Adenotonsillar Diseases Drbugnah

ADENOTONSILLAR DISEASES

Dr.Sherif Bugnah ENT Resident Armed Forces Hospitals Southern Region Khamis Mushayt - Saudi Arabia

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ADENOTONSILLAR DISEAS Outlines • INTRODUCTION

• ANATOMY & PHYSIOLOGY (Adenoid & Tonsils) • INFECTIONS : VIRAL INFECTIONS • Epstein-Barr virus (EBV) • Coxsackie virus • FUNGAL INFECTIONS

• BACTERIAL INFECTIONS • Group A -hemolytic streptococcus • Corynebacterium diphtheriae

Recurrent Acute Tonsillitis Chronic Tonsillitis Complications of Acute Adenotonsillitis • NONSUPPURATIVE COMPLICATIONS • SUPPURATIVE COMPLICATIONS

• Chronic Adenotonsillar Hypertrophy • TONSILLAR NEOPLASMS

INTRODUCTION  The tonsils and adenoids can be a source of infection and obstruction for both adults and children and are responsible for a significant childhood illnesses.  Tonsillectomy and adenoidectomy remain two of the most commonly performed procedures by otolaryngologists.

ANATOMY & PHYSIOLOGY  tonsils and the adenoids are both components of Waldeyer tonsillar ring.  The lymphoid tissue of Waldeyer tonsillar ring contains B-cell lymphocytes, T-cell lymphocytes, and a few mature plasma cells.

 Functions include secretory immunity & regulating immunoglobulin production.

ANATOMY & PHYSIOLOGY  most active from the ages of 4 to 10 and tend to supressed after puberty(secretory immune function these tissues remains, but much less.  The palatine tonsils are the largest component of the ring and have the most specialized structures..  A specialized portion of the pharyngobasilar fascia, forming afibrous capsule, binds the deep surface of the tonsil.

ANATOMY & PHYSIOLOGY (Tonsils)

 tonsillar fossa consist of three muscles form the. The palatoglossus muscle (the anterior tonsillar pillar) , palatopharyngeal muscle (posterior tonsillar pillar)  tonsillar fossa Base formed by the pharyngeal constrictors (primarily the superior constrictor).

ANATOMY & PHYSIOLOGY (Tonsils) Blood supply - Tonsils

Tonsillar branch

Tonsil(main branch)

Facial Artery Ascending palatine Lingual A.

Dorsal lingual

Ascending Pharyngeal Maxillary

Tonsil

Tonsil

Tonsil

Lesser descending palatine

Tonsil

ANATOMY & PHYSIOLOGY (Tonsils) enous Drainage

peritonsillar plexus

lingual and pharyngeal veins

ymphatic Drainage (behind angle of the mandible),

IJV

tonsillar lymph node jugulodigastric /upper

cervical lymph nodes.

erve Supply (tonsils): tonsillar branch of the glossopharyngeal nerve, also descending branches of the lesser palatine nerve.

ANATOMY & PHYSIOLOGY (Adenoids) he adenoids are located over the surface of the superior and posterior wall of the nasoph Blood supply – Adenoids  Ascending palatine branch of facial a.  Ascending pharyngeal a.  Pharyngeal branch of IMAX.  Ascending cervical branch of thyrocervical trunk  Venous drainage  Lymphatic drain

pharyngeal plexus retropharyngeal or

pharyngomaxillary lymph nodes.

INFECTIONS : VIRAL INFECTIONS

 Usually associated with viral pharyngitis, common complaint: sore throat and difficulty swallowing.  often fever and oropharyngeal erythema, usually without a tonsillar exudate.  Possible Viruses: adenovirus, rhinovirus, (RSV), influenza and parainfluenza .  Most of these infections are self-limited and require only symptomatic treatment.

INFECTIONS : VIRAL INFECTIONS Epstein-Barr virus (EBV)  Causes pharyngitis (infectious mononucleosis syndrome)  Children and young adults, Presents as fever, malaise, lymphadenopathy, hepatosplenomegaly  Petechiae may present at the junction of the soft & hard palates. Tonsils severely enlarged (may affect the airway),covered with grayish-white exudate.  Treatment: supportive, with IV fluids and rest.  If progressive airway obstruction, short course of systemic steroids can be helpful. Rarely, a nasopharyngeal airway, nasotracheal intubation or tracheotomy may needed.

INFECTIONS : VIRAL INFECTIONS

Coxsackie virus  ulcerative vesicles over the tonsils, posterior pharynx, and palate  Commonly in children under the age of 16.  headache, high fever, anorexia, & odynophagia.  Treatment : mostly supportive, tonsils can have a bacterial superinfection may benefit from systemic antibiotics.

