Adenotonsillar Disease Flashcards
describe general tonsil histology
luminal surface of the tonsil is covered by stratified squamous epithelium, which deeply invaginates the tonsil forming crypts
the base of the tonsil is separated from underyling muscle by a dense collagenous hemi-capsule
the parenchyma contains numerous lymphoid follicles dispersed just beneat the epithelium of the crypts
describe adenoid histology
deep folds and few crypts
surface is composed of ciliated pseudostratified columnar epithelium which functions in mucociliary clearance
deep to surface lies stratified squamous layer followed by transitional layer (responsible for antigen processing)
what happens to the adenoid layers with chronic infection
ciliated pseudostratified columnar epithelium is thinned, resulting in stasis of secretions and increased exposure of the tissue to antigenic stimuli
stratified squamous is thickened
describe tonsil histology
10-30 deep crypts
specialised squamous
lymphoid follicules
clinical features of acute viral tonsillitis
- able to undertake normal activity?
- duration?
sore throat ± lymphadenopathy
malaise
temperature
able to undertake normal activity
lasts 3-4 days
which lymph nodes are often enlarged in tonsillitis
jugulo-diagastric - palatine tonsil drains here first
clinical features of bacterial tonsillitis
- able to undertake normal activity?
- duration?
systemic upset
fever
odonyphagia
halitosis
unable to work/school
lymphadenopathy
lasts around a week and requires ABx to settle
causes of viral tonsillitis
- Rhinovirus, influenza, parainfluenza, enterovirus, adenovirus
causes of bacterial tonsillitis
often caused by Group A Streps eg Strep Pyogenes
also, staphs, Moraxella catarrhalis, mycoplasma, chlamydia, haemophilus
should suspected bacterial cases be swabbed
no - superficial swabs are irrelevant and can lead to over diagnosis
management
paracetamol and Difflam gargle if severe
ABx management?
most cases are viral
but if ill or Centor criteria positive, give penicillin
erythromycin if allergic
which ABx must not be given
amoxicillin
EBV is a DD, and this will cause a rash in those whose pharyngitis is due to EBV
give a recommendation for analgesia
alternate paracetamol and ibuprofen - both are anti-pyretic and analgesic
when should EBV be suspected
sore throat and malaise persist after ABX treatment, order WBC and Paul-Bunnell
tonsillectomy
removal of the palatine tonsils
outline the indications for tonsillectomy
recurrent severe sore throat in adults (not recommended in children)
- sore throats due to acute tonsillitis
- ≥5 episodes in past 2 years or ≥3 episodes in past 3 years
- episodes that are disabling and prevent normal functioning
post-op care
there is a lot of pain post-op - strong opiate recommended
otalgia is common
risk of haemorrhage post tonsillectomy
5%
differential diagnoses
- URTI viral infection
- Infectious mononucleosis (EBV)
- Peritonsillar abscess
- Candida infection
- Malignancy: lymphoma, leukaemia, carcinoma
- Diphtheria
- Scarlet fever
what is used to differentiate bacterial and viral cases
Centor clinical criteria
- Tonsillar exudate, tender anterior cervical lymph nodes, history of fever, absence of cough
Modified Centor Criteria
adds the patients age to the criteria:
- <15 add 1 point
- >44 subtract 1 point
describe the outcomes of Centor Clinical Criteria
positive in all 4 variables indicates a 40-60% positive prediction value for a culture of the throat to test positive for Group A strep bacteria (pyogenes)
the absence of all 4 indicates a negative prediction value of greater than 80%
therefore, it is more effective for ruling out strep throat than for diagnosing it
how many Centor points are required for ABx?
0-1 points: no ABx
2-3 points: receive ABx if symptoms progress
4-5 points: treat empirically with ABx
what is quinsy
peri-tonsillar abscess
can occur as a complication of tonsillitis - there is usually 3-7 days of preceding tonsillitis
bacteria between muscle and tonsil produce pus
how does quinsy present
unilateral sore throat, dysphagia and odonyphagia, peri-tonsillar bulge, uvular deviation, muffled voice and trismus (locked jaw)
concavity of palate is lost
management of quinsy
ABx and needle aspiration (this is preferred to surgical drainage)
what are some features of chronic/recurrent adenoiditis/tonsillitis
- Chronic sore throat
- Malodorous breath
- Presence of tonsilliths
- Peritonsillar erythema
- Persistent tender cervical lymphadenopathy
clinical features of adenoid hyperplasia
can obstruct the nasopharynx causing obligate mouth breathing
hyponasal voice
snoring and other signs of sleep disturbance
what can adenoid hyperplasia cause in the ear
AOM/OME due to blockage of Eustachian tube
symptoms of tonsillar hyperplasia
muffled voice
snoring etc
dysphagia ?
what can cause unilateral apparent enlargement of tonsil
tonsil can be displaced medially by peri-tonsillar abscess or parapharyngeal mass
which tumours are found in the tonsils
70% squamous cancer, benign papillomas, lymphoma
typical patient with tonsillar malignancy
elderly patient, sore throat, dysphagia ± otalgia
treatment of tonsillar malignancy
radiotherapy, surgery, cytotoxics
Tonsil crypt debris/Tonsilloliths
calcifications that form in the crypts of the palatine tonsils
symptoms of Tonsil crypt debris/Tonsilloliths
usually asymptomatic, can cause halitosis and dysphagia
metallic taste is sometimes noted
