Tonsils, Glue Ear and the Adenoids Flashcards
what happens at 8 weeks development?
tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch
tonsillar pillars originate from the 2nd/3rd arches
what happens at 6 weeks development?
adenoids develop as a subepithelial infiltration of lymphcytes
what are the 4 functions of the tonsils?
trap bacteria and viruses on inhalation
expose to immune system
antibodies produced by the immune cells in the tissue
help to prime immune system and help to prevent subsequent infections
how does the size of the tonsils change in growth?
smaller <2 yrs
- significant enlargement <2 y/o is rare
tonsils and adenoids decrease in bulk after early teenage years
what is waleyer’s ring?
ring of lymphoid aggregation in the subepithelial layer of oropharynx and nasopharynx comprised of - tonsils (palatine tonsil) - adenoids (pharyngeal tonsil) - lingual tonsil
describe the histological features of the tonsils
specialized squamous
deep crypts
lymphoid follicles
posterior capsule
describe the histological features of the adenoids
ciliated pseudostratified columnar
stratified squamous
transitional
deep folds
general histology of upper aerodigestive tract?
ciliated columnar respiratory type mucosa
squamous epithelium
general histology of where food goes/high use/trauma?
squamous
oral, pharyngeal, vocal cords, oesophagus
general histology of where air goes?
columnar
nose, PNS, larynx, trachea
what most commonly causes acute tonsillitis?
most are viral (EBV, rhinovirus, influenza, enterovirus, adenovirus)
5-30% are bacterial
group A beta haemolytic strep = most important pathogen
are throat swabs used in tonsillitis?
no
what are the most common organisms cultures from chronic tonsillar disease?
strep pyogenes H influenza staph aureus strep pneumonia beta lactamase producing
differential diagnoses of acute tonsilitis?
viral URTI glandular fever peritonsillar abscess candida infection malignancy diptheria scarlet fever
symptoms of viral tonsillitis?
malaise sore throat, mild analgesia requirement temperature able to go about normal activities possible lymphadenopathy lasts 3-4 days
symptoms of bacterial tonsillitis?
systemic upset fever odynophagia halitosis unable to work/school lymphadenopathy lasts 1 week, requires antibiotics to settle
centor criteria?
differentiates viral from bacterial tonsillitis fever tonsillar exudate tender anterior cervical lymphadenopathy absence of cough 0-1 = no antibiotic 2-3 = should get antibiotic if symptoms progress 4-5 = treat empirically with antibiotic
treatment of tnsilitis?
supportive (rest, eat and drink, analgesia)
antibiotic (penicillin 500g for 10 days, clarithromycin if allergic)
hospital if cant eat and drink (IV fluids and antibiotic, steroids)
surgery
problem with clarithromycin?
makes you sick
guidelines for tonsillectomy?
watch and wait more appropriate for children with mild sore throats
tonsillectomy is recommended for recurrent severe sore throats
- sore throats must be due to acute tonsillitis
- episodes os sore throats are disabling and prevent normal functioning
- seven or more well documented, clinically significant, adequately treated sore throats in preceeding year
or
- five or more per year in past 2 years
or
- three or more per year in past 3 years
features of post tonsillectomy?
very painful strong opiates required daycase pain worst at day 5 5% risk of haemorrhage
what is a peritonsillar abscess?
complications of acute tonsillitis where bacteria between muscle and tonsil produce pus
features of peritonsillar abscess?
unilateral throat pain and odynophagia trismus 3-7 days of preceeding acute tonsillitis medial displacement of tonsil and uvula concavity of palate is lost
how is peritonsillar abscess managed?
aspiration/drainage
antibiotics
what are the signs of glandular fever?
gross tonsillar enlargement with membranous exudate marked cervical lymphadenopathy palatal petechial haemorrhages generalised lymphadenopathy hepatosplenomegaly
how is glandular fever diagnosed?
atypical lymphocytes in peripheral blood (different to neutrophilia seen in tonsillitis)
+ve monospot or paul bunnel test
EBV IgE?
low CRP
how is glandular fever managed?
symptomatic supportive treatment
do not prescribe ampicillin?/amoxicillin?
antibiotics - penicillin
steroids
“chronic tonsillitis” included what?
chronic sore throat malodourous breath presence of tonsilliths peritonsillar erythema persistent tender cervical lymphadenopathy
features of obstructive hyperplasia due to adenoids?
obligate mouth breathing
hyponasal voice
snoring and other signs of sleep disturbance
AOM/OME (acute otitis media/otitis media with effusion)
features of obstructive hyperplasia due to tonsils?
snoring and other symptoms of sleep disturbance
muffled voice
dysphagia
is large tonsils always a pathological symptoms?
no
only when associated with other symptoms
causes of true unilateral tonsillar enlargement?
acute infection chronic infection hypertrophy congenital neoplasm
glue ear, otitis media with effusion and serous otitis media are interchangeable terms for what?
inflammation of the middle ear accompanied by accumulation of fluid without symptoms and signs of acute inflammation
what is acute otitis media?
inflammation of the middle ear accompanied by symptoms and signs of acute inflammation with/without accumulation of fluid
AOM vs OME?
hearing loss and fluid only in OME
earache, fever, irritability and opaque only in AOM
who is OME more common in?
children(30% < 4 yrs old)
males > female
increased incidence in day care, older siblings, smoking household, recurrent URTI
patient risk factors for OME?
recurrent URTI recurrent AOM prematurity craniofacial/genetic abnormalities - eustachian tube dysfunction immunodeficiency
environmental risk factors for OME?
household smoking day care allergy nutrition bottle feeding seasonal
what are the symptoms of chronic OM?
hearing loss poor school performance bad behaviour speech delay balance problems TV volume NOT OTALGIA
how is chronic otitis media diagnosed?
history otoscopy tuning fork test audiometry tympanometry
signs of chronic otitis media?
TM retraction reduced TM mobility altered TM colour visible ME fluid/bubbles CHL tuning fork tests
how is hearing investigated?
age appropriate hearing assessment audiometry - distraction testing (kids) - bone conduction - OAE (otoacoustic emissions) - pure tone audiometry tympanometry
how does tympanometry work?
measures vibration of tympanic membrane
TM cant vibrate much if middle ear is filled with fluid
how is chronic otitis media managed?
watchful waiting
- 60% resolve in 1 month
- 90% resolve in 3 months
can insert grommet if still present at 6-8 months
review at 3 months for otoscopy, PTA and tympanometry
explain that is wont cause long term hearing problems
how is chronic otitis media (glue ear) managed if present for more than 3 months?
referral
no evidence for antibiotics, decongestants, steroids or antihistamines etc
how can glue ear be managed surgically if persistent?
<3 yrs = grommet
>3 yrs, first intervention = grommet
>3 yrs, second intervention = grommets and removal of adenoids
- adenoidectomy may be considered earlier if nasal symptoms present
possible complications of glue ear?
short term speech, language and behavioural development problems (possibly)
no long term problems
complications of grommets?
infection/discharge early extrusion retention persistent perfusion swimming/bathing issues
