Tonsils, anatomy, tonsillitis, tonsillectomy

1. Dr Rajesh Kar,
MBBS, MS, DNB

2. 
TONSILS
 Tonsils are sub epithelial
collections of lymphoid
tissue scattered in the
pharynx.
 Anatomically the tonsils are
classified based on their
location into :
palatine(faucial),
nasopharyngeal
(“adenoids”), lingual and
tubal tonsils.
 Generally, the palatine
tonsils referred to as“the
tonsils”.

3. 
Embryology
 The tonsils develop
from the second
pharyngeal pouch.
 In the extraembryonic
life, the ventral part of
the 2nd pharyngeal
pouch is represented by
crypta magna or
intratonsillar cleft.

4. 
ANATOMY
The tonsils are 3 masses of tissue:
 - lingual tonsil
 - pharyngeal (adenoid) tonsil
 - palatine or faucial tonsil
 Together they form Waldeyer's ring, are
lymphoid tissue, covered by respiratory
epithelium pseudostratified ciliated
columnar epithelium.
 produce lymphocytes
 are active in the synthesis of
immunoglobulins.
 a ring of lymphoid tissue in the
oropharynx and nasopharynx.
 are the first lymphoid aggregates in the
aerodigestive tract – thought to play a role in
immunity

5. 
Overview
 *Site: lateral walls of
oropharynx, between the
anterior and posterior
pillars- tonsillar fossa
 *Shape: almond shape
 *2 surfaces: medial, lateral
 *2 poles: upper, lower
 * 10-12 primary crypts,
secondary crypts
 *Plica semilunaris and
plica triangularis

6. 
Medial surface
 Medial surface
 It is lined by stratified squamous non
keratinising epithelium which dips
into the crypts
 The crypts are 12-15 in number
 Secondary crypts arise from the
primary crypts and extend into the
substance of the tonsil
 One of the crypts located in the upper
part is larger than the rest – crypta
magna
 The crypts serve to increase the
surface area of the tonsil
 The crypts may be filled with cheesy
material – epithelial debris, food
particles and bacteria

7. 
Lateral surface
 It is covered by the fibrous
capsule of the tonsil
 The tonsillar bed is separated
from the capsule by loose areolar
tissue
 This makes it is easy to dissect
the tonsil from its bed during
tonsillectomy
 It is the site of collection of pus
in peritonsillar abscess (quinsy)
 Some fibers of palatoglossus
and palatopharyngeus muscles
get attached to the capsule of
tonsil

8. 
Upper pole
 It extends into the soft
palate
 There is a semilunar fold
of mucous membrane
 which covers the medial
part of the upper pole
 It extends from anterior
pillar to posterior pillar
 It encloses a potential
space – supratonsillar
fossa

9. 
Lower pole
 It is attached to the tongue
 A triangular fold of mucous
membrane extends from
theanterior tonsillar pillar to
the lower pole
 It encloses a space – anterior
tonsillar space
 The lower pole is separated
from the tongue by
thetonsillo-lingual sulcus
 This sulcus may harbour
carcinoma

10. 
Structures related to the
bed of tonsils
 Bed is formed by the 2
muscles
 1.Superior constrictor
 2.Styloglossus

11. 
TONSILLAR BED
 Loose areolar tissue
containing paratonsillar vein
 Pharyngo-basilar fascia
 Superior constrictor
muscle
 Bucco-pharyngeal fascia
 Styloglossus
 Medial pterygoid muscle
 Glossopharyngeal nerve
 Facial artery
 Submandibular salivary
gland

12. 
Relations
 Anterior: anterior pillar
 Posterior: posterior pillar
 Superior: soft palate
 Inferior: tongue
 Medial: cavity of the
oropharynx
 Lateral: loose areolar tissue,
paratonsillar veins, superior
constrictor,
buccopharyngeal fascia,
glossopharyngeal nerve,
facial artery, pterygoid
muscles and the mandible.

