ADENO TONSILLITIS

Dr. A. KARUNAGARAN, M.S.

Anatomy

• Waldeyer`s inner ring consists

collection of sub epithelial lymphoid
tissue
• Adenoids
• Palatine tonsil
• Tubal tonsil
• Lingual tonsil
Anatomy – tonsil
• Bilateral ovoid masses of lymphoid
tissue
• Almond shape
• Partly covered by capsule
• Medial surface has 15 – 20 crypts,
biggest is crypta magna
• Mucosal folds – in superior pole plica
semilunaris, in inferior pole plica
triangularis
Anatomy – adenoids

• Present at the junction of roof and

posterior wall of nasopharynx
• Has furrows and ridges
• Appear like bunch of banana
• Feels like bag of worms
Anatomy
Blood supply - Tonsils
Tonsillar branch Tonsil (main branch)
Facial a.
Ascending palatine Tonsil

Lingual a. Dorsal lingual Tonsil

Ascending pharyngeal Tonsil
Maxillary Lesser descending palatine
Tonsil
Anatomy
Blood supply – Adenoids

• Ascending palatine branch of facial a.

• Ascending pharyngeal a.
• Pharyngeal branch of IMAX.
• Ascending cervical branch of
thyrocervical trunk.
Differences between tonsils and
adenoids
Tonsils Adenoids
Paired structure Solitary structure
Present in lateral wall of oro Present in naso pharynx
pharynx

Covered by non keratinizing Coverd by ciliated columnar

stratified sqamous epithelium epithelium

Covered by capsule on the lateral No capsule

wall

Has crypts No crypts, only furrows

Almond shaped Bunch of banana
Both afferent and efferents no afferent only efferents present
present

Surface IgA present No capsule secretory IgA

 Infecting Organisms
Aerobic Bacteria
• Strep pyogenes (Gr A beta-hemolytic)
• Strep pneumoniae
• Strep viridans & other Streptococci
• Staph aureus
• H. Influenzae
• Diphtheroids
• Neisseria spp.
 Infecting Organisms
Anaerobic Bacteria
• Bacteroides
• Peptococcus
• Peptostreptococcus
• Veillonella
• Fusobacteria
Infecting Organisms
Viruses
• Epstein-Barr
• Cytomegalovirus
• Adenovirus
• Herpes simplex
• Influenza A and B
• Parainfluenzae
 Microbiology of Tonsillitis
Group A beta-hemolytic
• Is most recognized - associated with a risk of
rheumatic fever and glomerulonephritis

Beta-lactamase producing organisms

• Are of particular importance.
• Produced by Staph aureus, M. catarrhalis &
H.influenzae
• Protect Group A Streptococci from eradication
with penicillins
• Accounts for 39% of all cultured organisms
Who gets Tonsillitis ?
• Most often occurs in children – all
experience at least 1 episode
• Rarely in children younger than 2 yr
• Viral tonsillitis in younger children
• Streptococcal tonsillitis in children
aged 5-15 yr
• Poor socioeconomic status & over
crowding
Pathophysiology
• Viral Infections
• Bacterial Infections
• Inflammatory exudates of the crypts
• Epithelial keratinisation
• Deep-seated multiple abscess formation with
increasing germ centers
• Parenchyma destruction
• Immunologic Factors
Unanswered Questions
• Do virus infections in the pharynx and
tonsils predispose to bacterial infection?
• Is it possible to have an infective
condition involving the pharyngeal
lymphoid tissue without affecting the
tonsils?
• Is there such a condition as chronic
tonsillitis?
• Why are some patients susceptible to
acute pharyngitis and acute tonsillitis
and others not?
Acute Tonsillitis

Symptoms:
Fever
Sore throat
Dysphagia or Odynophagia
Airway Obstruction
Lethargy / malaise
Acute Tonsillitis - Signs
• Enlarged