FUNGAL INFECTIONS

 Oropharyngeal Candida (ie, thrush) mainly in immunocompromised patients or patients who have undergone prolonged treatment with antibiotics.  white plaques over the pharyngeal mucosa, bleeds if removed with a tongue depressor.  topical antifungal (e.g. nystatin or clotrimazole.)

BACTERIAL INFECTIONS  Acute Streptococcal Pharyngotonsillitis, Group A -hemolytic streptococcus is the most common.

 children aged 5–6, Presents with fever, dry sore throat, cervical adenopathy, dysphagia, and odynophagia.  Tonsils and pharyngeal mucosa erythematous ,may covered with purulent exudate; ("strawberry tongue")

BACTERIAL INFECTIONS  Major consideration is preventing complications (acute rheumatic fever & poststreptococcal glomerulonephritis. )  Suspected pharyngitis, Daignosed by rapid strep tests based on ELISA or latex agglutination, with a throat culture.  Treatment :Mainly Penicillin, if no response (48 hours), amoxicillin with clavulanate may be helpful. Therapy should be for 10 days to decrease recurrence.

Other Acute Bacterial Infections  Vincent angina is caused by Treponema vincentii and Spirochaeta denticulata.  Patients present with fever, unilateral pain (swallowing), ipsilateral cervical lymphadenopathy; unilateral deep ulcer on the upper pole of the tonsil, covered by a white exudative ulcer.  Treatment usually with penicillin and oral hygiene. heals in approximately 7–10 days membrane

Other Acute Bacterial Infections Corynebacterium diphtheriae  Usual symptoms of acute pharyngitis  Gay, firmly adherent pseudomembrane (covers the tonsils. 60% are localized to the pharynx; 8% spreads to the larynx, compromising the airway.  Diagnosis: Gram stain of the pseudomembrane reveals gram-positive aerobic bacillus  Treatment must started immediately, even before confirmation with the culture. antitoxin (within 48 hours of the onset of symptoms), high-dose penicillin.

Recurrent Acute Tonsillitis

 Episodes of acute tonsillitis with complete recovery between episodes.  due to their location and numerous crypts and crevices, seem to harbor bacteria.  Tonsillectomy is indicated in patients with recurrent acute tonsillitis involving 6–7 episodes of acute tonsillitis in 1 year, 5 episodes/y for 2 consecutive years, or 3 episodes/y for 3 years

Chronic Tonsillitis

 persistent sore throat, anorexia, dysphagia, and pharyngotonsillar erythema.  malodorous tonsillar concretions and the enlargement of jugulodigastric lymph nodes.  organisms involved are usually both aerobic and anaerobic mixed flora, with a predominance of streptococci.

Chronic Tonsillitis Tonsilloliths  deep or stenotic crypts, food and secretions stagnate, leading to bacterial overgrowth and a localized infection.  In some patients, a sensation of a foreign body in the throat, hard white material coming from the tonsils  mouth care, which includes irrigation of the tonsils or cleaning them with a cotton swab soaked in 3% hydrogen peroxide.  Tonsillar surgery and elimination of these cryptic structures may be needed to control these infections.

Grading the Size of Tonsils

Grading system: B. 0 – tonsils in fossa C. +1 – tonsils less than 25% D. +2 – tonsils less than 50% E. +3 – tonsils less than 75% F. +4 – tonsils greater than 75%

Complications of Acute Adenotonsillitis NONSUPPURATIVE COMPLICATIONS Scarlet Fever  fever, severe dysphagia, diffuse erythematous rash, pharyngeal symptoms.  yellow membranous exudate covering the tonsils and the pharynx, "strawberry tongue“, facial flush and petechiae , (eruptions followed by desquamation occur due to exotoxin produced by streptococcus. )  Symptom identification and treatment planning are important to prevent complications related to streptococcal infection. The traditional treatment is with penicillin.

Complications of Acute Adenotonsillitis

NONSUPPURATIVE COMPLICATIONS

Acute Rheumatic Fever  18 days post infection (group A -hemolytic strept.), when the throat culture is no longer positive. Streptococcal infection results in production of crossreactive antibodies, leading to damage of the heart tissues.  Patients should be placed on a penicillin prophylaxis or undergo tonsillectomy to eliminate the reservoir of streptococcal infection

Complications of Acute Adenotonsillitis NONSUPPURATIVE COMPLICATIONS Post-Streptococcal Glomerulonephritis  (12–25% incidence) typically 10 days after a pharyngotonsillar infection or (10% incidence) as skin infections with a nephrogenic strain caused by group A-H.S.  involves injury to the glomerulus by deposition of the immune complexes & autoantibodies  Antibiotic treatment has not been shown to affect the incidence of the disease.

