Tonsillitis and Adenoiditis
Adenoids and Tonsils
The adenoids are a mass of lymphoid tissue that occupy the roof of the nasopharynx. The adenoids have no capsule in comparison to the tonsils (faucial or pharyngeal). The lingual tonsils are imbedded in the base of the tongue. The tonsils occupy the tonsillar fossae between the anterior and posterior pillars, and are covered on their internal border by a capsule which separates them from the superior constrictor. This tissue forms Waldeyer’s ring. The function of this tissue is to stimulate an immune response from various ingested antigens. B and T lymphocytes are found in the tissue and function in their usual way with humoral and cell mediated immunity. However, it is not uncommon for the tonsils and adenoids to become infected themselves.
There is normally an increase in lymphoid tissue in Waldeyer’s ring in the first 6 to 7 years of life. There is generally no increased susceptibility to infection after tonsillectomy and adenoidectomy (T&A). There is a decreased production of IgA specific to the polio virus after adenoidectomy, resulting in an increased incidence of bulbar poliomyelitis in the first month after T&A.
This entity is commonly seen in children who “always have a cold.” Enlarged infected adenoids present with chronic or acute purulent nasal discharge, as well as chronic mouth breathing. Diagnosis is usually made on history and clinical exam. Posterior rhinoscopy with a nasopharyngeal mirror or flexible rhinoscopy is performed for a definitive diagnosis. These are poorly tolerated in the pediatric population, so lateral soft tissue films (X-rays) are obtained to determine the thickness of the adenoid pad. The acute infection is treated with antibiotics. Adenoid hypertrophy causes a variety of symptoms of nasal obstruction and chronic mouth breathing and contributes to snoring. Chronic or recurrent otitis media may occur secondary to eustachian tube obstruction as well.
Adenoid hypertrophy usually resolves in childhood and is unusual to see in an adult, so alternative diagnoses (i.e. cancer) must be considered in the older age group. Indications for adenoidectomy include obstruction secondary to adenoid hypertrophy with chronic mouth breathing, sleep apnea, failure to thrive, cor pulmonale, swallowing abnormalities, and speech abnormalities not attributed to other causes. Infectious indications include recurrent adenoiditis, chronic otitis media with effusion, recurrent otitis media, and chronic otitis media. Suspected malignancy requires biopsy. Surgical removal is curative for the adenoid hypertrophy but will obviously not eliminate all episodes of upper respiratory infections, etc. Post-operative recovery is one to 2 days associated with a mild sore throat and bloody rhinorrhea.
Visual inspection of the tonsils is often misleading. Between infections, tonsils may have a relatively benign appearance. Some tonsils are rather large and pedicled, others are relatively small and buried. History is the most important factor in determining the need for tonsillectomy.
Acute tonsillitis often presents with a sore throat, fever, malaise, and referred otalgia. The tonsils are usually swollen and red. The tonsillar crypts fill with debris and pus. Extreme difficulty with swallowing may then ensue. The infecting organisms are usually strep, staph, pneumococci, and H. influenza. Beta hemolytic strep is important to diagnose and treat to prevent cardiac and renal complications. Viruses account for nearly 50% of acute adenotonsillitis, and it is impossible to determine the invader by exam in most cases. Throat culture is sometimes helpful but should not delay treatment. The treatment is oral penicillin for ten days, analgesics, fluids, and bed rest. No response may be secondary to either a beta lactamase producing bacteria or a virus. The differential also includes infectious mononucleosis, diphtheria, and Vincent’s angina. Complications of untreated tonsillitis include quinsy (peritonsillar abscess), retropharyngeal abscess, or a lateral pharyngeal abscess.
The most common indication for tonsillectomy is repeated attacks of tonsillitis. An often quoted number is > 7 infections in 1 year, > 5 infections/year for 2 yrs, or > 3 infections/year for 3 yrs. Chronic tonsillitis with persistent sore throat, halitosis (bad breath), tonsillithiasis (concretions on crypts), and tender cervical adenitis are also considered surgical indications. The benefits have to be weighed against the surgical risks. Today, elective tonsillectomy is considered to be a safe outpatient procedure. Peritonsillar abscesses and abscessed cervical lymph nodes secondary to tonsillitis are also considered to be indications for tonsillectomy as well.
Tonsillar hypertrophy with upper airway obstruction, failure to thrive, cor pulmonale, speech or swallowing disorders and sleep apnea are also common indications for tonsillectomy. Other indications are less common, such as tonsillar asymmetry. In such situations, tonsillectomy is indicated to rule out a lymphoma or other type of cancer of the tonsil. Recovery after tonsillectomy requires one week in children and 1-2 weeks in adults. Complications are infrequent and include bleeding, emesis, dehydration, airway obstruction, and velopharyngeal insufficiency (increased in submucous cleft and cleft palate patients). Historic indications include rheumatic fever and valvular heart disease, glomerulonephritis, and diphtheria carriers.