• Erythematous

• Exudative forming
at times
pseudomembrane

• Enlarged neck
Grading the Size of Tonsils

Grading system:
A. 0 – tonsils in fossa
B. +1 – tonsils less than 25%
C. +2 – tonsils less than 50%
D. +3 – tonsils less than 75%
E. +4 – tonsils greater than
75%
Features of adenoid facies
• Open mouth and mouth breathing
• Pinched nostrils
• Crowded teeth andhyper plasia of gums
• Loss of naso labial fold
• Under slung mandible
• High arched V shaped palate
• Short upper lip
• Hypo plasia of maxilla
• Vacant expression
• Pectus excavatum
• Rouned shoulders
• Voice changes- nasal and lifeless
 Lingual Tonsils
• Hyperplasia is the most common abnormality of the
lingual tonsil.
• Lingual tonsils sit on the base of the tongue and
extend to the vallecula and do not have a capsule.
• Can be visualized by indirect mirror or flexible
laryngoscopy
• Clinically, infection is marked by erythema and
enlargement of tonsillar tissue.
• Suspension microlaryngoscopy with removal by CO2
laser, sharp dissection or hot knife cautery are some
of the treatments available.
Lingual Tonsil
• History and Physical:
– Sore throat
– Globus sensation
– Speech change
– Dysphagia
– Obstructive sleep apnea in adults
– Pediatric airway obstruction
– Often discovered incidentally during intubation in
preparation for surgery that is unrelated to the
ear, nose, and throat.
Lingual Tonsils
• Differential diagnosis
– lingual thyroid tissue
– thyroglossal duct cyst
– dermoid cyst
– lymphangioma
– angioma
– adenoma
– fibroma
– papilloma
– lymphoma
– squamous cell carcinoma
– minor salivary gland tumors on the base of the
tongue
Lingual Tonsils
• Hypertrophy of lingual tonsils in 62% of
persons with laryngoscopic signs of reflux
and in 75% of persons with
pharyngolaryngeal symptoms of LPR.
• Although the lymphoid tissue in Waldeyer's
ring tends to decrease with advancing age,
the lingual tonsil may increase in size.
• The most important cause of lingual tonsil
hypertrophy is the occurrence of
compensatory hyperplasia following
adenotonsillectomy.
Differential Diagnosis of
pseudomembranous
tonsillitis
Infectious Mononucleosis
• Cheesy exudates
covering tonsil

• Lymphadenopathy
of
neck, axilla &
groin

• Hepato/Spleenome
galy
Oral Thrush
• Painful throat
• White candidiasis
patches when
removed leaves
erythematous
ulcer
• Immunosuppressi
ve state
Keratosis tonsils

• Incidental finding
• May cause slight
discomfort
• Yellow horny
outgrowths in the
crypts
Agranulocytosis
• Halistosis, fever,
headache &
dysphagia
• Single , multiple
or coalesce
necrotic slough
covered ulcers
• Leucopenia
• H/O causative
drugs intake
Diphtheria
• Malaise, fever &
headache
• Greyish green
membrane across
tonsils to larynx
• Tender bilateral
cervical
lymphadenopathy
Vincent’s angina
• Fetor oris, pyrexia
• Tonsillar deep ulcers
with grey slough in its
base
• Necrotising gingivitis
• Enlarged tender
cervical adenitis
• Smear:

Spirochaetes &
Acute lymphatic leukemia
• Fever, anaemia &
bleeding
disorders
• Slough covered
membrane
forming
ulcerations
• Cervical
lymphadenopathy
• Exaggerated
leucocytosis
Recurrent Acute Tonsillitis
• Same signs and • Ant pillar peri
symptoms as tonsillar erythema
acute • Smooth glistening
• Occurring in 4-7 tonsil with dilated
separate blood vessels on
episodes per the surface
year • Debris in crypts
• 5 episodes per which are few due
year for 2 years to loss of tonsil
architecture
• 3 episodes per
Chronic Tonsillitis
• Chronic sore throat
• Malodorous breath
• Presence of tonsilliths
• Peritonsillar erythema
• Persistent cervical
lymphadenopathy
• Lasting at least 3 months
Local Complications
• Respiratory obstruction
• Quinsy
• Acute retropharyngeal abscess
• Parapharyngeal abscess
• Neck space infections
• Acute otitis media
Retropharyngeal abscess

