Palatine Tonsils
The palatine tonsils are part of the Waldeyer ring which is an annular arrangement of lymphoid tissue in the subepithelial layer of the pharynx.
Other lymphoid aggregates that are part of the Waldeyer ring include the include:
- Nasopharyngeal tonsils (Adenoids)
- Tubal tonsils
- Lingual tonsils
- Lateral pharyngeal bands
- Palatine tonsils
There are two palatine tonsils in number, each an ovoid mass of lymphoid tissue in the lateral wall of the oropharynx between the anterior pillar (palatoglossal arch) and posterior pillar (palatopharyngeal arch). They provide local immunity and immunosurveillance by coming into contact with inhaled and ingested antigens.
Surfaces
| Surface | Description |
|---|---|
| Medial surface | Covered by non-keratinised stratified squamous epithelium which dips to form crypts the largest of which is known as Crypta magna or intratonsillar cleft. Crypts may be filled with cheesy material consisting of epithelial cells, bacteria and food debris which can be expressed by pressure over the anterior pillar. |
| Lateral surface | Made up of a well defined fibrous capsule |
| Upper pole | Extends to the soft palate |
| Lower pole | Attaches to the tongue |
| Bed of the tonsil | Made up of the superior constrictor and styloglossus muscle |
Acute Tonsillitis
Acute tonsillitis is an acute inflammation of the palatine tonsils. It commonly affects school-going children. It is rare in infants and adults > 50 years. Tonsilitis is most commonly viral with the common viruses being: Herpes Simplex virus, Epstein-Barr virus, cytomegalovirus, adenovirus, measles virus. Bacterial causative organisms include Streptococcus pyogenes, Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Diagnosis is clinical. Throat swab and culture are the standard for detecting Group A Beta haemolytic streptococci such as Streptococcus pyogenes. Imaging is only indicated if you suspect infection has spread to deep neck structures.
Primarily the tonsils are made up of surface epithelium, crypts, and lymphoid tissue. Inflammation of these different parts gives us this classification:
Classification of tonsillitis
| Classification | Description |
|---|---|
| Acute catarrhal tonsillitis (superficial) | Tonsilitis is part of a generalized pharyngitis. Viral in origin. |
| Acute follicular tonsillitis | Infection spreads into the crypts which are filled with pus. Appears as yellowish spots. |
| Acute parenchymatous tonsillitis | Infection spreads to the parenchyma. The tonsils are enlarged and red. |
| Acute membranous tonsillitis | Exudate from the crypts coalesce and form a membrane over the tonsils |
- Signs and symptoms
- Throat pain (sore throat)
- Foul breath
- Difficulty swallowing (dysphagia)
- Pain on swallowing (odynophagia)
- Fever (may be associated with chills and rigors)
- Ear pain (may be referred from the tonsils or due to acute otitis media)
- Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing (sleep apnea)
- Constitutional symptoms: Headache, malaise, constipation, abdominal pain (due to mesenteric lymphadenitis)
- Physical examination
- Fetid breath
- Open mouth breathing
- Subtle voice change (Thicker voice)
- Hyperemia of pillars, soft palate, and uvula
- Tonsils are red and swollen
- Yellowish spots of pus (acute follicular tonsilitis)
- Whitish membrane over the medial surface of the tonsils (acute membranous tonsilitis; can be wiped with a swab)
- Tonsils are enlarged and almost meet in the midline + edema of the uvula and soft palate (acute parenchymatous tonsilitis)
- Jugulodigastric lymphadenitis
- Stiff neck
- Investigations
- Complete blood count
- Peripheral blood film
- Throat swab and culture
- Rapid antigen detection test
- Serum testing for anti-streptococcal antibodies
- Differential diagnosis for membranous exudate over the tonsils
- Membranous tonsillitis
- Diphtheria
- Vincent angina
- Candidiasis of the tonsils
- Infectious mononucleosis
- Agranulocytosis
- Leukemia
- Aphthous ulcers
- Malignant tonsil
- Traumatic ulcer
- Supportive treatment
- Bed rest + plenty of fluids
- Analgesia: Acetaminophen, NSAIDs
- Antibiotics for 7-10 days
- Antihistamines and decongestants
- Antiseptic gargle
- Airway obstruction: nasal airway device, intravenous corticosteroids, and administering humidified oxygen.
