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ENT Medicine > Adenotonsillar Disease > Flashcards

Adenotonsillar Disease Flashcards

1
Q

When do the tonsils begin to develop?

A

8 weeks gestation = tonsillar fossa and palatine tonsils develop from dorsal wing of 1st pharyngeal pouch and the ventral wing of the 2nd pouch, tonsillar pillars originate from second/third arches

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2
Q

When do the adenoids begin to develop?

A

16 weeks gestation = develop as subepithelial infiltration of lymphocytes

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3
Q

What are some other important embryological developments related to the tonsils and adenoids?

A

Crypts develop from 3-6 months gestation, capsule develops in 5th month, germinal centres develop after birth

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4
Q

What are the main functions of the tonsils and the adenoids?

A

Trap bacteria/viruses on inhalation and expose them to immune system, production of antibodies by tissue immune cells, help prime immune system and prevent subsequent infections

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5
Q

When is it unusual to have significant adenotonsilar enlargement?

A

Before the age of 2

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6
Q

What happens to the adenoids and the tonsils after the early teenage years?

A

Decrease in bulk

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7
Q

What is Waldeyer’s ring?

A

Ring of lymphoid aggregation in the subepithelial layer of the oropharynx and nasopharynx

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8
Q

What structures make up Waldeyer’s ring?

A

Tonsils (palatine tonsils), adenoids (pharyngeal tonsils) and lingual tonsil

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9
Q

What are the histological features of the tonsils?

A

Specialised squamous, deep crypts, lymphoid follicles, posterior capsule

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10
Q

What are the histological features of the adenoids?

A

Ciliated pseudostratified columnar, stratified squamous, transitional, deep folds

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11
Q

What cell types are present in the upper aerodigestive parts of the tonsils and adenoids?

A

Ciliated columnar respiratory type mucosa, squamous epithelium

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12
Q

Where are some areas that would have squamous epithelium?

A

Areas where food goes in/high use/trauma = oral, pharyngeal, vocal cords, oesophagus

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13
Q

What are some examples of areas with columnar epithelium?

A

Areas where air goes = nose, PNS, trachea

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14
Q

What are some common pathologies of the tonsils and adenoids?

A

Acute tonsillitis, recurrent/chronic tonsillitis/adenoiditis, obstructive hyperplasia, malignancy, tonsil crypt debris/tonsiliths, glue ear

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15
Q

What are the majority of acute tonsillitis cases due to?

A

Viral aetiology = EBV, rhinovirus, influenza, parainfluenza, enterovirus, adenovirus

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16
Q

How common are bacterial causes of acute tonsillitis?

A

About 5-30% = group A strep important because of potential sequalae

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17
Q

Are throat swabs taken in patients with acute tonsillitis?

A

No

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18
Q

What are the most common bacteria that cause acute tonsillitis?

A

Group A strep, h. influenzae, staph aureus, strep pneumoniae, 39% are beta lactamase producing (BLPO)

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19
Q

What are the differentials of acute tonsillitis?

A

URT viral infection, glandular fever, peritonsillar abscess, candida infection, lymphoma, leukaemia, carcinoma, diphtheria, scarlet fever

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20
Q

What are the symptoms of a viral case of acute tonsillitis?

A

Malaise, temperature, sore throat (needs mild analgesia), able to undertake near normal activity, possible lymphadenopathy, lasts 3-4 days

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21
Q

What are the symptoms of bacterial acute tonsillitis?

A

Systemic upset, fever, odynophagia, halitosis, unable to work/school, lymphadenopathy, lasts about 1 week (need antibiotics to settle)

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22
Q

What is the purpose of the modified Centor criteria for acute tonsillitis?

A

Differentiates between viral and bacterial causes

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23
Q

What criteria make up the modified Centor criteria?

A

History of fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough

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24
Q

How does the modified Centor criteria dictate how a patient will be treated for acute tonsillitis?

A

0-1 point = no antibiotics (<10% risk of bacterial cause)
2-3 points = antibiotic only if symptoms progress (risk 15% if 2, 32% if 3)
4-5 points = treat empirically with antibiotic (56% risk)

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25
Q

What are the treatment options for acute tonsillitis?

A

Supportive = eat/drink, rest, paracetamol/NSAIDs

Antibiotics, hospital (IV fluid/antibiotics, steroids), surgery

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26
Q

What antibiotics are used to treat acute tonsillitis?

A

500 mg penicillin qid for 10 days, clarithromycin if allergic

27
Q

When are tonsillectomies recommended to treat acute tonsillitis?

A

Recurrent severe throats in adults, recurrent sore throats due to acute tonsillitis, episodes of sore throats that are disabling and prevent normal function

28
Q

How often would a patient need to have acute tonsillitis to qualify for a tonsillectomy?

A 
>= 7 episodes in previous year
>= 5 episodes in each of previous two years
>= 3 episodes in each of previous three years
29
Q

What are some features of surgery for acute tonsillitis?