• Dysphagia, fever
• Pharynx either
normal or smooth
bulge of posterior
pharyngeal wall
• Airway
obstruction
• Neck rigid
Peritonsillar Abscess
• Abscess formation
outside tonsillar
capsule
• Signs and symptoms:
– Fever
– Sore throat
– Dysphagia/odynophagi
a
– Drooling
– Trismus
– Unilateral swelling of
soft palate/pharynx
with uvula deviation
Peritonsillar
Abscess
• Incidence: estimated 30 cases
per 100,000 in US.
• Diagnosis is usually by physical exam
but other modalities have been
used such as US and CT.
• Widely accepted that Staphylococcus
aureus is the most common organism
causing the infection and origin is usually
from the superior pole of the tonsil (from
minor salivary gland - AKA: Weber gland).
Peritonsillar Abscess
• Quinsy tonsillectomy vs. Interval
tonsillectomy
– Quinsy tonsillectomy can be a treatment option
in pediatric patients to young to withstand
bedside aspiration or I&D for recurrent PTA.
– Quinsy tonsillectomy can be surgically easier
than interval tonsillectomy as fibrosis has not
had time to set into the tonsillar capsule.
– Review by Johnson, discussed interval
tonsillectomy for recurrent PTA with prevalence
of 10%.
– Interval tonsillectomy can be considered after
successful abscess drainage, usually from
recurrent PTA after 6 weeks.
Parapharyngeal
abscess
• Fever,
dysphagia &
airway
obstruction
• Swelling below
soft palate over
the pharynx
• Tender firm
swelling in the
upper part of
neck
Acute otits media
• Preceding URI &
blocked ear
• Severe otalgia
• Bulging
congested ear
drum
• Eustachian
catarrh
Systemic Complications
• Acute rheumatic fever
• Acute glomerulonephritis
• Bacterial endocarditis
• Dermatitis
• Septicemia
• Septic abscesses
• Septic arthritis
• Menigitis
 Investigations
• CBC & serum electrolytes
• Crypt swab culture & sensitivity – 60%
specificity
• Crypt aspiration culture & sensitivity –↑ed
specificity
• A rapid antigen detection test (RADT) has 95%
specificity
• Serum examined for anti-streptococcal
antibodies – ASO titre - Useful for documenting
prior infections in – acute rheumatic fever,
glomerulonephritis or other complications
• Monospot serum test
Medical Management of
Acute Tonsillitis
Largely supportive
Adequate hydration and caloric intake
Control pain
Antibiotics –
• Penicillin – 1st line treatment
• Macrolides, Cephalosporins, Clindamycin
• Vancomycin and Rifampin are also used
Current Indications for
Tonsillectomy
• Recurrent tonsillitis
• Chronic persistent tonsillitis
• Hypertrophic obstructive Tonsillitis not responding to
medicine causing dysphagia or OSA
• Diphtheria carrier state
• Rec Peritonsillar abscess +/_ Rec tonsillitis
• Unilateral tonsillar hypertrophy
• Benign tumours of tonsil like papilloma, adenoma
• Chronic tonsillolith
• As an approach to IX nerve, elongated styloid process
Adenoidectomy-Indications
• Recurrent or chronic sinusitis or adenoiditis
– Poorly understood - possibly caused by
obstructive adenoid tissue causing stasis of
secretions predisposing the nasal cavity to
infection.
• Otitis media
– Proximity of adenoid tissue to eustachian tube
– Adenoidectomy can be recommended on 1st set
of tubes if nasal obstruction and recurrent
rhinorrhea is present or on 2nd set of tubes if
needed.
Contra indications for adeno
tonsillectomy
• Epidemic of polio
• Age below 3 years
• Acute infections
• Blood dyscrasiasis: hemophilia, purpura
• Uncontrolled systemic diseases like diabetes and heart
diseases
• Velopharyngeal insufficiency
– Overt cleft palate, submucous (covert) cleft
– Neurologic or neuromuscular abnormality leading to impaired
palate function
• Anemia
Cold steel Instruments
Complications of
Tonsillectomy
• Haemorrhage
• Haematoma & oedema uvula
• Infection
• Pulmonary complications
• Remnant tonsils
• Referred otalgia
• Post operative scarring causing voice change or
nasal regurgitation
Complications
• Noniatrogenic complications after adenoidectomy
– Regrowth of adenoid tissue, particularly in very
young children, which may require revision
(secondary) adenoidectomy.
– Hypernasality, because of temporary pain
splinting. Persistent hypernasality is rare and
probably caused by unrecognized pre-existing
velopharyngeal weakness.
– Atlantoaxial subluxation (Grisel’s syndrome),
which presents with persistent torticollis 1-2
weeks after surgery.
• Iatrogenic complications after adenoidectomy
include
– Dental injury, from intubation or the mouth gag
– Nasopharyngeal stenosis, caused by excessive
tissue removal.
• History
• Indications
• Innovative Techniques and Comorbidites
– Intracapsular tonsillectomy
– Harmonic scalpel
– Laser
– Coblation
• Adjuvant Therapy
– Local Anesthesia: Bupivacaine
– Postoperative Antibiotics
History
• Aulus Cornelius Celsus
– 1st Century AD
– “the tonsils are loosened by scraping around them and
then torn out” with a finger
– Used vinegar and medication for postoperative
hemostasis
• Aetius of Amida
– 6th Century AD
– Hook and knife method
• Philip Syng Physick (“Father of American surgery”)
– First to develop the tonsillotome
• Mackenzie
– Late 1800s
– Made tonsillotome use common
Innovative Techniques
• Intracapsular • Guiding Principle:
Tonsillectomy reduce morbidity
• Harmonic Scalpel – Hemorrhage
– Pain
• Laser
– Diet
• Coblation – Activity
– Cost
Intracapsular Tonsillectomy

