The tonsils are 3 masses of tissue:
- lingual tonsil
- pharyngeal (adenoid) tonsil
- palatine or fascial tonsil
Together they form Waldeyer's ring
are lymphoid tissue
covered by respiratory epithelium
- pseudostratified ciliated
produce lymphocytesproduce lymphocytes
are active in theare active in the synthesis of immunoglobulinssynthesis of immunoglobulins
a ring of lymphoid tissue in the oropharynx anda ring of lymphoid tissue in the oropharynx and
are the first lymphoid aggregates in theare the first lymphoid aggregates in the
aerodigestive tract – thought to play a role inaerodigestive tract – thought to play a role in
Normal TonsilsNormal Tonsils
are located laterally in the oropharynx
are bordered by the following tissues:
- Deep - Superior constrictor muscle
- Anterior - Palatoglossus muscle
- Posterior - Palatopharyngeus muscle
- Superior - Soft palate
- Inferior - Lingual tonsil
Blood supplyBlood supply
through the externalthrough the external
carotid artery branches:carotid artery branches:
Superior poleSuperior pole
Ascending pharyngeal arteryAscending pharyngeal artery
(tonsilar branches)(tonsilar branches)
Lesser palatine arteryLesser palatine artery
Inferior poleInferior pole
Facial artery branchesFacial artery branches
Dorsal lingual arteryDorsal lingual artery
Ascending palatine arteryAscending palatine artery
Venous outflowVenous outflow - by the plexus around the- by the plexus around the
tonsilar capsule, the lingual vein, and thetonsilar capsule, the lingual vein, and the
pharyngeal plexus.pharyngeal plexus.
Lymphatic drainageLymphatic drainage - the superior deep- the superior deep
cervical nodes, the jugulodigastric nodes.cervical nodes, the jugulodigastric nodes.
Sensory supplySensory supply - the glossopharyngeal nerve,- the glossopharyngeal nerve,
the lesser palatine nervethe lesser palatine nerve
Anatomic & physiologic diff btn normal Adenoid
1.Anatomic location posterior wall of
lateral wall of oropharynx
2.Gross Triangular shape
3.microscopic Transitional antigen
No afferent fibers
No afferent fibers
4.physiology Muciliary clearance
Tonsillitis is inflammation of the pharyngealTonsillitis is inflammation of the pharyngeal
The inflammation usually extends to theThe inflammation usually extends to the
adenoid and the lingual tonsils; therefore, theadenoid and the lingual tonsils; therefore, the
term pharyngitis may also be used.term pharyngitis may also be used.
Lingual tonsillitis refers to isolated inflammationLingual tonsillitis refers to isolated inflammation
of the lymphoid tissue at the tongue base.of the lymphoid tissue at the tongue base.
Pathophysiology and Etiology
Viral or bacterial infectionsViral or bacterial infections andand immunologic factorsimmunologic factors lead tolead to
tonsillitis and its complications. Overcrowded conditions andtonsillitis and its complications. Overcrowded conditions and
malnourishment promote tonsillitis. Most episodes of acutemalnourishment promote tonsillitis. Most episodes of acute
pharyngitis and acute tonsillitis are caused by viruses such aspharyngitis and acute tonsillitis are caused by viruses such as
the following:the following:
Herpes simplex virusHerpes simplex virus
Epstein-Barr virus (EBV)Epstein-Barr virus (EBV)
Other herpes virusesOther herpes viruses
Measles virusMeasles virus 13
Bacteria cause 15-30% of cases of pharyngotonsillitis.
Anaerobic bacteria play an important role in tonsillar
Most cases of bacterial tonsillitis are caused by group A
beta-hemolytic Streptococcus pyogenes (GABHS).
S pyogenes adheres to adhesin receptors that are located
on the tonsillar epithelium.
Immunoglobulin coating of pathogens may be important in
the initial induction of bacterial tonsillitis.
Mycoplasma pneumoniaeMycoplasma pneumoniae,, Corynebacterium diphtheriaeCorynebacterium diphtheriae,,
andand Chlamydia pneumoniaeChlamydia pneumoniae rarely cause acute pharyngitis.rarely cause acute pharyngitis.
Neisseria gonorrheaNeisseria gonorrhea may cause pharyngitis in sexually activemay cause pharyngitis in sexually active
Arcanobacterium haemolyticumArcanobacterium haemolyticum is an important cause ofis an important cause of
pharyngitis in Scandinavia and the United Kingdom but ispharyngitis in Scandinavia and the United Kingdom but is
not recognized as such in the United States.not recognized as such in the United States.