- Definitive treatment
- Tonsillectomy
- Regional complications
- Chronic tonsilitis with recurrent attacks (due to incomplete resolution of acute infection)
- Peritonsillar abscess (Quinsy)
- Parapharyngeal abscess
- Retropharyngeal abscess
- Cervical abscess (following suppuration of jugulodigastric nodes)
- Acute otitis media
- Sinusitis
- Cervical lymphadenitis
- Mastoiditis
- Internal jugular vein thrombophlebitis
- Systemic complications
- Rheumatic fever
- Acute post-streptococcal glomerulonephritis
- Subacute bacterial endocarditis (in patients with valvular heart disease)
- Septicemia
Grading of Tonsillar enlargement
| Grade | Definition | Description |
|---|---|---|
| 1 | < 25% | Tonsils fill less than 25% of the transverse oropharyngeal space measured |
| 2 | 25-49% | Tonsils fill less than 50% of the transverse oropharyngeal space |
| 3 | 50-74% | Tonsils fill less than 75% of the transverse oropharyngeal space |
| 4 | > 75% | Tonsils fill 75% or more of the oropharyngeal space |
Chronic Tonsillitis
Chronic tonsillitis is chronic inflammation of the tonsils lasting longer than two weeks. It can come about as a complication of acute tonsillitis. Micro-abscesses walled off by fibrous tissue have been seen in the lymphoid follicles of the tonsils and have been implicated in causing recurrent infection. Chronic infection of surrounding tissues such as teeth, sinuses may also trigger it. Subclinical infections of tonsils without an acute attack may also occur leading to chronic tonsillitis. A polymicrobial involvement is seen with alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species.
Chronic tonsillitis is classified into the following:
| Classification | Description |
|---|---|
| Chronic Follicular tonsillitis. | Tonsillar crypts are full of purulent material which shows on the surface as yellowish spots. |
| Chronic Parenchymatous tonsillitis | There is hyperplasia of lymphoid tissue interfering with speech, deglutition and respiration. Attacks of sleep apnoea may occur. |
| Chronic Fibroid tonsillitis | Tonsils are small but infected, with history of repeated sore throats. |
- Signs and symptoms
- Chronic sore throat
- Halitosis
- Bad taste in the mouth
- Thick speech
- Difficulty and pain swallowing
- Poor sleep due to choking episodes at night
- Physical examination
- Tonsils may show varying degree of enlargement. Sometimes they meet in the midline (chronic parenchymatous).
- There may be yellowish beads of pus on the medial surface of tonsil (chronic follicular)
- Tonsils are small but pressure on the anterior pillar expresses frank pus (chronic fibroid).
- Enlargement of jugulodigastric lymph nodes. During acute attacks, the nodes enlarge further and become tender.
- Conservative treatment
- Rest
- Adequate hydration and caloric intake
- Treatment of coexistent infections
- Definitive treatment
- Tonsillectomy
- Complications
- Peritonsillar abscess
- Parapharyngeal abscess.
- Intratonsillar abscess.
- Tonsilloliths
- Tonsillar cyst
- Rheumatic fever
- Acute glomerulonephritis
https://www.dentistabbotsford.com.au/unveiling-the-mystery-of-tonsil-stones-what-you-need-to-know/ A tonsilloliths (tonsil stone)
https://www.dentistabbotsford.com.au/unveiling-the-mystery-of-tonsil-stones-what-you-need-to-know/ A tonsilloliths (tonsil stone)
Tonsillectomy
Tonsillectomy is surgical removal of the tonsils.
- Indications for tonsillectomy
- Obstructive symptoms
- Sleep-disordered breathing: Apnoea-Hypopnea Index > 5
- Adenotonsillar hypertrophy with dysphagia
- Adenotonsillar hypertrophy with craniofacial anomalies
- Mononucleosis with obstructive tonsillar hypertrophy unresponsive to steroids
- Peritonsillar abscess (Quinsy)
- 1 PTA with 2-3 previous episodes of tonsillits
- More than one episodes of PTA
- Meets the paradise criteria
- Failure to Thrive
- Febrile convulsions
- Tonsillar lesion suspicious for malignancy
- Tonsil stones
- Obstructive symptoms
- Paradise criteria for tonsillectomy
- Recurrent tonsillitis (7-5-3 rule of Paradise Criteria)
- 7 episodes in one year or
- 5 episodes each year for two consecutive years or
- 3 episodes each year for three consecutive years
- Sore throat + one of the following accounts for an episode:
- Temperature > 38.3
- Tonsillar exudate
- Cervical adenopathy
- Culture positive for GABHS
- Treatment: antibiotics given in conventional doses for proven or suspected Strep episodes
- Documentation: each episode in medical records
- If not, at least 2 episodes of throat infection with pattern of frequency and clinical history noted by physician
- Recurrent tonsillitis (7-5-3 rule of Paradise Criteria)
- Immediate complications for tonsillectomy
- Hemorrhage
- Trauma to the teeth and tongue by the mouth gag
- Anaesthetic complications
- Acute airway obstruction due to laryngospasms and bronchospasms)
- Odynophagia
- Decreased activity
- Dehydration due to decreased feeding
- Long-term complications of tonsillectomy
- Nasopharyngeal stenosis
- Retained packs causing infection
- Management of a patient post-tonsillectomy
- Recovery position: prevent aspiration of secretions and airway obstruction by the tongue
- Monitor vital signs, and for bleeding and pain overnight
- Analgesia: alternate paracetamol and an NSAID 4- hourly
- Discharge on prophylactic abx, PPIs (due to NSAID use)
- When patient is fully recovered they are permitted to take liquids, e.g. cold milk or ice cream, sucking of ice cubes
- Salt water gargles three to four times a day.
- Review after 7 days- white slough
