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Common Diseases of the Tonsils and

Adenoids
Acute adenoiditis/tonsillitis
Recurrent/chronic adenoiditis/tonsillitis
Obstructive hyperplasia
Malignancy

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 The Nasopharyngeal Tonsil
It is a mass of sub-epithelial
lymphoid tissue present at the
junction between the roof &
posterior wall of the
nasopharynx
The free surface has 6 folds
It has no capsule
It is covered by pseudo-
stratified columner epithelium
It drains to the The palatine tonsil has a capsule
on its lateral surface
Retropharyngeal lymph nodes which separate the lateral wall
Upper Deep Cervical Lymph from the bed
Nodes The palatine tonsil
is covered by stratified
columner epithelium

The palatine tonsil drains to

The Jagulodigastric lymph nodes
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below the angle of the mandible
DEFINITION
Adenoid =pharyngeal tonsil = Nasopharyngeal
Mass of sub epithelial lympoid tissue
situated posterior to the nasal cavity in the roof
of the nasopharynx
In children it forms a soft mound in the roof
and posterior wall of the nasopharynx, above
and behind the uvula.
Age enlargement from less than a year old to
12 years.

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HISTOLOGY OF ADENOID
Unlike other types of tonsils.
Has pseudostratified columnar
ciliated epithelium.
Lack crypts (opening or outlet) but
has a capsule
It drains to the jugulodigastric lymph
nodes below the angle of the
mandible.
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IMPORTANCE OF ADENOID AND
TONSILLAR TISSUE.
Part of lymphoid tissue of Waldeyers
ring
Its size increases progressively until
puberty, then diminishes until about
the age of 20 years and from this
time onwards, maintains its adult
size.
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 Protective Functions
Formation of lymphocytes
Formation of antibodies
Acquisition of immunity
Localization of infection filters to
the upper respiratory passages.

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PATHOLOGY
An enlarged adenoid or adenoid
hypertrophy, can become nearly the size of
a ping pong ball.
Completely block airflow through the nasal
passages or block the back of the nose.
1. Breathing through the nose requiring an
uncomfortable amount of work.
2. Inhalation occurs instead through an open mouth.
3. Affects voice mechanism (speech hyponasality)
4. Recurrent upper respiratory tract infection.
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CLINICAL FEATURES OF ADENOID
FACES IN CHILDREN.
It causes an atypical appearance of the face
(adenoid face)
Features of adenoid faces include
Mouth breathing
Elongated face
Prominent incisors
Hypoplastic maxilla
Short upper lip
Elevated nostril
High Arched palate
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Symptoms
Bilateral Nasal
- Bilateral Nasal discharge
Obstruction - Mucoid or mucopurulent
- Mouth Breathing discharge WHY? Due to
- Snoring & OSA blockage of the choanae
- Speech hyponasality
- Difficult suckling - Excoriation of the nasal
vestibule & upper lip

- Post nasal discharge causing

frequent nocturnal cough
Rhinolalia clausa
(speech hyponasality)

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Signs
Posterior Rhinoscopy difficult
Digital palpation not pleasant
Endoscopic examination the best

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 Investigations
Lateral soft tisue X ray of
the nasopharynx
It is not the size of the
nasopharyngeal tonsil which is
important but the size of the
mass in relation to the
nasopharyngeal space

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Complications
1- OSAS: Restless sleep,
- During Sleep: Night mare, Nocturnal
- During day time
eneuresis
2- Descending infection
3- Adenoid Facies Morning headache
Impaired concentration
Excessive day-time sleepiness

Recurrent OM
Pharyngitis, Laryngitis, bronchitis

Idiot look
Pinched nostril
Short upper lip
Prominent incisor
High arched palate
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Removal
Adenoidectomy procedure of surgical
removal of the adenoid
Studies have shown that adenoid regrowth
occurs in as many as 20% of the cases after
removal. Why?
Adenoid tissue is not encompassed by a
capsule like the tonsils. Complete removal of
all adenoid tissue is nearly impossible and thus
recurrent hypertrophy or infection is possible.

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Indications for Adenoidectomy
Paradise study (1984)
28-35% fewer acute episodes of OM with adenoidectomy in
kids with previous tube placement
Adenoidectomy or T & A not indicated in children with
recurrent OM who had not undergone previous tube placement
Gates et al (1994)
Recommend adenoidectomy with M & T as the initial surgical
treatment for children with MEE > 90 days and CHL > 20 dB

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Indications for Adenoidectomy
Obstruction:
Chronic nasal obstruction or obligate mouth breathing
OSA with FTT, cor pulmonale
Dysphagia
Speech problems
Severe orofacial/dental abnormalities
Infection:
Recurrent/chronic adenoiditis (3 or more episodes/year)
Recurrent/chronic OME (+/- previous BMT)

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 PreOp Evaluation of Adenoid Disease
Triad of hyponasality,
snoring, and mouth
breathing
Rhinorrhea, nocturnal
cough, post nasal drip
Adenoid facies
Milkman & Micky
Mouse
Overbite, long face,
crowded incisors
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PreOp Evaluation of Adenoid Disease
Differential diagnoses
Allergic rhinitis
Sinusitis
GERD
For concomitant sinus disease, treat
adenoids first

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PreOp Evaluation of Adenoid Disease
Evaluate palate
Symptoms/FH of CP or
VPI
Midline diastasis of
muscles, bifid uvula
CNS or neuromuscular
disease
Preexisting speech
disorder?