13. 
Blood supply
 through the external
carotid artery branches:
 Superior pole
 Ascending pharyngeal
artery(tonsilar branches)
Lesser palatine artery
 Inferior pole
 Facial artery branches
 Dorsal lingual artery
 Ascending palatine artery

14. 
 Venous outflow - by the
plexus around the tonsilar
capsule, the lingual vein,
and the pharyngeal plexus.
 Lymphatic drainage - The
tonsils do not have any
afferent vessels but has
efferents which drain into
the Jugulodigastric nodes.
 Sensory supply - the
glossopharyngeal nerve,the
lesser palatine nerve

15. 
Histology
 - True fibrous capsule
 - Fibrous septa
 - Crypts lined by
stratified squamous
epithelium
 - Lymphoid nodules:
germinal centres – B
cells and plasma cells;
surrounded by T cells.

16. 
Functions of Tonsils
 1. Immunity
 2. Lymphocyte
formation
 3. Antibodies formation
 4. Barrier to infections

17. 
What is
tonsillitis ?
 Tonsillitis is inflammation of
the tonsils most commonly
caused by a viral or bacterial
infection.
 Mostly affects children in
the age group of 5-15 years,
may also affect adults
 Organisms beta-
hemolytic streptococci(most
common), staphylococci,
pneumococci, H.influenzae
 Symptoms: sore throat,
difficulty in swallowing,
fever, ear ache, constitutional
symptoms

18. 
Tonsillitis
 Types:-Tonsillitis is often
labelled as acute, sub-
acute, or chronic.
 Acute tonsillitis tends to
be bacterial or viral in
nature, while
 Sub-acute tonsillitis is
caused by the bacterium
Actinomyces.
 Chronic tonsillitis
generally lasts for a long
time and is caused by
bacteria.
Acute
tonsillitis
Sub-acute
Chronic
tonsillitis

19. 
Acute Tonsillitis
Acute
catarrhal/superficial
(here tonsillitis is a part of
generalized pharyngitis,
mostly seen in viral
infections)
Acute follicular
(infection spread into the crypts
with purulent material,
presenting at the opening of
crypts as yellow spots.)

20. 
Acute membranous
(follows stage of acute
follicular tonsillitis where
exudates coalesce to
form membrane on the surface)
Acute
parenchymatous
Tonsillitis(tonsil is uniformly
enlarged and congested)

21. 
Predisposing factors
Endogenous
 - URTI
 - Postnasal discharge
due to sinusitis
 - Residual tonsillar
tissue after
tonsillectomy
 - Exanthemata
 - Blood dyscrasias
Exogenous
 - Cold drinks and foods
 - Contact with infected
persons
 - Crowded and ill
ventilated environment
 - Imbedded foreign
body

22.  Symptoms:
 1. Sore throat – raw sensation in
the throat
 2. Refusal to eat due to
odynophagia
 3. Earache – either referred pain
from the tonsil
 or due to acute otitis media
 4. Voice becomes thick and
muffled
 5. Jugulodigastric nodes are
enlarged and painful
 6. Fever, may be associated with
chills and rigor.
 Headache, tachycardia.

23. 

24. 
Signs
 1.Tonsils appear congested and
swollen
 - Yellowish spots – follicular
 - Whitish membrane – membranous
 - Red and enlarged – parenchymatous
 2.Hyperemia of pillars, uvula, soft
palate
 3.Halitosis, impeded movements of
palate and increased secretions
 4.Enlarged and tender jugulodigastric
nodes

25. 
Treatment
 1. Bed rest, soft diet,
plenty of fluids, warm
 saline gargles
 2. Analgesics- aspirin,
paracetamol; lozenges
 3. Antimicrobial therapy-
penicillin,
 erythromycin; for 7 to
10days