A rash similar to that of scarlet fever accompanies AA rash similar to that of scarlet fever accompanies A
haemolyticum pharyngitis.haemolyticum pharyngitis.
ACUTE TONSILITISACUTE TONSILITIS
This is the commonest URTI in children.This is the commonest URTI in children.
Occurs up to the age of 15Occurs up to the age of 15
Its common in all sexesIts common in all sexes
Viral: HSV, EBV,CMV, Adenovirus, Measles.Viral: HSV, EBV,CMV, Adenovirus, Measles.
Bacteral: anaerobes, group A beta hemolyticBacteral: anaerobes, group A beta hemolytic
strepto pyogens, mycoplasma, chlamydia,strepto pyogens, mycoplasma, chlamydia,
ACUTE TONSILLITIS-TYPESACUTE TONSILLITIS-TYPES
Acute catarrhal/superficialAcute catarrhal/superficial here tonsillitis is a part ofhere tonsillitis is a part of
generalized pharyngitis, mostly seen in viral infectionsgeneralized pharyngitis, mostly seen in viral infections
Acute follicularAcute follicular infection spread into the crypts withinfection spread into the crypts with
purulent material, presenting at the opening of crypts aspurulent material, presenting at the opening of crypts as
yellow spotsyellow spots
Acute parenchymatousAcute parenchymatous tonsil in uniformly enlarged andtonsil in uniformly enlarged and
Acute membranousAcute membranous follows stage of acute follicularfollows stage of acute follicular
tonsillitis where exudates coalesce to form membrane ontonsillitis where exudates coalesce to form membrane on
the surfacethe surface
Coated tongueCoated tongue
Congestion of pillars, soft palate andCongestion of pillars, soft palate and
Jugulo-digastric nodes enlarged andJugulo-digastric nodes enlarged and
Tonsils are congested and enlargedTonsils are congested and enlarged
depending on type of acute tonsillitisdepending on type of acute tonsillitis
Bed restBed rest
Plenty of oral fluidsPlenty of oral fluids
Antimicrobial therapyAntimicrobial therapy penicillinpenicillin
In case of penicillin sensitivityIn case of penicillin sensitivity
macrolides are givenmacrolides are given
DIFFERENTIAL DIAGNOSIS OF MEMBRANE
OVER THE TONSIL
CHRONIC TONSILLITISCHRONIC TONSILLITIS
Complication of acute tonsillitisComplication of acute tonsillitis
Sub clinical infection of tonsilSub clinical infection of tonsil
Chronic sinusitis or dental sepsisChronic sinusitis or dental sepsis
Mostly affects children and youngMostly affects children and young
TYPES OF CHRONIC TONSILLITISTYPES OF CHRONIC TONSILLITIS
Chronic follicular tonsillitisChronic follicular tonsillitis
Chronic parenchymatous tonsillitisChronic parenchymatous tonsillitis : tonsils: tonsils
are very much enlarged uniformly andare very much enlarged uniformly and
may interfere with speech, deglutition andmay interfere with speech, deglutition and
respiration, long standing cases mayrespiration, long standing cases may
develop pulmonary hypertensiondevelop pulmonary hypertension
Chronic fibroid tonsillitisChronic fibroid tonsillitis
CLINICAL FEATURESCLINICAL FEATURES
recurrent attacks of sore throatrecurrent attacks of sore throat
chronic irritation in throat with coughchronic irritation in throat with cough
thick speechthick speech
Tonsil may show varying degree ofTonsil may show varying degree of
enlargement depending on the typeenlargement depending on the type
Irwin-moore signIrwin-moore sign pressure on the anteriorpressure on the anterior
pillar expresses frank pus or cheesy materialpillar expresses frank pus or cheesy material
mainly seen in fibroid typemainly seen in fibroid type
Flushing of the anterior pillar compared to restFlushing of the anterior pillar compared to rest
of the pharyngeal mucosaof the pharyngeal mucosa
Enlargement of the jugulo-digastric nodeEnlargement of the jugulo-digastric node
soft non tendersoft non tender
Peritonsillar abscessPeritonsillar abscess
Parapharyngeal abscessParapharyngeal abscess
Retro pharyngeal abscessRetro pharyngeal abscess
Intra tonsillar abscessIntra tonsillar abscess
Tonsillar cystTonsillar cyst
Focus of infection for RF, AGNFocus of infection for RF, AGN
Clinical presentationClinical presentation
Individuals with acute tonsillitis present withIndividuals with acute tonsillitis present with feverfever,, sore throatsore throat,,
foul breathfoul breath,, dysphagiadysphagia,, odynophagiaodynophagia andand tender cervicaltender cervical
lymph nodes.lymph nodes.
