tonsil

1. ANATOMY AND PATHOLOGY
OF THE PALATINE TONSIL

2. INTRODUCTION
 The palatine tonsils are dense compact bodies
of lymphoid tissue that are located in the
lateral wall of the oropharynx.
 The palatine tonsil represent the largest
accumulation of lymphoid tissue in Waldeyer's
ring.
 The Waldeyer ring is involved in the
production of immunoglobulins and the
development of both B-cell and T-cell
lymphocytes.

4. GROSS ANATOMY

5.  SITUATION: The palatine tonsils occupy the
tonsillar sinus or fossa between the diverging
palatoglossal and palatopharyngeal arches.
 SIZE:
 For the first 5 or 6 years of life the tonsils increase
rapidly in size.
 They usually reach a maximum at puberty when they
average 20-25 mm in vertical, and 10-15 mm in
transverse diameters.
 Tonsillar involution begins at puberty, when the
reactive lymphoid tissue begins to atrophy, and by
old age only a little tonsillar lymphoid tissue remains.

7. Medial Surface
• Its free surface usually presents a pitted
appearance.
 The pits, 10-20 in number, lead into a system of
blind-ending, often highly branching, crypts which
extend through the whole thickness of the tonsil and
almost reach the connective tissue hemicapsule.
 Covered by non-keratinizing stratified squamous
epithelium
 FEATURES
 Two surfaces
 Two poles
 Two borders

8. Lateral Surface
 covered by a layer of fibrous tissue, the tonsillar
hemicapsule.
 Capsule is Formed by the condensation of pharyngo
basillar fascia.
 The external palatine or paratonsillar vein, descends
from soft palate lateral to the tonsillar hemicapsule
before piercing the pharyngeal wall.
 Haemorrhage from this vessel from the upper angle
of the tonsillar fossa may complicate tonsillectomy.

10. BLOOD SUPPLY
 Upper Pole
 Descending Palatine br. Of Maxillay artery
(Ant.)
 Ascending pharyngeal artery br. Of Ext.
Carotid artey (Post.)
 Lower Pole
 Dorsal Lingual br. Lingual Artery (Ant.)
 Tonsillar br. Of Facial Artery (Main)
 Ascending palatine br. Of Facial Artery
(Post.)

12.  VENOUS DRAINAGE
 Paratonsillar vein – common facial vein –
pharyngeal venous plexus – int. Jugular vein
 LYMPHATIC DRAINAGE
 drain to the upper deep cervical lymph nodes
directly (especially the jugulodigastric nodes)
or indirectly through the retropharyngeal
lymph nodes.
 NERVE SUPPLY
 Tonsillar br. Of Maxillary Nerve through
Lesser palatine br. Of Sphenopalatine
Ganglion
 Glossopharyngeal N.

13. APPLIED ASPECTS
• ACUTE AND CHRONIC TONSILLITIS
• TONSILLECTOMY

14. Tonsillitis:
Inflammation of tonsils due to bacterial or viral infection
causing a sore throat , fever, and difficulty in
swallowing is called tonsillitis.
1. Acute Tonsillitis
2. Recurrent Acute Tonsillitis
3. Chronic (Persistent) Tonsillitis
4. Obstructive Tonsillar Hyperplasia

15. Acute tonsillitis
• Mostly affects children in the age group of 5-15
years, may also affect adults
·Etiology
„
. GABHS is a precursor of serious conditions like:acute
rheumatic fever,poststreptococcal glomerulonephritis
and subacute bacterial endocarditis
It is the most common cause of acute bacterial
tonsillitispharyngitis.
GABHS are Gram-positive cocci that grow
in chain.
Natural reservoir: Skin, nasopharynx and oropharynx.

16. Types of acute tonsillitis
1).Acute catarrhal/superficial  here tonsillitis is a
part of generalized pharyngitis, mostly seen in viral
infections

17. Types of acute tonsillitis
2).Acute follicular  infection spread into the
crypts with purulent material, presenting at the
opening of crypts as yellow spots.

18. Types of acute tonsillitis
3).Acute membranous  follows stage of acute
follicular tonsillitis where exudates coalesce to form
membrane on the surface

19. Types of acute tonsillitis
4).Acute parenchymatous  tonsil is uniformly
enlarged and congested

20. Grades of Tonsillar Enlargement

21. Symptoms
„
. Throat pain: Dry throat, fullness in throat or sore
throat.
„
. Dysphagia: Difficulty in swallowing or odynophagia.
„
. Fever: Temperatures 38–40°C may be associated
with chills and rigors. The child may present as a
case of pyrexia of unknown origin.
„
. Earache: It may be either referred, or due to acute
otitis media.
„
. Constitutional symptoms: Headache, limb and back
pain, malaise and constipation.
„
. Abdominal pain: It is due to mesenteric lymphadenitis,
and simulates acute appendicitis.

