Adenotonsillar Disease Flashcards
When do the tonsils begin to develop?
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
When do the adenoids begin to develop?
16 weeks gestation = develop as subepithelial infiltration of lymphocytes
What are some other important embryological developments related to the tonsils and adenoids?
Crypts develop from 3-6 months gestation, capsule develops in 5th month, germinal centres develop after birth
What are the main functions of the tonsils and the adenoids?
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
When is it unusual to have significant adenotonsilar enlargement?
Before the age of 2
What happens to the adenoids and the tonsils after the early teenage years?
Decrease in bulk
What is Waldeyer’s ring?
Ring of lymphoid aggregation in the subepithelial layer of the oropharynx and nasopharynx
What structures make up Waldeyer’s ring?
Tonsils (palatine tonsils), adenoids (pharyngeal tonsils) and lingual tonsil
What are the histological features of the tonsils?
Specialised squamous, deep crypts, lymphoid follicles, posterior capsule
What are the histological features of the adenoids?
Ciliated pseudostratified columnar, stratified squamous, transitional, deep folds
What cell types are present in the upper aerodigestive parts of the tonsils and adenoids?
Ciliated columnar respiratory type mucosa, squamous epithelium
Where are some areas that would have squamous epithelium?
Areas where food goes in/high use/trauma = oral, pharyngeal, vocal cords, oesophagus
What are some examples of areas with columnar epithelium?
Areas where air goes = nose, PNS, trachea
What are some common pathologies of the tonsils and adenoids?
Acute tonsillitis, recurrent/chronic tonsillitis/adenoiditis, obstructive hyperplasia, malignancy, tonsil crypt debris/tonsiliths, glue ear
What are the majority of acute tonsillitis cases due to?
Viral aetiology = EBV, rhinovirus, influenza, parainfluenza, enterovirus, adenovirus
How common are bacterial causes of acute tonsillitis?
About 5-30% = group A strep important because of potential sequalae
Are throat swabs taken in patients with acute tonsillitis?
No
What are the most common bacteria that cause acute tonsillitis?
Group A strep, h. influenzae, staph aureus, strep pneumoniae, 39% are beta lactamase producing (BLPO)
What are the differentials of acute tonsillitis?
URT viral infection, glandular fever, peritonsillar abscess, candida infection, lymphoma, leukaemia, carcinoma, diphtheria, scarlet fever
What are the symptoms of a viral case of acute tonsillitis?
Malaise, temperature, sore throat (needs mild analgesia), able to undertake near normal activity, possible lymphadenopathy, lasts 3-4 days
What are the symptoms of bacterial acute tonsillitis?
Systemic upset, fever, odynophagia, halitosis, unable to work/school, lymphadenopathy, lasts about 1 week (need antibiotics to settle)
What is the purpose of the modified Centor criteria for acute tonsillitis?
Differentiates between viral and bacterial causes
What criteria make up the modified Centor criteria?
History of fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough
How does the modified Centor criteria dictate how a patient will be treated for acute tonsillitis?
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)
What are the treatment options for acute tonsillitis?
Supportive = eat/drink, rest, paracetamol/NSAIDs
Antibiotics, hospital (IV fluid/antibiotics, steroids), surgery
What antibiotics are used to treat acute tonsillitis?
500 mg penicillin qid for 10 days, clarithromycin if allergic
When are tonsillectomies recommended to treat acute tonsillitis?
Recurrent severe throats in adults, recurrent sore throats due to acute tonsillitis, episodes of sore throats that are disabling and prevent normal function
How often would a patient need to have acute tonsillitis to qualify for a tonsillectomy?
>= 7 episodes in previous year >= 5 episodes in each of previous two years >= 3 episodes in each of previous three years
What are some features of surgery for acute tonsillitis?
Very sore afterwards, worst day is the 5th one post surgery, may need strong opiates, daycase surgery, 5% risk of haemorrhage
How do peritonsillar abscesses normally occur?
As a complication of acute tonsillitis = bacteria between muscle and tonsils produces pus
How do peritonsillar abscesses present?