Airway obstruction may manifest asAirway obstruction may manifest as mouth breathingmouth breathing,,
snoringsnoring,, sleep-disordered breathingsleep-disordered breathing,, nocturnal breathingnocturnal breathing
pausespauses, or, or sleep apneasleep apnea..
LethargyLethargy andand malaisemalaise are common.are common.
Symptoms usually resolve in 3-4 days but may last up to 2Symptoms usually resolve in 3-4 days but may last up to 2
weeks despite adequate therapy.weeks despite adequate therapy.
Recurrent streptococcal tonsillitis is diagnosed whenRecurrent streptococcal tonsillitis is diagnosed when
an individual hasan individual has
7 culture-proven episodes in 1 year7 culture-proven episodes in 1 year,,
5 infections in 2 consecutive years5 infections in 2 consecutive years, or, or
3 infections each year for 3 years consecutively3 infections each year for 3 years consecutively..
Individuals with chronic tonsillitis may present withIndividuals with chronic tonsillitis may present with
chronic sore throatchronic sore throat,, halitosishalitosis,, tonsillitistonsillitis, and, and persistentpersistent
tender cervical nodes.tender cervical nodes.
Children are most susceptible to infection by those inChildren are most susceptible to infection by those in
the carrier state.the carrier state. 33
Individuals withIndividuals with peritonsillarperitonsillar
abscess (PTA)abscess (PTA) present withpresent with severesevere
throat painthroat pain,, feverfever,, droolingdrooling,, foulfoul
breathbreath,, trismustrismus (difficulty opening(difficulty opening
the mouth), andthe mouth), and altered voicealtered voice
qualityquality (the hot-potato voice).(the hot-potato voice).
2.PHYSICAL EXAM..2.PHYSICAL EXAM..
Should begin by determining the degree of distressShould begin by determining the degree of distress
regarding airways and swallowing.regarding airways and swallowing.
Examination of pharynx may be facilitated by mouthExamination of pharynx may be facilitated by mouth
opening without tongue protrusion, followed byopening without tongue protrusion, followed by
gentle central depression of the tongue.gentle central depression of the tongue.
Full assessment of oral mucosa, dentation, andFull assessment of oral mucosa, dentation, and
salivary ducts may then be performed by gentlysalivary ducts may then be performed by gently
“walking ”a tongue depressor about the lateral oral“walking ”a tongue depressor about the lateral oral
Flexible fiberoptic nasopharyngoscopy may be useful in
Acute tonsilitis reveals fever and enlarged inflammed
tonsil that may have exudates.
Open mouth breathing and voice changes result from
obstructive tonsilar enlargement.
Voice change in acute tonsilitis is not as severe as that
assc with peritonsilar abscess.
In PTA , pharyngeal edema and trismus cause a hot
Tender cervical nodes and neck stiffness observed in
Examine skine and mucosa for sign of dehydration.
Chronic tonsilitis,express pus on squeezing the tonsil and
excess tonsilar debris(tonsiliolith)
Hypertrophic inflammed tonsil for childrens and atrophic
tonsil in adult.
Tonsil in this pt were so swollen that they caused
resp distress necessitating tonsillectomy
Palatine tonsil which are bright red,swollen and
Tonsillitis and peritonsillar abscess (PTA) are clinical
Testing is indicated when group A beta-hemolytic
Streptococcus pyogenes (GABHS) infection is suspected.
Throat cultures (sensitivity 90-95%) are the criterion
standard for detecting GABHS.
For patients in whom acute tonsillitis is suspected to have
spread to deep neck structures radiologic imaging using
plain films of the lateral neck or CT scans with contrast is
In cases of PTA, CT scanning with contrast is indicated 43
Lab StudiesLab Studies
Throat cultures are the criterion standard forThroat cultures are the criterion standard for
detecting group A beta-hemolytic Streptococcusdetecting group A beta-hemolytic Streptococcus
pyogenes (GABHS).pyogenes (GABHS).
GABHS is the principal organism for which antibioticGABHS is the principal organism for which antibiotic
therapy (sensitivity 90-95%) is definitely indicated.therapy (sensitivity 90-95%) is definitely indicated.
Relying only on clinical criteria, such as the presenceRelying only on clinical criteria, such as the presence
of exudate, erythema, fever, andof exudate, erythema, fever, and
lymphadenopathy, is not an accurate method forlymphadenopathy, is not an accurate method for
distinguishing GABHS from viral tonsillitis.distinguishing GABHS from viral tonsillitis.
