Adeno tonsillitis dr.p.k arthikeyan, 11.07.16

1. ACUTE & CHRONICACUTE & CHRONIC
ADENO TONSILLITISADENO TONSILLITIS
Dr. P. Karthikeyan D.L.O.,DNB(ENT)Dr. P. Karthikeyan D.L.O.,DNB(ENT)
Professor & HOD,Professor & HOD,
Dept. of ENT,Dept. of ENT,
MGMC&RI.MGMC&RI.

2. Waldeyer’s Ring consist ofWaldeyer’s Ring consist of
1. Adenoids1. Adenoids
2. Tubal tonsils2. Tubal tonsils
3. Palatine tonsils3. Palatine tonsils
4. Lingual tonsils4. Lingual tonsils
5. Pharyngeal bands5. Pharyngeal bands

4. Naso pharyngeal bursaNaso pharyngeal bursa
It is an epithelial lined medianIt is an epithelial lined median
recess found within the adenoid mass andrecess found within the adenoid mass and
extends from pharyngeal mucosa to theextends from pharyngeal mucosa to the
periosteum of the basiocciput.periosteum of the basiocciput.
It represents the attachment ofIt represents the attachment of
notochord to the pharyngeal endodermnotochord to the pharyngeal endoderm
during embryonic life.during embryonic life.

5. Rathke’s pouch
• It is represented clinically by a dimple
above the adenoids.
• It is reminiscent of the buccal mucosal
invagination, to form the anterior lobe of
pituitary

7. Lymphoid tissue in Lymph Node
waldeyer’s ring
1. Subepithelial in Position Subcutaneous
2. No demarcation between It has cortex,
Cortex and medulla medulla and germinal
centre.
3. Partly capsulated or non Capsulated
capsulated
4. Crypts or furrows - No crypts
present
5. No afferent, only efferent Both afferent and efferent.

8. Adenoids Tonsil
1. Luscka’s tonsil Faucial tonsil
2. Unilateral Bilateral
3. Furrows seen Crypts present
4. Present in the posterosuperior Between pillars-Oropharynx
wall of the nasopharynx
5. Pseudostratified ciliated Stratified squamous
columnar epithelium epithelium
6. Truncated pyramid Almond shaped
7. Uncapsulated Partly capsulated
8. Regresses completely Persist.
after puberty

9. • A tonsil presents two surfaces – a medial
and a lateral, and two poles – an upper
and a lower.
MEDIAL SURFACE
• Covered by non keratinising stratified
squamous epithelium
• 12 – 15 crypts.
• One of the crypts, situated near the upper
part of tonsil is very large and deep and is
called crypta magna or intratonsillar cleft

10. LATERAL SURFACE
• Well defined fibrous capsule, between the
capsule and the bed of tonsil is the loose
areolar tissue- peritonsillar space.
• Buccopharyngeal fascia.
• Superior constrictor & Styloglossus
muscles
• Pharyngobasilar fascia.
• Facial artery, submandibular salivary
gland, medial pterygoid muscle and the
angle of mandible.

11. • Tonsillar branch of facial Artery. This is
the main artery
• Ascending pharyngeal artery from external
carotid.
• Ascending palatine, a branch of facial
artery
• Dorsal linguae branches of lingual artery
• Descending palatine branch of maxillary
artery

13. • Venous drainage
Paratonsillar vein- Dennis brown vein
• Lymphatic drainage
Jugulodigastric (tonsillar) node – ½ -1
inch below and behind the angle of
mandibule
• Nerve supply
Lesser palatine branches of
sphenopalatine ganglion (CN V) and
glossopharyngeal nerve provide sensory
nerve supply.

15. AdenoiditisAdenoiditis
Signs & symptoms
1. Nasal
2. Ear
3. General
Adenoid facies

17. Postnasal examination of Adenoids

18. General symptoms
Adenoid facies
 Elongated face with dull expression
 Open mouth
 The prominent and crowded upper teeth
 Hyperplasia of gums
 Hypoplasia of maxilla
 Loss of nasolabial fold
 Pinched nostrils
 High arched palate
 Drooling of saliva.
Loss of appetite
Abdominal pain – Mesentric adenitis

19. X-ray shows Protruded teeth and crowded teeth

20. X-ray lateral view of Nasopharynx showing Adenoids

21. Investigation
1. Blood investigations
2. X ray soft tissue Naso pharynx lateral view
3. Digital palpation
4. Nasal endoscopy
Treatment
Adenoidectomy

22. ADENOIDECTOMY
Indications
 Adenoiditis
 Adenoid hypertrophy causing sleep apnoea syndrome.
 Chronic secretory otitis media associated with adenoid
hyperplasia.
 CSOM with adenoid hyperplasia (Focal sepsis)
Contraindications
 Cleft palate or submucous palate.
 Bleeding diathesis.
 Acute upper respiratory tract infection.