22. Physical Findings
„
. Tongue: Dry and coated tongue.
„
. Breath: Fetid breath (halitosis).
„
. Oropharynx : Hyperemia of pillars, soft palate and
uvula.
• Tonsils red and swollen with yellowish spots of pus
at the opening of crypts (acute follicular tonsillitis)
which may coalesce, and form a membrane on the
surface of tonsil (acute membranous tonsillitis). This
membrane can be easily wiped away with a swab.
• Edema of the uvula and soft palate may be present.
• „
Lymph nodes: Enlarged and tender jugulodigastric
lymph nodes.

23. Diagnosis of Acute Tonsillitis
• Sore throat and fever with cervical adenopathy and pharynx
with exudative covering are highly suggestive of Streptococcus
pyogenes.
„
Rapid strep tests:It is the most costeffective and accurate test
Latex agglutination or enzyme-linked immunosorbent assay
(ELISA) methods extract antigen (group-A streptococcal) from
a swab. It is highly specific (95%), but less sensitive (60–
100%) than culture.
„
Throat culture: Swab from the posterior pharynx and tonsillar
area when body temperature is greater than 38.3°C or when
patient presents only with sore throat, or when rapid streptest
is negative in strongly suspected cases.

24. Treatment
„
.Bed rest and plenty of fluids.
„
. Symptomatic: Analgesics and antipyretics such as
aspirin or paracetamol.
„
. Specific: Antibiotics for 7–10 days reduces the
chances of suppurative complications and acute
rheumatic fever, but not poststreptococcal
glomerulonephritis.
Penicillin or amoxicillin is the drug of choice. If there is
no response then suspect beta-lactamase producing
organisms and anaerobes, and start
–– Amoxicillin + clavulanic acid or
–– Clindamycin or
–– Erythromycin + metronidazole

25. Asymptomatic carriers: They usually do not need any
treatment except when:
• Family member is having rheumatic fever.
• Family members are getting recurrent streptococcal
infection.

26. Tonsillectomy
• The technique of adenotonsillectomy has evolved
significantly over the past 2000 years
• Whereas chronic infection was the primary surgical
indication for adenotonsillectomy in the 1950s and
1960s, airway obstruction and obstructive sleep
apnea have now become the most common
preoperative indications for surgery

28. Tonsillectomy Techniques:
‘COLD STEEL’ TECHNIQUE:
• The traditional methods for removing the tonsils are the so-
called ‘cold steel’ techniques using metal instruments.
• The most common method of ‘cold steel’ tonsillectomy is the
dissection technique
• An alternative method of ‘cold steel’ tonsillectomy is the
guillotine technique,whereby the tonsil is amputated using a
specially designed guillotine device and haemostasis is
achieved either by ligature or diathermy as required.
• Blood loss during tonsillectomy can be considerable and may
constitute over 10 percent of total circulating blood volume

30. COBLATION TONSILLECTOMY
• This relies on the use of a specially designed bipolar electrical
probe, which both coagulates and cuts the tissues as it develops
the dissection plane between tonsil and capsule.
• The probes or ‘wands’ are single use and there is a cost
consideration.
• Postoperative bleed rates were unacceptably high as compared
to cold techniques.
ULTRASONIC DISSECTION
• Ultrasonic dissection uses an oscillating blade also known as
Harmonic Scalpel, which acts as both a cutting and coagulating
device.
• Reduced pain and general morbidity

31. LASER TONSILLECTOMY:
• Laser Tonsillectomy has been advocated as having
advantages in terms of reduction of bleeding, postoperative
pain and more rapid healing.
• Studies suggest that the rate of secondary haemorrhage and
late postoperative pain is significantly greater with laser.
‘CAPSULOTOMY’ TECHNIQUES
• All the above discussed techniques are designed to remove
the entire palatine tonsil
• Here ablation of a part of the tonsil is done, usually leaving the
capsule intact.
• this technique is considered when tonsillectomy is undertaken
in the very young where it may be desirable to leave some
functioning lymphoid tissue

32. Complications of Tonsillectomy
Immediate:
 Reactionary haemorrhage
 Airway obstruction secondary to reactionary haemorrhage with blood
entering airway, laryngospasm, dislodged teeth or forgotten swabs
 Nausea and vomiting relating to anaesthesia, opiate analgesia or
swallowed blood
 Excessive pain due to greater than expected tissue trauma related to
insertion of Boyle Davis mouth gag, uvula or pillar trauma during dissection

33. Intermediate:
 Secondary haemorrhage
 Oedema of the uvula
 Excessive pain often associated with otalgia
 Infection in tonsillar fossae promoting secondary haemorrhage
 Atlantoaxial subluxation (Grisel’s syndrome)
 Peritonsillar abscess

34. Late:
 Postoperative scarring
 Tonsil remnants
 Pharyngeal stenosis
 Nasal regurgitation/velopharyngeal insufficiency due to excess removal of
anterior pillars
 Glossopharyngeal nerve paralysis

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