A

Very sore afterwards, worst day is the 5th one post surgery, may need strong opiates, daycase surgery, 5% risk of haemorrhage

30
Q

How do peritonsillar abscesses normally occur?

A

As a complication of acute tonsillitis = bacteria between muscle and tonsils produces pus

31
Q

How do peritonsillar abscesses present?

A

Unilateral throat pain and odynophagia, trismus, 3-7 days of preceding acute tonsillitis

32
Q

What are some signs that a patient may have a peritonsillar abscess?

A

Medial displacement of tonsil and uvula, concavity of palate lost

33
Q

How are peritonsillar abscesses treated?

A

Aspiration and antibiotics

34
Q

What causes glandular fever?

A

Epstein Barr virus

35
Q

What are the signs of glandular fever?

A

Gross tonsillar enlargement with membranous exudate, marked cervical lymphadenopathy, palatal petechial haemorrhage, generalised lymphadenopathy, hepatosplenomegaly

36
Q

How is glandular fever diagnosed?

A

Atypical lymphocytes in peripheral blood, positive Monospot or Paul-Bunnell test, low CRP (<100)

37
Q

How is glandular fever treated?

A

Symptomatic treatment, antibiotics, steroids

38
Q

What antibiotics should never be given to a patient with glandular fever?

A

Ampicillin or amoxicillin = will cause a rash

39
Q

How would chronic tonsillitis present?

A

Chronic sore throat, malodorous breath, presence of tonsillitis, peritonsillar erythema, persistent tender cervical lymphadenopathy

40
Q

What is a controversial treatment option for chronic tonsillitis?

A

Surgery = rarely offered

41
Q

How does obstructive hyperplasia of the adenoids present?

A

Obligate mouth breathing, hyponasal voice, snoring and other symptoms of sleep disturbance, acute otitis media/otitis media with effusion

42
Q

How would obstructive hyperplasia of the tonsils present?

A

Snoring and other symptoms of sleep disturbance, muffled voice, dysphagia

43
Q

What must be differentiated between in unilateral tonsillar enlargement?

A

Apparent enlargement vs true enlargement

44
Q

What are some causes of unilateral tonsillar enlargement?

A

Non-neoplastic = acute/chronic infection, hypertrophy, congenital
Neoplasm

45
Q

What are other terms used to describe glue ear?

A

Otitis media with effusion, serous otitis media

46
Q

Is acute otitis media the same as glue ear?

A

No = they are different

47
Q

What is glue ear?

A

Inflammation of the middle ear with accumulation of fluid but no symptoms of acute inflammation

48
Q

What is acute otitis media?

A

Inflammation of the middle ear with symptoms of acute inflammation that may also have an accumulation of fluid

49
Q

What is the epidemiology of otitis media with effusion?

A

May occur in any child but less common as age increases, more common in males, present in 30% of children <4 years old at any time

50
Q

What are the risk factors for developing otitis media with effusion?

A

Day care, older sibling, smoking household, recurrent URTI/acute otitis media, prematurity, craniofacial/genetic abnormalities, immunodeficiency, bottle feeding

51
Q

What are some associations of otitis media with effusion?

A

May be seasonal, linked with allergy and nutrition

52
Q

What is not a symptom of glue ear?

A

Otalgia

53
Q

What are the symptoms of glue ear?

A

Deafness, poor school/behaviour problems, speech delay, balance problems, TV volume

54
Q

What is used to diagnose glue ear?

A

History, otoscopy, tuning fork test, audiometry, tympanometry

55
Q

What are some signs of glue ear?

A

TM retraction, reduced TM motility, altered TM colour, visible ME fluid/bubbles, CHL tuning fork tests

56
Q

What investigations may be done for glue ear?

A

Age appropriate hearing assessment
Audiometry = OAE, distraction testing, COR, PTA
Tympanometry

57
Q

How is simple glue ear treated?

A

Watchful waiting = 60% resolved by 1 month, 90% resolved by 3 months
Review at 3 months = otoscopy, PTA, tympanometry

58
Q

How is glue ear treated if it lasts over 3 months with symptoms?

A

No evidence to support antibiotics, decongestants, mucolytics, steroids or antihistamines
Autoinflation may be beneficial

59
Q

When should a patient be referred for glue ear?

A

Persistent (.3 months) and bilateral, CHL > 25dB, speech/language problems, developmental behaviour problems

60
Q

What surgery is done to treat a child <3 years old with glue ear?

A

Grommets

61
Q

What is the surgical management of a child >3 years old?

A

1st intervention = grommets

2nd intervention = grommets and adenoidectomy

62
Q

When may an adenoidectomy be considered earlier than normal in a patient with glue ear?

A

If they have nasal symptoms

63
Q

What are some complications of glue ear?

A

Some evidence of short term speech, language and behaviour problems, no evidence of long term complications

64
Q

What are some complications of grommets?

A

Infection/discharge, early extrusion, retention, persistent perforation, swimming/bathing issues

ENT Medicine (22 decks)

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