23. Adenoidectomy

24. COMPLICATIONS
 Haemorrhage usually seen in immediate post-operative
period.
 Injury to Eustachian tube opening.
 Injury to pharyngeal musculature and vertebrae due to
hyperextension of neck.
 Gracielle’s sign – Anterior spinal ligament will get injured while
doing overenthusiastic adenoidectomy and produce neck
stiffness.
 Velopharyngeal insufficiency.
 Nasopharyngeal stenosis due to scarring.

26. Tonsil consists of
1. Surface epithelium
2. Crypts
3. Lymphoid tissue

27. ACUTE TONSILLITIS

28. Types
1) Acute follicular Tonsillitis
2) Acute Parenchymatous Tonsillitis
3) Acute membranous Tonsillitis

29. Etiology
1) Group A Beta heamolytic streptococcus.
Staph, Pneumococci, H.influenzae
2) Secondary to viral infection

30. Clinical Features
Symptoms
1) Throat pain
2) Difficulty in swallowing
3) Painful swallowing
4) Sore throat
5) Earache - Referred, Aom
6) Abdominal Pain
7) Constitutional symptoms

31. Signs
1) Foetid breath and coated tongue
2) Congestion
3) Sometimes trismus
4) Tender JD nodes
Treatment
Conservative

33. Complications
Chr. Tonsillitis
Abscess
Tonsillolith
Rheumatic fever
AGN
Subacute bacterial endocarditis

34. D.D of membrane over the TonsilD.D of membrane over the Tonsil
1) Membranous Tonsillitis
2) Diptheria
3) Vincent’s angina
4) Im
5) Agranulocytosis
6) Leukaemia
7) Apthous ulcers
8) Oral thrush

35. Chronic TonsillitisChronic Tonsillitis
Etiology:
1) Complication of Acute Tonsillitis
2) Chronic Sinusitis may be a predisposing
factor
Types:
1. Chronic follicular
2. Chronic parenchymatous
3. Chronic fibrotic

36. Clinical features
Symptoms:
1) Recurrent attacks of sore throat
2) Difficulty in swallowing
3) Chronic cough
4) Throat irritation

37. Signs
1) Congestion of anterior pillar
2) May enlarged or fibrotic
3) Squeeze test or Irwin Moore sign
4) Non tender JD nodes

39. Inv
TC,DC,ESR
Hb%
BT,CT, platelet count
Urine - alb, sugar
Blood grouping & typhing.
Blood urea & sugar
ASO titre
Throat swab

40. Treatment
1) Conservative
2) Tonsillectomy

41. TONSILLECTOMY
Indication
 Chronic tonsillitis
 Recurrent attacks of acute tonsillitis
 4-6 weeks following an attacks of peritonsillar abscess (Interval
tonsillectomy)
 Huge tonsil causing obstructive sleep apnoea syndrome.
 Huge tonsil causing mechanical obstruction to swallowing.
 Persistent carrier of Group – A Beta Haemolytic streptococcus
or diptheira bacilli.
 Sarcoma or lymphoma
 Benign tumours – Fibroma, papilloma.

42. UNILATERAL
1. Approach
Glosso-pharyngeal neurectomy in glossopharyngeal
neuralgia
Elongated styloid process.
UPPP
2. Tonsillar cyst, Tonsillolith.
3. Foreign body – tonsil.
4. Suspected malignancy for biopsy.

43. Methods of Tonsillectomy
1. Dissection method
2. Laser (Light amplification by stimulated emission of
radiation )
Advantage: Less bleeding, less pain, less scarring,
quick healing.
Disadvantage: Cost of laser therapy is high.
.