26. 
Complications
 1. Chronic tonsillitis – incomplete
resolution of acute tonsillitis
 2. Peritonsillar abscess
 3. Parapharyngeal abscess
 4. Acute otitis media – recurrent
attacks
 5. Cervical abscess due to suppuration
of jugulodigastric nodes
 6. Rheumatic fever – group A B-
hemolytic streptococci
 7. Subacute bacterial endocarditis
(patients with valvular heart disease)
– streptococcus viridans

27. 
DIFFERENTIAL DIAGNOSIS OF MEMBRANE
OVER THE TONSIL
MALA D VICTiM

28. 
 - Characterised by recurrent acute
attacks
 Etiology:
 1. Recurrent acute tonsillitis
 2. Subclinical infection of tonsils
 3. Chronic infection in sinuses or teeth
Chronic Tonsillitis
Chronic parenchymatous
Chronic Follicular
Chronic fibrotic

29. 
Pathology
 1. Keratinous plug presses the adjacent
epithelium and lymphoid tissue- causing
their atrophy.
 2. When many plugs are present they
produce an appearance clinically
resembling follicular tonsillitis but
inflammatory reaction is absent.
 3. Histology: In chronic tonsillitis lumen
of the crypt contains bacterial colonies,
inflammatory cells including polymorphs
and lymphocytes with increased vascularity.
 4. The lymphoid tissue is hyperplastic
with germinal follicle .

30. 
SIGNS & SYMPTOMS
Symptoms:
 1. Recurrent throat pain
 2. Cough
 3. Halitosis and bad taste in the mouth
 4. Quiescent phase: discomfort, irritation, pain;
 asymptomatic
 Signs:
 1. Appearance: hypertrophied, congested – chr.
parenchymatous; small, fibrotic with cheesy debris –
chr. Follicular
 2. Irwin-moore sign pressure on the
anterior pillar expresses frank pus or cheesy
material mainly seen in fibroid type
 3. Flushing of the anterior pillar compared to rest of
the pharyngeal mucosa
 4. Enlarged jugulodigastric nodes

31. 
 1. Conservative treatment: general health care,
nutritious diet,treatment of co-existing infections of
teeth, sinuses and nose
 2. Surgical treatment: Tonsillectomy – when the
enlarged tonsils interfere with speech, deglutition,
respiration or in case of recurrent attacks
Treatment

32. 
COMPLICATIONS
 Peritonsillar abscess
 Parapharyngeal
abscess
 Retro pharyngeal
abscess
 Intra tonsillar abscess
 Tonsillar cyst
 Tonsillolith
 Focus of infection
forRF, AGN

33. 
PHYSICAL EXAM..

34. 
 It’s the surgical removal of tonsils , done in
 the treatment of chronic infection of
 tonsils ,obstructive sleep apnea ,
 supporative ottits media etc.
Tonsillectomy

35. 
Indications
A. Absolute
 1. Recurrent infections of throat
 2. Peritonsillar abscess
 3. Tonsillitis causing febrile seizures
 4. Hypertrophy of tonsils causing obstruction
 5. Suspicion of malignancy
 B. Relative
 1. Diphtheria carriers,
 2. Streptococcal carriers
 3. Chronic tonsillitis with bad taste or halitosis
 4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease
 C. As a Part of Another Operation
 1. Palatopharyngoplasty
 2. Glossopharyngeal neurectomy.
 3. Removal of styloid process.

36. 
Contraindications
 1. Haemoglobin level less than 10 g%.
 2. Acute upper respiratory tract infection, acute tonsillitis.
 3. Children under 3 years of age.
 4. Overt or submucous cleft palate.
 5. Bleeding disorders, e.g. leukaemia, purpura, aplastic
anaemia, haemophilia.
 6. At the time of epidemic of polio.
 7. Uncontrolled systemic disease, e.g. diabetes, cardiac
disease, hypertension or asthma.
 8. Tonsillectomy is avoided during the period of menses.