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PreOp Evaluation of Adenoid Disease
Lateral neck films are
useful only when
history and physical
exam are not in
agreement.
Accuracy of lateral
neck films is
dependent on proper
positioning and
patient cooperation.
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PreOp Evaluation of Adenoid Disease

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Treatment
Adenoidectomy operation

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Adenoidectomy with great care
Adenoidectomy for speech problems
Look for short palate, submucous cleft of the
short or hard palate to avoid velopharyngeal
insufficiency after the procedure as the voice
may become hypernasal.
Should be avoided in patients with cleft
palate.

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Acute tonillitis
Acue inflammation of the palatine tonsils

Age: Any age but common in children

Etiology :
- Beta hemolyic streptococci
- Streptococcus pneumonia
- Hemophylus influenza

Mode of transmission
droplet infection

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Embryology
8 weeks: Tonsillar fossa and palatine tonsils
develop from the dorsal wing of the 1st
pharyngeal pouch and the ventral wing of the
2nd pouch; tonsillar pillars originate from
2nd/3rd arches
Crypts 3-6 months; capsule 5th month;
germinal centers after birth
16 weeks: Adenoids develop as a subepithelial
infiltration of lymphocytes

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 Anatomy
Tonsils
Plica triangularis
Gerlachs tonsil
Adenoids
Fossa of Rosenmller
Passavants ridge

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Blood Supply
Tonsils
Ascending and descending
palatine arteries
Tonsillar artery
1% aberrant ICA just deep to
superior constrictor
Adenoids
Ascending pharyngeal,
sphenopalatine arteries

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Histology
Tonsils
Specialized squamous
Extrafollicular
Mantle zone
Germinal center
Adenoids
Ciliated pseudostratified
columnar
Stratified squamous
Transitional

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Symptoms
Rapid onset of
- Fever, Headache, Anorrhexia, Malaise
- Severe sore throat referred otagia
- Halitosis

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Signs
General :
High Fever with flushed face

Pharyngeal
Acute follicular tonsillitis
Acute membranous tonsillitis
Acute parynchymatous tonsillitis
Cervical
Enlarged tender jugulo-digastric
lymph nodes
The crypts of the tonsils
are full of purulent exudate
Giving yellow spots on the
Marked hyperemia and tonsils
enlargement of the tonsils
The yellow spots may
Coalease to form a
Yellow membrane
Acute follicular T. Acute membranous T Acute parynchymatous T32
Complications
Local:
- Peritonsillar abscess
- Parapharyngeal abscess
- Retropharyngeal abscess
Systemic
- Rheumatic fever (carditis and
arthritis)
- Acute glomerulonephritis

Quinzy

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PreOp Evaluation of Tonsillar Disease

History
Documentation of episodes by physician
FTT
Cor pulmonale
Poststreptococcal GN
Rheumatic fever

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PreOp Evaluation of Tonsillar Disease
TONSIL SIZE
0 in fossa
+1 <25% occupation
of oropharynx
+2 25-50%
+3 50-75%
+4 >75%

Avoid gagging the patient

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PreOp Evaluation of Tonsillar Disease
Down syndrome
10% have AA laxity
Obtain lateral cervical films (flexion/extension) when
positive findings on history, PE
If unstable, need neurosurgical evaluation
preoperatively
Large tongue and small mandible difficult
intubation
Prone to cardiac arrhythmias/hypotension during
induction
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 Treatment

Antibiotics: 10 days
Rest
Ample fluid intake
Cold compresses
Analgesic Antipyretics
Gargles

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Chronic Tonsillitis
Chronic inflammation of the palatine tonsils

Etiology :
Repeated attacks of acute tonsillitis
Symptoms: one or more of the following
- History of repeated attacks of AT
- Irritation in the throat
- Foetor oris
If hypertrophic
- Difficult swallowing
- Obsrtuctive sleep apnea
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Signs:
Pharyngeal
- Asymmetry of the size of the
tonsils
- Hypertrophy of the tonsils
- The crypts ooze pus on
pressure by tongue depressor
- Hyperaemia of the anterior
pillars
Cervical
Persistent enlargement of
jagulodigastric lymph nodes

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 Acute Adenotonsillitis
Etiology
5-30% bacterial; of these
39% are beta-lactamase-
producing (BLPO)
Anaerobic BLPO
GABHS most important
pathogen because of
potential sequelae
Throat culture
Treatment
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Microbiology of Adenotonsillitis
Most common organisms cultured from patients with
chronic tonsillar disease (recurrent/chronic infection,
hyperplasia):
Streptococcus pyogenes (Group A beta-hemolytic
streptococcus)
H.influenza
S. aureus
Streptococcus pneumoniae
Tonsil weight is directly proportional to bacterial
load.