Complications of Acute Adenotonsillitis SUPPURATIVE COMPLICATIONS Peritonsillar Abscess  Lies in the potential space between the tonsillar capsule and surrounding pharyngeal muscle bed.  Symptoms include malaise, severe odynophagia leads to dehydration & trismus.  O/E a bulging palate with the corresponding tonsil displaced to the midline or beyond.

Complications of Acute Adenotonsillitis SUPPURATIVE COMPLICATIONS Peritonsillar Abscess  Needle aspiration confirms diagnosis and ocate the abscess.  Definitive Treatment incision and drainage  recurrence rate for peritonsillar abscess indicate tonsillectomy. some surgeons favor a "Quincy tonsillectomy”, most surgeons prefer either to surgery after all the acute infection has resolved or to perform an interval tonsillectomy.

Complications of Acute Adenotonsillitis SUPPURATIVE COMPLICATIONS Deep Neck Infections  common cause of parapharyngeal abscesses is bacterial pharyngitis or tonsillitis.  odynophagia, trismus, and shortness of breath.  asymmetric pharyngeal swelling, including the palate, extends more inferiorly than the tonsil, into the hypopharynx.  Ultrasound may be helpful, a definitive diagnosis requires (CT) scan of the neck.  management includes control of the airway, intravenous antibiotics, I&D of the abscess.

Chronic Adenotonsillar Hypertrophy  Hypertrophy occurs in response to colonization with normal flora, pathogenic microorganisms & Secondhand smoke .  Symptoms: (adenoid hypertrophy) Nasal obstruction, rhinorrhea, hyponasal voice. (tonsillar enlargement) snoring, dysphagia, and hypernasal or a muffled voice.  Chronic adenotonsillar hypertrophy is the most common cause of sleep-disordered breathing in children

Chronic Adenotonsillar Hypertrophy  Adenotonsillar hypertrophy and chronic mouth breathing due to nasal obstruction is associated with craniofacial growth abnormalities (increased anterior facial height and a retrognathic mandible, with subsequent malocclusion.)  Flexible endoscopy is helpful in diagnosing adenoid hypertrophy and forruling out other causes of nasal obstruction.  Lateral neck soft-tissue radiography can be helpful if endoscopy is not performed.

TONSILLAR NEOPLASMS  Asymmetric tonsillar hypertrophy, if accompanied by a suspicious clinical course or history, a tonsillectomy should be performed for biopsy.  Lymphoma and squamous cell carcinoma are the most common primary tonsillar neoplasms.  Many primary malignant neoplasms metastasize to tonsils (eg, melanoma, renal, lung, breast, gastric and colon ca)  Benign tumors are rare, include lipomas, fibromas and schwannomas.

TONSILLAR NEOPLASMS  Parapharyngeal space tumors are important to consider, may present with similar signs and symptoms.  Risk Factors for Malignanency include tonsillar asymmetry associated with rapid enlargement, constitutional symptoms, atypical tonsillar appearance, ipsilateral cervical lymphadenopathy, and Hx of previous tumers.  Unilateral tonsillar enlargement in asymptomatic children is rarely of neoplastic , However, the diagnosis of tonsillar lymphoma should be considered when unilateral tonsillar enlargement is present either in an immunocompromised child or when acute tonsillitis is asymmetric and unresponsive to medical therapy.

ADENOTONSILLAR DISEASES : Refrences  Current Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 2nd Edition Copyright © 2008 

Harley EH. Asymmetric tonsil size in children. Arch Otolaryngol Head Neck Surg. 2002;128(7):767. (Prospective controlled study of the implication of pediatric tonsillar asymmetry.) [PMID: 12117331]

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Syms MJ, Birkmire-Peters DP, Holtel MR. Incidence of carcinoma in incidental tonsil asymmetry. Laryngoscope. 2000;110(11):1807. (Retrospective review examining the incidence of malignant neoplasms in incidentally discovered unilateral tonsillar enlargement.) [PMID: 11081589

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Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope. 2002;112:6. (A thorough review of the indications for tonsillectomy and adenoidectomy based on evidence in the medical literature.) [PMID: 12172229]

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Krisha P, Lee D. Post-tonsillectomy bleeding: A meta-analysis, Laryngoscope. 2001;111:1358. (A review of reports on post-tonsillectomy bleeding, the major complication of tonsillectomy.) [PMID: 11568568]

ADENOTONSILLAR DISEASES

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