Unilateral throat pain and odynophagia, trismus, 3-7 days of preceding acute tonsillitis
What are some signs that a patient may have a peritonsillar abscess?
Medial displacement of tonsil and uvula, concavity of palate lost
How are peritonsillar abscesses treated?
Aspiration and antibiotics
What causes glandular fever?
Epstein Barr virus
What are the signs of glandular fever?
Gross tonsillar enlargement with membranous exudate, marked cervical lymphadenopathy, palatal petechial haemorrhage, generalised lymphadenopathy, hepatosplenomegaly
How is glandular fever diagnosed?
Atypical lymphocytes in peripheral blood, positive Monospot or Paul-Bunnell test, low CRP (<100)
How is glandular fever treated?
Symptomatic treatment, antibiotics, steroids
What antibiotics should never be given to a patient with glandular fever?
Ampicillin or amoxicillin = will cause a rash
How would chronic tonsillitis present?
Chronic sore throat, malodorous breath, presence of tonsillitis, peritonsillar erythema, persistent tender cervical lymphadenopathy
What is a controversial treatment option for chronic tonsillitis?
Surgery = rarely offered
How does obstructive hyperplasia of the adenoids present?
Obligate mouth breathing, hyponasal voice, snoring and other symptoms of sleep disturbance, acute otitis media/otitis media with effusion
How would obstructive hyperplasia of the tonsils present?
Snoring and other symptoms of sleep disturbance, muffled voice, dysphagia
What must be differentiated between in unilateral tonsillar enlargement?
Apparent enlargement vs true enlargement
What are some causes of unilateral tonsillar enlargement?
Non-neoplastic = acute/chronic infection, hypertrophy, congenital
Neoplasm
What are other terms used to describe glue ear?
Otitis media with effusion, serous otitis media
Is acute otitis media the same as glue ear?
No = they are different
What is glue ear?
Inflammation of the middle ear with accumulation of fluid but no symptoms of acute inflammation
What is acute otitis media?
Inflammation of the middle ear with symptoms of acute inflammation that may also have an accumulation of fluid
What is the epidemiology of otitis media with effusion?
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
What are the risk factors for developing otitis media with effusion?
Day care, older sibling, smoking household, recurrent URTI/acute otitis media, prematurity, craniofacial/genetic abnormalities, immunodeficiency, bottle feeding
What are some associations of otitis media with effusion?
May be seasonal, linked with allergy and nutrition
What is not a symptom of glue ear?
Otalgia
What are the symptoms of glue ear?
Deafness, poor school/behaviour problems, speech delay, balance problems, TV volume
What is used to diagnose glue ear?
History, otoscopy, tuning fork test, audiometry, tympanometry
What are some signs of glue ear?
TM retraction, reduced TM motility, altered TM colour, visible ME fluid/bubbles, CHL tuning fork tests
What investigations may be done for glue ear?
Age appropriate hearing assessment
Audiometry = OAE, distraction testing, COR, PTA
Tympanometry
How is simple glue ear treated?
Watchful waiting = 60% resolved by 1 month, 90% resolved by 3 months
Review at 3 months = otoscopy, PTA, tympanometry
How is glue ear treated if it lasts over 3 months with symptoms?
No evidence to support antibiotics, decongestants, mucolytics, steroids or antihistamines
Autoinflation may be beneficial
When should a patient be referred for glue ear?
Persistent (.3 months) and bilateral, CHL > 25dB, speech/language problems, developmental behaviour problems
What surgery is done to treat a child <3 years old with glue ear?
Grommets
What is the surgical management of a child >3 years old?
1st intervention = grommets
2nd intervention = grommets and adenoidectomy
When may an adenoidectomy be considered earlier than normal in a patient with glue ear?
If they have nasal symptoms
What are some complications of glue ear?
Some evidence of short term speech, language and behaviour problems, no evidence of long term complications
What are some complications of grommets?
Infection/discharge, early extrusion, retention, persistent perforation, swimming/bathing issues