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Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis
Malignancy: lymphoma, leukemia,
carcinoma
Diptheria
Scarlet fever
Agranulocytosis

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Medical Management
PCN is first line, even if throat culture is negative
for GABHS
For acute UAO: NP airway, steroids, IV abx, and
immediate tonsillectomy for poor response
Recurrent tonsillitis: PCN injection if concerned
about noncompliance or antibiotics aimed against
BLPO and anaerobes
For chronic tonsillitis or obstruction, antibiotics
directed against BLPO and anaerobes for 3-6 weeks
will eliminate need for surgery in 17%

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PreOp Evaluation for Adenotonsillar Disease

Coagulation disorders
Historical screening
CBC, PT/PTT, BT, vWF activity
Hematology consult
von Willebrands disease
ITP
Sickle cell anemia

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Principles of Surgical Management
Numerous techniques:
Guillotine
Tonsillotome
Becks snare
Dissection with snare (Scissor dissection, Fishers
knife dissection, Finger dissection
Electrodissection
Laser dissection (CO2, KTP)
Surgeons preference
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Post Operative Managment
Criteria for Overnight Observation
Poor oral intake, vomiting, hemorrhage
Age < 3
Home > 45 minutes away
Poor socioeconomic condition
Comorbid medical problems
Surgery for OSA or PTA
Abnormal coagulation values (+/- identified disorder)
in patient or family member

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Complications
#1 Postoperative bleeding
Other:
Sore throat, otalgia, uvular swelling
Respiratory compromise
Dehydration
Burns and iatrogenic trauma

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Rare Complications
Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation/ Grisels syndrome
Regrowth
Eustachian tube injury
Depression
Laceration of ICA/ pseudoaneursym of ICA

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Management of Hemorrhage
Ice water gargle, afrin
Overnight observation and IV fluids
Dangerous induction
ECA ligation
Arteriography

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Obstructive Hyperplasia
Adenotonsillar hypertrophy most
common cause of SDB in children
Diagnosis
Indications for polysomnography
Interpretation of polysomnography
Perioperative considerations

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Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
Acute infective
Chronic infective
Hypertrophy
Congenital
Neoplastic

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Peritonsillar Abscess 52
Pleomorphic Adenoma
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Other Tonsillar Pathology
Hyperkeratosis,
mycosis leptothrica
Tonsilloliths

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Candidiasis
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Syphilis 56
Retention Cysts 57
Supratonsillar Cleft 58
Indications for Tonsillectomy; Historical
Evolution

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Indications for Tonsillectomy
Paradise study
Frequency criteria: 7 episodes in 1 year
or 5 episodes/year for 2 years or 3
episodes/year for 3 years
Clinical features (one or more): T 38.3,
cervical LAD (>2cm) or tender LAD;
tonsillar/pharyngeal exudate; positive
culture for GABHS; antibiotic treatment
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Indications for Tonsillectomy
AAO-HNS:
3 or more episodes/year
Hypertrophy causing malocclusion, UAO
PTA unresponsive to nonsurgical mgmt
Halitosis, not responsive to medical therapy
UTE, suspicious for malignancy
Individual considerations

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Case study
13 year old female referred by PCP
for frequent throat infections
Shes always sick. Shes been on
four different antibiotics this year.
You call her pediatrician he is out
of town and his nurse cant find the
chart
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Case study
No known medical problems, no prior
surgical procedures
Takes motrin for menustrual cramps
No personal history of bleeding other than
occasional nose bleeds and extremely
heavy periods.
Family history unknown. Patient is
adopted.
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Case study
Physical exam is unremarkable.
Mom breaks down in tears when you tell her
you do not have enough documentation of
illness to warrant T & A. I had to go on
welfare because Ive missed so much work
from her being out sick.
You hesitate. She adds, Her grades have
dropped from all As to all Fs. If she misses
any more school, shell be held back.

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Case study
You confirm with her pediatrician that she
has had 4 episodes of tonsillitis this year and
agree to T & A.
Because of her history of epistaxis and
menorrhagia, you order a PT, PTT, CBC,
BT.
She has a mild microcytic anemia and
prolonged bleeding time.
You order vWF activity level and consult
hematology
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Case study
She has a subnormal level of vWF, which
responds to a DDAVP challenge (rise in
vWF and Factor VII greater than 100%).
You advise her to stop taking motrin.
Before surgery, she receives
desmopressin 0.3 microg/kg IV over 30
min and amicar 200mg/kg.

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Case study
She receives the same dose of DDVAP 12
hours postoperatively and every morning.
Amicar is given 100mg/kg PO q 6 hr.
Before each dose of DDAVP, serum
sodium is drawn. Sodium levels drop to
130.
Desmopressin is discontinued and
substituted with cryoprecipitate.
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Case study
Patient presents to the ER on POD # 7
complaining of intermittent bleeding from
her mouth.
You order cryoprecipitate, draw a Factor
VII level and CBC, and call her
hematologist.
Hemoglobin has dropped from 11.9 to 9.6.

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Case study
PE reveals no active bleeding; an old clot
is present
You establish IV access, admit the patient
for overnight observation, have her gargle
with ice water, and administer
crypoprecipitate
No further bleeding occurs, patient is
discharged the next day
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