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Common Diseases of the Tonsils and Common Diseases of the Tonsils and AdenoidsAdenoids

• Acute adenoiditis/tonsillitis

• Recurrent/chronic adenoiditis/tonsillitis

• Obstructive hyperplasia

• Malignancy

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The Nasopharyngeal TonsilThe 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

Retropharyngeal lymph nodes Upper Deep Cervical Lymph Nodes

The palatine tonsil has a capsuleon its lateral surface

which separate the lateral wall

from the bed The palatine tonsil

is covered by stratified columner epithelium

The palatine tonsil drains to The Jagulodigastric lymph nodes below the angle of the mandible 3

DEFINITIONDEFINITION• 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 ADENOIDHISTOLOGY OF ADENOIDUnlike other types of tonsils.Has pseudostratified columnar

ciliated epithelium.Lack crypts (opening or outlet) but

has a capsuleIt drains to the jugulodigastric lymph

nodes below the angle of the mandible.

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IMPORTANCE OF ADENOID IMPORTANCE OF ADENOID AND TONSILLAR TISSUE.AND TONSILLAR TISSUE.

• Part of lymphoid tissue of Waldeyer’s 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 FunctionsFormation of lymphocytesFormation of antibodiesAcquisition of immunityLocalization of infection – “filters” to

the upper respiratory passages.

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PATHOLOGYPATHOLOGY• 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.8

CLINICAL FEATURES OF ADENOID FACES IN CHILDREN.• It causes an atypical appearance of the face

(adenoid face)Features of adenoid faces includeMouth breathingElongated faceProminent incisorsHypoplastic maxillaShort upper lipElevated nostrilHigh Arched palate

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Symptoms

- Bilateral Nasal Obstruction

- Mouth Breathing- Snoring & OSA- Speech hyponasality- Difficult suckling

• Bilateral Nasal discharge- Mucoid or mucopurulent

discharge WHY? Due to blockage of the choanae

- 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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InvestigationsInvestigations

• 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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ComplicationsComplications

1- OSAS:- During Sleep:- During day time2- Descending infection3- ِ Adenoid Facies Morning headache

Impaired concentrationExcessive day-time sleepiness

Recurrent OMPharyngitis, Laryngitis, bronchitis

Restless sleep, Night mare, Nocturnal

eneuresis

Idiot lookPinched nostrilShort upper lipProminent incisorHigh arched palate

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RemovalRemoval

• Adenoidectomy – procedure of surgical removal of the adenoidStudies 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 AdenoidectomyIndications 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 AdenoidectomyIndications for AdenoidectomyObstruction:• 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 ofPreOp Evaluation of Adenoid DiseaseAdenoid 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 DiseasePreOp Evaluation of Adenoid Disease

Differential diagnosesDifferential diagnoses• Allergic rhinitis

• Sinusitis

• GERD

• For concomitant sinus disease, treat adenoids first

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PreOp Evaluation of Adenoid DiseasePreOp Evaluation of Adenoid Disease

Evaluate palateEvaluate 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 DiseasePreOp 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 DiseasePreOp Evaluation of Adenoid Disease

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Treatment Treatment

Adenoidectomy operation

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Adenoidectomy with great careAdenoidectomy with great care

Adenoidectomy for speech problemsLook 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 tonillitisAcue inflammation of the palatine tonsils

Age: Any age but common in children

Etiology :- Beta hemolyic streptococci

- Streptococcus pneumonia

- Hemophylus influenza

Mode of transmissiondroplet infection

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EmbryologyEmbryology

• 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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AnatomyAnatomy

TonsilsTonsils• Plica triangularis• Gerlach’s tonsil

AdenoidsAdenoids• Fossa of Rosenmüller• Passavant’s ridge

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Blood SupplyBlood Supply

TonsilsTonsils• Ascending and descending

palatine arteries• Tonsillar artery• 1% aberrant ICA just deep to

superior constrictor

AdenoidsAdenoids• Ascending pharyngeal,

sphenopalatine arteries

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HistologyHistologyTonsilsTonsils• Specialized squamous• Extrafollicular• Mantle zone• Germinal center

AdenoidsAdenoids• Ciliated pseudostratified

columnar• Stratified squamous• Transitional

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SymptomsRapid onset of - Fever, Headache, Anorrhexia, Malaise- Severe sore throat ± referred otagia- Halitosis