A rapid antigen detection test (RADT), also known asA rapid antigen detection test (RADT), also known as
the rapid streptococcal test, detects the presencethe rapid streptococcal test, detects the presence
of GABHS cell wall carbohydrate from swabbedof GABHS cell wall carbohydrate from swabbed
material and is considered less sensitive than throatmaterial and is considered less sensitive than throat
however, the test has a specificity of 95% or morehowever, the test has a specificity of 95% or more
and produces a result in significantly less time thanand produces a result in significantly less time than
that required for throat cultures.that required for throat cultures.
A negative RADT requires that a throat culture beA negative RADT requires that a throat culture be
obtained before excluding GABHS infection.obtained before excluding GABHS infection. 45
Routine imaging is not useful in cases of acuteRoutine imaging is not useful in cases of acute
For pts whom acute tonsillitis is suspected toFor pts whom acute tonsillitis is suspected to
have spread to deep neck structures (i.e.have spread to deep neck structures (i.e.
beyond the facial planes of thebeyond the facial planes of the
oropharynx),radiologic imaging using plainoropharynx),radiologic imaging using plain
films of lateral neck or CT scan with contrast isfilms of lateral neck or CT scan with contrast is
Peritonsilar abscess CT scan with contrastPeritonsilar abscess CT scan with contrast
is indicated in general for unusualis indicated in general for unusual
presentation(e.g. inferior pole abscess)presentation(e.g. inferior pole abscess)
and for pts at high risk of drainageand for pts at high risk of drainage
CTscan may be used to guide needleCTscan may be used to guide needle
aspiration for draining PTA.aspiration for draining PTA.
- If tonsils are asymmetric- If tonsils are asymmetric
- they should be submitted- they should be submitted
- examined histologically to rule- examined histologically to rule
out cancerout cancer
-corticosteroids(shorten the duration of fever and
- antibiotics(oral penicillin for 10 days),im for non
compliant pt of oral therapy.
INDICATIONS FOR TONSILLECTOMYINDICATIONS FOR TONSILLECTOMY
The American Academy of Otolaryngology–The American Academy of Otolaryngology–
Head and Neck Surgery (AAO-HNS):Head and Neck Surgery (AAO-HNS):
Enlarged tonsils that cause upper airwayEnlarged tonsils that cause upper airway
obstruction, severe dysphagia, sleep disordersobstruction, severe dysphagia, sleep disorders
Recurrent peritonsillar abscessRecurrent peritonsillar abscess
Unilateral tonsil hypertrophy that is presumed to beUnilateral tonsil hypertrophy that is presumed to be
neoplastic (tumour tonsillectomy)neoplastic (tumour tonsillectomy)
Chronic or recurrent tonsillitis, Cor pulmonaleChronic or recurrent tonsillitis, Cor pulmonale
Bleeding disordersBleeding disorders
Acute infectionAcute infection
Uncontrolled medical illnessUncontrolled medical illness
Place the patient in the Rose position
with a shoulder roll.
Carefully, insert a Davis Boyle’s mouth
gauge, open and suspend it.
Apply an Alyss clamp to the tonsil to
allow for traction during dissection.
Variations in dissection methods include the following
- cold steel (eg, scissors, curettes)
- monopolar cautery
- bipolar cautery
- radiofrequency ablation/coblation (can be used to shrink tonsils)
- harmonic scalpel with vibrating titanium blades
- microdebrider - for an intracapsular technique
Variations in haemostasis methods include the following:
- pressure with sponge for several minutes
- bismuth subgallate
- the most common complication- the most common complication
- intraoperative/primary (occurring within the first 24hrs)- intraoperative/primary (occurring within the first 24hrs)
- secondary (occurring between 24hrs and 10 days)- secondary (occurring between 24hrs and 10 days)
Pain (sore throat, otalgia)Pain (sore throat, otalgia)
Dehydration (children - do not eat because of pain)Dehydration (children - do not eat because of pain)
Fever (not common, usually related to local infection)Fever (not common, usually related to local infection)
Postoperative airway obstruction (uvular oedema,Postoperative airway obstruction (uvular oedema,
haematoma, aspirated material)haematoma, aspirated material)
Local trauma to oral tissuesLocal trauma to oral tissues
Temporomandibular joint dislocationTemporomandibular joint dislocation
Psychological trauma, night terrors, or depressionPsychological trauma, night terrors, or depression
Nasopharyngeal stenosisNasopharyngeal stenosis
- uncommon- uncommon
- bleeding- bleeding
- or anaesthetic complications- or anaesthetic complications
Head & Neck ENT surgery 4th
ABC of ENT
Pubmed…current articles 2013
Current diagnosis & treatment in otolaryngology..