– Tonsillar hypertrophy causing sleep

disordered breathing
• Intracapsular tonsillectomy
– Microdebrider at 1500 rpm in oscillating mode
– Hemostasis with suction cautery
• Total tonsillectomy
– Subcapsular
• Conclusions
– Intracapsular tonsillectomy is safe and
efficacious in children under 3 years for tonsillar
hypertrophy and sleep disordered breathing
without need for admission
• Limitations
– Retrospective study
– Uneven distribution
– Long term results of tonsillar regrowth unknown
 Harmonic Scalpel
Tonsillectomy
• Ultrasonic dissector and coagulator
• Vibratory energy
– Cutting: sharp blade with frequency of
55.5 kHz over distance of 80 μm
– Coagulating: vibration breaks H-bonds,
thermal energy
• 50° – 100° C
• Electrocautery 150° – 400° C
• Operative time statistically significant
– Harmonic scalpel 8 min 42 sec
– Electrocautery 4 min 33 sec
• No significant difference in intraoperative blood
loss and postoperative ability to eat and drink
• Level of activity for the first postop day
significantly lower in harmonic scalpel group
• Postoperative pain scores tended to be lower in
harmonic scalpel group
• Postoperative bleeding
– Harmonic scalpel: 6
– Electrocautery: 3
– Not statistically significant
Laser Tonsillectomy
Compared the use of KTP laser
tonsillectomy versus cold dissection
and snare
– KTP 532 laser at 10W, continuous beam
– Outcomes measured
• Operative time
• Operative bleeding
• Postoperative pain
• Postoperative advancement to diet
• Results
– Operative time:
• Laser 12 min
• Dissection 10 min
• Not statistically significant
– Intraoperative blood loss
• Laser 20 mL
• Dissection 95 mL
• Statistically significant
– Laser group with higher postop pain scores
– Laser group with greater difficulty resuming
postoperative diet
– Readmission for delayed hemorrhage was 8%
in the laser group and 4% in the dissection
group
• Not statistically significant
• Conclusion
– KTP laser provides little benefit over
dissection tonsillectomy except to
minimize intraoperative bleeding
• Limitations
– Technical expertise
– Electrocautery not included
Coblation Tonsillectomy
• Bipolar radiofrequency energy transferred
to sodium molecules to create an ion or
plasma field
• This thin layer of plasma is utilized to
ablate tissues at molecular level
• No need for electrocautery for hemostasis
• Temperature from 40° to 85° C
• Electrocautery at 20W: above 400° C
• Coblation
– From surface out laterally
– Coblate 9 setting to ablate tissues
– Coblate 5 setting to coagulate
– Capsule not penetrated
• Electrocautery
– Bovie set to 20 W
• Outcomes measured
– Questionnaire
• Pain
• Analgesics
• Nausea/vomiting
• Diet
• Activity
– Complications
Coblation Tonsillectomy
• Future considerations
– To evaluate coblation
for intracapsular
tonsillectomy, a fair
study would use another
intracapsular technique
such as power-assisted
tonsillectomy with a
microdebrider
• Technique
– Monopolar electrocautery used most often
• Greatest for otolaryngologists in practice < 20 years
• Hemostasis
– Sharp dissection most common for group in
practice > 20 years
• Decreased pain
• Method of hemostasis not mentioned
• Local Anesthetic evenly distributed
Conclusions

• Tonsillectomy is a surgical procedure that

carries significant postoperative
morbidity
• To minimize postoperative morbidity
various techniques and adjuvant
therapies have been studied
• There are many options available and it
behooves an otolaryngologist to stay as
up to date as possible
THANK YOU