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3.tonsils and adenoids

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3.tonsils and adenoids

  1. 1. Tonsils and Adenoids Dr. Krishna Koirala2016-12-12
  2. 2. • Definition Palatine tonsils are dense compact bodies of lymphoid tissue located in the lateral wall of the oropharynx, bounded by the palatoglossus muscle anteriorly and the palatopharyngeus and superior constrictor muscles
  3. 3. Arterial supply of tonsils
  4. 4. • Venous drainage – Para tonsillar vein → pharyngeal venous plexus → internal jugular vein • Lymphatic drainage – Jugulo- digastric lymph node of Woods • Nerve supply – Glossopharyngeal nerve and lesser palatine nerve
  5. 5. Relations of tonsillar bed
  6. 6. Relations of tonsillar bed (Inside out) 1. Tonsillar capsule 2. Peritonsillar space with paratonsillar vein 3.Pharyngobasilar fascia , Superior constrictor muscle, Bucco-pharyngeal fascia 4.Styloid process, muscles, glossopharyngeal nerve
  7. 7. Differences between tonsils and lymph node Tonsils Lymph Nodes Subepithelial Connective Tissue Partly encapsulated Fully encapsulated Efferent only Afferent + Efferent Crypts present Absent No cortex or medulla Present Growth curve present Absent
  8. 8. Differences between adenoids and Tonsils Adenoids Tonsils Ciliated columnar epithelium Non-keratinizing squamous epithelium No capsule Partly encapsulated Has furrows Has crypts Peak growth : 6 yrs 8 yrs Growth stops at 12 yrs 15 yrs Disappears at 20 yrs Partial regression at 18 yrs
  9. 9. Acute tonsillitis Classification • Superficial / catarrhal: as a part of generalized pharyngitis • Follicular: Crypts filled with pus, visible as yellow-white dots • Membranous: Multiple follicles join to form a yellow-white membrane • Parenchymatous: Infection of lymphoid
  10. 10. Superficial Tonsillitis
  11. 11. Follicular Tonsillitis
  12. 12. Membranous Tonsillitis
  13. 13. Parenchymatous tonsillitis
  14. 14. Types of chronic tonsillitis • Follicular: crypts filled with pus, visible as yellow-white dots • Parenchymatous: infection of lymphoid parenchyma → tonsil enlargement • Fibrotic: small tonsil with hidden pus inside, expressed by pressure on anterior tonsillar pillar (tonsillar squeeze)
  15. 15. Fibrotic tonsillitis
  16. 16. Signs of tonsillitis • Congested tonsil and tonsillar pillars • Enlarged tonsil (except chronic fibrotic type) • Tonsil squeezed by tongue depressor pressing on anterior tonsillar pillar → pus comes out in chronic fibrotic tonsillitis
  17. 17. Grades of tonsillar enlargement
  18. 18. Grade 1 enlargement
  19. 19. Grade 2 enlargement
  20. 20. Grade 3 enlargement
  21. 21. Grade 4 enlargement
  22. 22. Complications of acute tonsillitis • Local / locoregional – Recurrent tonsillitis – Intra-tonsillar abscess – Peritonsillar abscess (Quinsy) – Parapharyngeal abscess – Retropharyngeal abscess – Otitis media – Suppurative cervical • Systemic – Rheumatic fever – Subacute bacterial endocarditis (SABE) – Glomerulonephri tis – Septicemia
  23. 23. Differential diagnosis of white patch on the tonsil • Membranous tonsillitis • Faucial diphtheria • Infectious mononucleosis (Mono spot test) • Candidiasis (throat swab → Candida albicans) • Vincent's angina (fusiform bacilli, spirochete)
  24. 24. Treatment of tonsillitis • Bed rest • Adequate hydration • Systemic antibiotic: ampicillin, erythromycin , ceftriaxone, cefuroxime, amoxyclav • Antihistamines and decongestants • Analgesics • Antiseptic gargle
  25. 25. Differenc es between Membranous Tonsillitis Diphtheria Age > 5 yr 2- 5 yr Onset Acute Insidious General Symptoms More Less Odynopha gia More Less Temperatu re High Low Tachycard ia Proportionate Disproportion ate
  26. 26. Membranous tonsillitis Diphtheria Membrane Bilateral Whitish yellow Thin Limited to tonsil Easily removed May be unilateral Gray Thick May go beyond Bleeds on removal Culture β Hemolytic streptococci Corynebacterium diphtheriae Lymph Jugulo- Generalized (Bull
  27. 27. Treatment of faucial diphtheria • Isolation and bed rest • I.V. benzyl penicillin 600 mg q6h • Diphtheritic anti - toxin infusion in saline – 20,000 – 40,000 U : ≤ 48 hrs duration, tonsillar – 40,000 – 80,000 U : nasopharynx / larynx – 80,000 – 120,000 U : ≥ 48 hrs, neck edema
  28. 28. Tonsillolith and Tonsillar cyst Recurrent tonsillitis / retention of debris Blockage of tonsillar crypts pus and debris calcify yellow colored inclusion cystTonsillo lith tonsillar cyst
  29. 29. Tonsillolith and Tonsillar cyst contd…... • Clinical features – Halitosis, bitter taste in mouth – White outgrowths from tonsillar crypts or yellow cyst in supra-tonsillar cleft • Treatment – Asymptomatic → drainage of cyst or manual expression of tonsillolith – Severe symptoms → tonsillectomy
  30. 30. Keratosis pharyngis • Benign , self limiting condition • Etiology : Smoking, alcohol, vitamin A deficiency • O/E: – Yellowish, horn-like outgrowths from mucosa of tonsil that cannot be wiped off • Histopathology :
  31. 31. Keratosis pharyngis • Treatment: – Reassurance – Tonsillectomy in severe cases
  32. 32. D/D of Unilateral tonsillar enlargement • Tonsillar causes – Tonsillar malignancy – Peritonsillar abscess – Intra-tonsillar abscess – Tonsillolith – Tonsillar cyst – Tonsillar artery aneurysm – Vincent's angina • Extra-tonsillar causes – Parapharyngeal abscess – Parapharyngeal tumors – Tumors of deep parotid lobe – Internal carotid art.
  33. 33. Adenoids • Symptomatic, hypertrophic nasopharyngeal (Luschka's) tonsils • Adenoids lead to – Nasal obstruction  Mouth breathing – Eustachian tube block  OME • Features like adenoids are also seen in – Dental mal-occlusion – B/L nasal block ( Nasal polyps, choanal atresia)
  34. 34. Adenoid facies
  35. 35. • Features of nasal obstruction – B/L nose block & nasal discharge – Rhinolalia clausa (flat toneless voice) – Difficulty in feeding – Snoring – Pulmonary hypertension – Pinched nostrils (due to disuse atrophy)
  36. 36. • Features of mouth breathing – Open mouth, dribbling of saliva – High-arched palate (d/t moulding action of tongue) – Crowding of teeth, protruding central incisor – Hitched upper lip (hare lip) – Under shot mandible – Chronic pharyngitis (by breathing impure air)
  37. 37. • Features of Eustachian tube block – Earache – Conductive deafness (due to O.M.E.) – Dull, expressionless look – Inattentive child • Other Features – Pectus excavatum – Nocturnal enuresis
  38. 38. Nasopharyngoscopy
  39. 39. Plain X-ray soft tissue nasopharynx lateral view
  40. 40. Management • Diagnosis – Nasopharyngoscopy → rigid / flexible – Plain X–ray soft tissue nasopharynx lateral view with head extended → adenoid mass • Treatment – Mild symptoms → antihistamine +