37. 
 Usually done under general anaesthesia
 with endotracheal intubation.
 In adults, it may be done under local
 anaesthesia.
Anaesthesia

38. 
Position
 Rose's position, i.e. patient lies supine
with head extended by placing a pillow
under the shoulders and a rubber pad
under the head.
 Advantages of Rose
position:
 1. There is virtually no aspiration of
blood or secretions into the airway.
 2. Both hands of the surgeon are
free. This position helps in proper
application of the Boyles Davis mouth
gag.
 3. The surgeon can be comfortably
seated at the head end of the patient

39. 
Boyles Davis mouth gag
 Boyles tongue blade  Davis mouth gag

40.  1. Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffin's
bipods .
 2. Tonsil is grasped with tonsil-holding forceps and pulled medially.
 3. Incision is made in the mucous membrane where it reflects from the tonsil to
anterior pillar. It may be extended along the upper pole to mucous membrane
between the tonsil and posterior pillar.
 4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar
tissue and separate its upper pole.
 5. Now the tonsil is held at its upper pole and traction applied downwards and
medially. Dissection is continued with tonsillar dissector or scissors until lower pole
is reached
 6. Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle,
tightened, and the pedicle cut and the tonsil removed.
 7. A gauze sponge is placed in the fossa and pressure applied for a few minutes.
 8. Bleeding points are tied with silk. Procedure is repeated on the other side.
Steps of Operation
(Dissection and Snare
Method)

41. 

42. 
 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
Methods

43.  1. Immediate general care
 (a) Keep the patient in coma position until
 fully recovered from anaesthesia.
 (b) Keep a watch on bleeding from the
 nose and mouth.
 (c) Keep check on vital signs, e.g. pulse,
 respiration and blood pressure.
 2. Diet
 a.When patient is fully recovered he is to take
 liquids, e.g. cold milk or ice cream.
 b.Sucking of ice cubes gives relief from pain.
 c.Diet is gradually built from soft to solid food.
 They may take custard, jelly, soft boiled eggs
 or slice of bread soaked in milk on the 2nd
 day.
 d. Plenty of fluids should be encouraged.
Post-operative Care

44.  A. Immediate
 1 immediate haemorrhage. Occurs at the
 time of operation. It can be controlled by
 pressure, ligation or electrocoagulation of
 the bleeding vessels.
 2. Reactionary haemorrhage. Occurs within
 a period of 24 hours and can be controlled
 by simple measures such as removal of the
 clot, application of pressure or
 vasoconstrictor.
 3. Injury to tonsillar pillars, uvula, soft
 palate, tongue or superior constrictor
 muscle due to bad surgical technique. 4. Injury to teeth.
 5. Aspiration of blood.
 6. Facial oedema. Some patients get oedema
 of the face particularly of the eyelids.
 7. Surgical emphysema. Rarely occurs due to
 injury to superior constrictor muscle.
Complications

45. 
 1. Infection. Infection of tonsillar fossa may
 lead to parapharyngeal abscess or otitis
 media.
 2. Lung complications. Aspiration of blood,
 mucus or tissue fragments may cause
 atelectasis or lung abscess.
 3. Scarring in soft palate and pillars.
Delayed Complications

46. Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-
toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar
retractor, (6)Luc'sforceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10)
Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's
mouth gag, (13) Adenoid curette, (14) Tonsil swabs,
(15) Nasopharyngeal pack, (16) Towel clip

47. 
 Due to elongated styloid process or calcification of
stylohyoid ligament
 Patient complains of pain in tonsillar fossaand
upper neck which radiates to ipsilateral ear
 It gets aggravated on swallowing
 Diagnosis is by transoral palpation in tonsillar
fossa
 X-ray Townes view is helpful in diagnosis
 Treatment is by excision of styloid process by
transoral or cervical approach
STYALGIA (EAGLE’S
SYNDROME)

48. 
Thank You