Cervical lymphadenitis in the anterior chain
o Asymmetric tonsillar hypertrophy
o Local fluctuance
o Inferior and medial displacement of the tonsil
o Contralateral deviation of the uvula
o Erythema of the tonsil
o Exudates on the tonsil
 Untreated complications: erosions of the ICA, sepsis, mediatstinitis, deep neck
space infections; airway obstruction, sequelae of streptococcal infection

Causes
 Usually polymicrobial
 Most common aerobic species: Streptococcus (esp. pyogenes), S. aureus, H.
influenzae

DDx
 Peritonsillar cellulitis
 Peritonsillar phlegmon
 Retropharyngeal abscess
 Mononucleosis
 Pharyngitis
 Parapharyngeal abscess

Investigations
 Usually clinical history and examination is sufficient
 CBCD to r/o viral tonsillitis
 CT of neck with contrast if suspecting other deep space neck infections

Needle Aspiration (effective for 85% of patients)

 Spray with benzocaine

 ~ 6 – 10 cc of 1% Lidocaine with epinephrine
 16 to 18 G with 10 mL syringe
 Insert no more than 0.5 cm
 Aspirate the superior pole first
 May require incision and drainage with a No. 11 blade
o Incision are made superior and medial to the tonsil
 Have suction available
 Tongue depressor
 Usually aspirate grows GAS and anaerobic bacteria

CONTRAINDICATIONS: malignancy, vascular malformations

 COMPLICATIONS: bleeding, aspiration of contents into the patient’s airway, pain

Other management
 IV fluid resuscitation if signs of dehydration
 Antipyretics (Tylenol)
 Analgesics (Tylenol plain, or T3s - elixir)
 Antibiotic therapy (5 – 10 days)
o Penicillin VK 500 mg QID
o Metronidazole 500 mg QID
o Clindamycin 600 mg BID or 300 mg QID
o Cefuroxime 500 mg PO BID
 Dexamethasone IV single dose

TONSILLECTOMY

Indications
 Recurrent tonsillitis
o 7 episodes/yr
o 5 episodes x 2 years
o 3 episodes x 3 years
 Obstructive sleep apnea
 AAO Guidelines (2000)
o 3 tonsilitis +/- adenoids per yr despite adequate medical therapy
o hypertrophy of tonsils leading to dental malocclusion
o hypertrophy of tonsils leading to airway obstruction, severe dysphagia, sleep
disorders, or cardiopulmonary complications
o PTA unresponsive to medical management and drainage
o Persistent foul taste/breath due to chronic tonsillitis
o Chronic or recurrent tonsillitis associated with streptococcal carrier stage and
not responding to beta-lactamase resistant antibiotics
o Unilateral tonsil hypertrophy presumed neoplastic
o T&A in the setting of recurrent suppurative or otitis media with effusion plus
one of the above indications

Complications
 primary bleeding (within first 24hrs)
 secondary hemorrhage (24 hrs and 10 days)
o 1 – 3%; 0.04% require transfusion; 1 in 40,000 death
 pain, dehydration, weight loss, fever, post-op airway obstruction, pulmonary
edema (from auto-PEEP), local trauma to oral tissues, tonsillar remnants, voice
changes, night terrors

Techniques
  Intra-capsular tonsillectomy
o Microdebrider
o Suction cautery
 Harmonic scalpel
 Laser
 Cold ablation
 Adjuvant therapies:
o Dexamethasone
 Anti-emetic
 Decreases post-operative pain
 Antibiotics do not significantly reduce pain

ADENOIDECTOMY

Indications
 Airway obstruction with secondary cardiopulmonary complications and FTT
 AAO-HNS Guidelines:
o Four or more episodes of recurrent purulent rhinorrhea in prior 12 months
in a child <12. One episode documented by intranasal examination or
diagnostic imaging.
o Persisting symptoms of adenoiditis after 2 courses of antibiotic therapy.
One course of antibiotics should be with a beta-lactamase stable antibiotic
for at least 2 weeks.
o Sleep disturbance with nasal airway obstruction persisting for at least 3
months. d) Hyponasal or nasal speech
o Otitis media with effusion >3 months or second set of tubes
o Dental malocclusion or orofacial growth disturbance documented by
orthodontists
o Cardiopulmonary complications including cor pulmonale, pulmonary
hypertension, right ventricular hypertrophy associated with upper airway
obstruction.
o Otitis media with effusion over age 4

Pathophysiology
 Acts as a nidus/resevoir for chronic infection:
o Contributes to chronic or recurrent middle ear effusion
o Chronic sinusitis
o Nasal airway obstruction

Relative indications
 Obstructive sleep apnea
 Chronic nasal obstruction with rhinorrhea/recurrent sinusitis
 Recurrent otitis media with effusion
 Recurrent and chronic adenoiditis
  Speech and swallowing abnormalities
 Suspected neoplasia

Complications
 Eustachian tube injury and dysfunction
 Nasopharyngeal stenosis
 VPI
 Mild auto-PEEP (leading to pulmonary edema)

Contraindications
 VPI (esp. in the setting of cleft palate/neuromuscular disease)
 Anemia, coagulopathy/bleeding diasthesis
 Active infection
 Allergic rhinitis/respiratory allergy

Techniques (transoral approach)

 Cold surgical techniques
o Blind (mirror) curettage
o Adenoid punch
 Suction diathermy ablation and curettage
 Electrocautery with suction
 Surgical microdebrider
 Laser
 Coblation