44. 3. Cryosurgery
It utilizes freezing for excision of tissues with the help of
cryoprobe. Nitrous oxide cryoprobe can achieve a temperature of –
70c while liquefied nitrogen can cool upto –196c.
Mode of action:
1. Cell membrance ruptures due to the formation of intracellular ice
crystals.
2. Intracellular dehydration occurs due to ice crystallization.
3. Proteins become denatured.
4. Enzymatic inhibition follows destruction of cellular metabolism.
5. Local ischaemia and microthrombosis of blood vessels occur.
Advantage: Less bleeding, less pain
Dis advantage: Histopathology of the excised tissue is not
possible due to destruction of the tissue by
freezing.

45. 4 . Radiofrequency method
5 . Coblation Method
Advantage: Less bleeding, less pain, less scarring,
quick healing.
Disadvantage: Cost is high.
.

46. Contra indications
Absolute
1. Bleeding diathesis
2. Aneurysm of internal carotid artery.
3. Acute infection
Relative
1. During epidemic of polio.
2. Severe diabetes and hypertension.
3. Gross allergy and severe asthma.
4. Children under 3 years of age.
5. Hemoglobin level less than 10g %

47. Complications
1. Haemorhage
Primary
Reactionary
Secondary
2. Aspiration pneumonia
3. Collapse of lung
4. Injury to tonsillar pillars, uvula, soft palate results in
nasopharyngeal incompetence and nasal intonation.
5. Dental injury
6. Scoline apnoea – common in vaishnavas due to pseudocholine
esterase deficiency.
7. TM joint dislocation
8. Tonsillar remnants
9. Hypertrophy of lingual tonsil.

48. T
H
A
N
K
Y
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49. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS
(QUINSY)(QUINSY)
It is a collection of pus in the peritonsillarIt is a collection of pus in the peritonsillar
space which lies between the capsule ofspace which lies between the capsule of
tonsil and the superior constrictor muscletonsil and the superior constrictor muscle

51. AETIOLOGY
• Peritonsillar abscess usually follows acute
tonsillitis
• First, one of the tonsillar crypts, usually
the crypta magna, gets infected and
sealed off. It forms an intratonsillar
abscess which then bursts through the
tonsillar capsule to set up peritonsillitis
and then an abscess.
• Culture of pus
• Growth of strept. Pyogenes, staph.
Aureus or anaerobic organisms. More
often the growth is mixed, with both
aerobic and anaerobic organisms.

52. CLINICAL FEATURES
• Peritonsillar abscess mostly affects adults
and rarely the children though acute
tonsillitis is more common in children
• General
• Fever (up to 104◦F) chills and rigors,
general malaise body aches headache
nausea and constipation
• Local
• Severe pain in throat
• Odynophagia
• Muffled and thich speech often called “hot
potato voice”

53. • Foul breath due to sepsis in the oral cavity
• Ipsilateral earache. This is referred pain via CN
IX which supplies both the tonsil and the ear.
• Trismus due to spasm of pterygoid muscles
• EXAMINATION
• The tonsil, pillars and soft on the involved side
are congested and swollen
• Uvula is swollen and oedematous and pushed to
the oposite side
• Bulge of the soft palate and anterior pillar
• Cervical lymphadenopathy is commonly seen
• Jugulodigastric lymph nodes
• Torticollis, patient keeps the neck tilted to the
side of abscess.

54. TREATMENT
• Hospitalisation
• Intravenous fluids to combat dehydration
• Antibiotics
• Analgesics like paracetamol
• Oral hygiene
• Incision and drainage of abscess. A
peritonsillar abscess is opened at the
point of maximum bulge above the upper
pole of tonsil or just lateral to the point of
junction of anterior pillar with a line drawn
through the base of uvula or midway
between base of uvula and 3rd molar.

55. • Interval tonsillectomy. Tonsils are
removed four to six weeks following an
attack of quinsy
• Abscess or hot tonsillectomy. Some
people prefer to do “hot” tonsillectomy
instead of incision and drainage. Abscess
tonsillectomy has the risk of rupture of the
abscess during anesthesia, and excessive
bleeding at the time of operation.

56. Complication
• Parapharyngeal abscess
• Oedema of larynx. Tracheostomy may be
required
• Septicaemia other complications like
endocarditis, nephritis, brain abscess may
occur.
• Pneumonitis or lung abscess. Due to
aspiration of pus, if spontaneous rupture
of abscess takes place
• Jugular vein thrombosis
• Spontaneous haemorrhage from carotid
artery or jugular vein