TONSILLITIS

-Vandana

The tonsils

Tonsils are subepithelial collections of lymphoid tissue scattered in the pharynx. Anatomically the tonsils are classified based on their location into : palatine (faucial), nasopharyngeal (“adenoids”), lingual and tubal tonsils.

Generally, the palatine tonsils referred to as “the tonsils”.

The Waldeyer’s ring is formed by :1. Palatine tonsils2. Nasopharyngeal tonsil3. Lingual tonsils4. Tubal tonsils5. Lateral pharyngeal bands 6. Posterior pharyngeal nodules

Embryology

The tonsils develop from the second pharyngeal pouch.

In the extraembryonic life, the ventral part of the 2nd pharyngeal pouch is represented by crypta magna or intratonsillar cleft.

Anatomy of tonsils

*Site: lateral walls of oropharynx, between the anterior and posterior pillars- tonsillar fossa

*Shape: almond shape

*2 surfaces: medial, lateral

*2 poles: upper, lower

* 10-12 primary crypts,

secondary crypts

*Plica semilunaris and plica triangularis

Relations

Anterior: anterior pillar

Posterior: posterior pillar

Superior: soft palate

Inferior: tongue

Medial: cavity of the oropharynx

Lateral: loose areolar tissue, paratonsillar veins, superior constrictor, buccopharyngeal fascia, glossopharyngeal nerve, facial artery, pterygoid muscles and the mandible.

Transverse section showing right tonsil from above

Blood Supply and Venous DrainageBlood supply- Tonsillar branch of

facial artery- Ascending pharyngeal

artery- Descending lingual

artery- Greater palatine artery

Venous drainage: paratonsillar vein

pharyngeal plexus of veins

Lymphatic drainage:The tonsils do not have any afferent vessels but has efferents which drain into the Jugulo-digastric nodes.

Nerve supply:Glossopharyngeal nerve and lesser palatine nerves.

Histology

- True fibrous capsule- Fibrous septa- Crypts lined by stratified

squamous epithelium- Lymphoid nodules:

germinal centres – B cells and plasma cells;

surrounded by T cells.

Functions of Tonsils

1. Immunity

2. Lymphocyte formation

3. Antibodies formation

4. Barrier to infections

What is tonsillitis ?

Tonsillitis is inflammation of the tonsils most commonly caused by a viral or bacterial infection.

Types

Acute tonsillitis Chronic tonsillitis

Tonsillitis is often labelled as acute, sub-acute, or chronic. Acute tonsillitis tends to be bacterial or viral in nature, while sub-acute tonsillitis is caused by the bacterium Actinomyces. Chronic tonsillitis generally lasts for a long time and is caused by bacteria.

Sub-acute

Acute Tonsillitis

- Acute infection of the tonsils involving the surface epithelium, crypts and lymphoid tissue

Acute superficial tonsillitis

Acute follicular tonsillitis

Acute parenchymatous tonsillitis

Acute membranous tonsillitis

Predisposing factors

Endogenous - URTI- Postnasal discharge due to

sinusitis- Residual tonsillar tissue after

tonsillectomy- Exanthemata- Blood dyscrasias

Exogenous - Cold drinks and foods- Contact with infected

persons- Crowded and ill-

ventilated environment- Imbedded foreign body

Etiology

Although tonsillitis can occur at any age, school-going children are much more likely to suffer from the condition.

In fact, tonsillitis is more common in an environment where people are in close contact and germs can be easily spread.

*Haemolyticus streptococcus

*Staphylococci

*Pneumococci

*H.influenzae

Primary infection

Secondary infection

Symptoms and Signs

Symptoms:

1. Sore throat – raw sensation in the throat

2. Refusal to eat due to odynophagia

3. Earache – either referred pain from the tonsil or due to acute otitis media

4. Voice becomes thick and muffled

5. Jugulodigastric nodes are enlarged and painful

6. Fever, may be associated with chills and rigor. Headache, tachycardia.

Signs:

1.Tonsils appear congested and swollen- Yellowish spots – follicular- Whitish membrane – membranous- Red and enlarged – parenchymatous

2.Hyperemia of pillars, uvula, soft palate

3.Halitosis, impeded movements of palate and increased secretions

4.Enlarged and tender jugulodigastric nodes

Acute follicular tonsillitis

Acute catarrhal or superficial tonsillitis

Acute membranous tonsillitis

Treatment

1. Bed rest, soft diet, plenty of fluids, warm saline gargles

2. Analgesics- aspirin, paracetamol; lozenges

3. Antimicrobial therapy- penicillin, erythromycin; for 7 to 10days

Complications

1. Chronic tonsillitis – incomplete resolution of acute tonsillitis

2. Peritonsillar abscess

3. Parapharyngeal abscess

4. Acute otitis media – recurrent attacks

5. Cervical abscess due to suppuration of jugulodigastric nodes

6. Rheumatic fever – group A B-hemolytic streptococci

7. Subacute bacterial endocarditis (patients with valvular heart disease) – streptococcus viridans

Chronic Tonsillitis- Characterised by recurrent acute attacks

Etiology:

1. Recurrent acute tonsillitis

2. Subclinical infection of tonsils

3. Chronic infection in sinuses or teeth

Pathology

1. Keratinous plug presses the adjacent epithelium and lymphoid tissue- causing their atrophy.2. When many plugs are present they produce an appearance clinically resembling follicular tonsillitis but inflammatory reaction is absent.3. Histology: In chronic tonsillitis lumen of the crypt contains bacterial colonies, inflammatory cells including polymorphs and lymphocytes with increased vascularity.4. The lymphoid tissue is hyperplastic with germinal follicle .

Chronic tonsillitis

Chronic follicular tonsillitis Chronic

parenchymatous tonsillitis

Chronic fibroid tonsillitis

Symptoms and SignsSymptoms:

1. Recurrent throat pain

2. Cough

3. Halitosis and bad taste in the mouth

4. Quiescent phase: discomfort, irritation, pain; asymptomatic

Signs:

5. Appearance: hypertrophied, congested – chr. parenchymatous; small, fibrotic with cheesy debris – chr. follicular

2. Squeezing: pus oozes out – should be distinguished from lymphatic fluid of normal tonsils

3. Retention cysts: yellowish swellings filled with yellow liquid and debris

4. Enlarged jugulodigastric nodes

Treatment

1. Conservative treatment: general health care, nutritious diet, treatment of co-existing infections of teeth, sinuses and nose

2. Surgical treatment: Tonsillectomy – when the enlarged tonsils interfere with speech, deglutition, respiration or in case of recurrent attacks

Complications

Besides those caused by acute tonsillitis, chronic tonsillitis may also result in tonsilloliths (stones), tonsillar cysts, sleep apnoea.

Thank you