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SignsGeneral :High Fever with flushed face

PharyngealAcute follicular tonsillitisAcute membranous tonsillitisAcute parynchymatous tonsillitis

CervicalEnlarged tender jugulo-digastric

lymph nodesThe crypts of the tonsils are full of purulent exudateGiving yellow spots on the tonsils

The yellow spots may Coalease to form a Yellow membrane

Marked hyperemia and enlargement of the tonsils

Acute follicular T. Acute membranous T Acute parynchymatous T32

ComplicationsLocal:- Peritonsillar abscess- Parapharyngeal abscess- Retropharyngeal abscess

Systemic- Rheumatic fever (carditis and

arthritis)- Acute glomerulonephritis

Quinzy

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PreOp Evaluation of Tonsillar DiseasePreOp Evaluation of Tonsillar Disease

History• Documentation of episodes by physician

• FTT

• Cor pulmonale

• Poststreptococcal GN

• Rheumatic fever

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PreOp PreOp EvaluationEvaluation of Tonsillar Disease 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 DiseasePreOp 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 TonsillitisChronic TonsillitisChronic inflammation of the palatine tonsilsChronic 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 AdenotonsillitisAcute AdenotonsillitisEtiology

• 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 AdenotonsillitisMicrobiology of AdenotonsillitisMost 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 AdenotonsillitisAcute Adenotonsillitis

Differential diagnosisInfectious mononucleosisMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis

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Medical ManagementMedical 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 DiseasePreOp Evaluation for Adenotonsillar Disease

Coagulation disordersCoagulation disorders• Historical screening

• CBC, PT/PTT, BT, vWF activity

• Hematology consult

• von Willebrand’s disease

• ITP

• Sickle cell anemia

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Principles of Surgical ManagementPrinciples of Surgical Management

Numerous techniques:• Guillotine

• Tonsillotome

• Beck’s snare

• Dissection with snare (Scissor dissection, Fisher’s knife dissection, Finger dissection

• Electrodissection

• Laser dissection (CO2, KTP)

… Surgeon’s preference

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Post Operative ManagmentPost Operative ManagmentCriteria 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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ComplicationsComplications#1 Postoperative bleeding

Other:• Sore throat, otalgia, uvular swelling

• Respiratory compromise

• Dehydration

• Burns and iatrogenic trauma

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Rare ComplicationsRare Complications• Velopharyngeal Insufficiency

• Nasopharyngeal stenosis

• Atlantoaxial subluxation/ Grisel’s syndrome

• Regrowth

• Eustachian tube injury

• Depression

• Laceration of ICA/ pseudoaneursym of ICA

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Management of HemorrhageManagement of Hemorrhage

• Ice water gargle, afrin

• Overnight observation and IV fluids

• Dangerous induction

• ECA ligation

• Arteriography

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Obstructive HyperplasiaObstructive 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 EnlargementUnilateral Tonsillar EnlargementApparent enlargement vs true enlargement

Non-neoplastic:

• Acute infective

• Chronic infective

• Hypertrophy

• Congenital

Neoplastic

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Peritonsillar Abscess 52

Pleomorphic AdenomaPleomorphic Adenoma53

Other Tonsillar PathologyOther Tonsillar Pathology

• Hyperkeratosis, mycosis leptothrica

• Tonsilloliths

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Candidiasis55

SyphilisSyphilis56

Retention CystsRetention Cysts57

Supratonsillar CleftSupratonsillar Cleft58

Indications for Tonsillectomy; Historical Indications for Tonsillectomy; Historical EvolutionEvolution

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Indications for TonsillectomyIndications 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 TonsillectomyIndications for TonsillectomyAAO-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 studyCase study• 13 year old female referred by PCP

for frequent throat infections

• “She’s always sick. She’s been on four different antibiotics this year.”

• You call her pediatrician… he is out of town and his nurse can’t find the chart

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Case studyCase 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 studyCase 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 I’ve missed so much work from her being out sick.”

• You hesitate. She adds, “Her grades have dropped from all A’s to all F’s. If she misses any more school, she’ll be held back.”

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Case studyCase 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 studyCase 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 studyCase 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 studyCase 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 studyCase 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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