د.حسين جاسم
L.3  The palatine tonsils

	They are an oval mass of specialized subepithelial lymphoid tissue lying between the anterior & posterior pillars, on each side of the oropharynx. The free surface is covered by stratified squamous epithelia & contains 12-15 crypts open on the surface, they have efferent lymph vessels but no afferent lymph vessels.

Functions of the tonsils:
1.	Formation of lymphocytes.
2.	Formation of antibodies.
3.	Acquisition of immunity.
4.	Localization of infection (filtering).

Acute tonsillitis

	It may affect any age group but, it’s most frequently found in children, it may be caused by the following microorganisms:
In adults:
a.	Beta hemolytic streptococcus group (A).
b.	Haemophilus influenzae.
c.	Staphylococcus aureus.
d.	Pneumococcus.
In children:
a.	Beta hemolytic streptococcus group (A).
b.	Streptococcus pneumoniae.
c.	Haemophilus influenzae.

Pathological types:
A.	Acute paranchymatous tonsillitis:
The whole tonsil is infected, causing marked generalized swelling. The surface appear reddened with the crypts orifices more injected but not exuding pus.
B.	Acute follicular tonsillitis:
The crypts are filled with infected fibrin, the mouths of the crypts contain pus (spotted appearance) & sometimes whitish-yellowish false membrane may be formed.

Clinical features:
Symptoms:
1.Prodromal symptoms: fever, headache & malaise appear 1-2 days before the classical symptoms. 
2.Sorethroat:is the predominant symptom, aggravated by swallowing especially to solid food (odenophagia).
3.Change in voice: due to either accumulation of saliva or restriction of soft palate & tongue movement.
4.Otalgia: either referred or due to acute OM.
5.Pain in the neck: due to enlarged cervical lymph nodes.
6.Abdominal pain & vomiting: especially in children due to mesenteric lymphadenitis, which should be differentiated from acute appendicitis.
Signes: 
1.	Tonsils: enlarged, hyperemic & pus accumulate in the crypts (in follicular tonsillitis) which rarely coalesce forming false membrane.
2.	Vital Signes: pulse rate reach > 120/min in children & < 120/min in adults. The temperature may reach >39 C especially in children.
3.	Tongue is furred & the breath is foeted.
4.	Skin is flashed with slight skin rash may occur.
5.	Trismus may occur especially in complicated cases.
6.	In sever cases: rigor, oligurea, thirst & toxemia may occur. 

Diagnosis:
1.	Clinical features.
2.	Throat swab: for C/S.
3.CBP & Blood film to exclude blood diseases (leukemia, agranulocytosis).
4.Monospot test to exclude IMN.
5.KLB to exclude diphtheria. 
Treatment:
1.	Bed rest, soft diet & a lot of oral fluids.
2.	Analgesia: paracetamole is given in a dose of 10 mg/kg/4-6 hourly in children & 500mg/6 hrs in adults.
3.	Antibiotics: benzyl penicillin 10-20 mg/kg/day (in children) & 600mg/6 hourly (in adults) IM or IV for 2-3 days followed by oral penicillin V for additional few days.
4.	In case of allergy to penicillin erythromycin is used in a dose of 25 mg/kg/6hr. in children & 500 mg/6hr. in adults.
5.	In resistant cases clindamycin or ciprofloxacillin with or without metronidazole may be used.

Complications of acute tonsillitis:
A. Local complication
1.	Respiratory obstruction: due to spread of infection & inflammation to the hypopharynx & larynx, it’s a very rare complication.
2.	Mediastinitis: also a rare complication but is rapidly fatal.
3.	Acute infection of the middle ear cleft: especially in children.
4.	Chronic tonsillitis:
Chronic paranchymatous tonsillitis: it follows acute tonsillitis & usually affects children between 4-15 yr. Old, there is a chronic hypertrophy associated with enlarged adenoids.
Clinical features: 
-	Recurrent or persistent sorethroat.
-	Persistent cervical lymph nodes enlargement.
-	Marked tonsilar enlargement.
-	Injected anterior pillars.
-	Irritative cough.
    Treatment:
Conservative treatment is tried at first, by good nutrition, general health care, but the standard treatment is by tonsillectomy if the symptoms persist or associated with breathing & feeding problems.
     Chronic follicular tonsillitis: it follows repeated attacks of acute follicular tonsillitis, it’s more common in adults.
    Clinical features:
-	Repeated sore throat with whitish yellowish plagues on the tonsils.
-	Cervical lymphadenopathy.
-	Cough.
-	Bad taste & halitosis.
Treatment:
       Conservative treatment is tried at first (debris removed with spatula, cysts can be incised & evacuated) but the definitive treatment is by tonsillectomy if the symptoms persist.
5.	Parapharyngeal abscess: it’s a suppurative infection of the parapharyngeal space, usually affects adults. It occur mostly due to (tonsillitis, dental infection of the wisdom tooth) & rarely due to (quinsy, FB & mastoiditis).
Clinically there is fever, trismus, the tonsil looks normal & pushed medially from the inferior part (the soft palate is not affected) & tender firm swelling in the upper part of the neck.
Treatment is by analgesia, antibiotics (penicillin for 10 days) if no response then surgical drainage is done by collar incision at the level of the hyoid bone.
6.	Retropharyngeal abscess: it’s the collection of pus between the posterior pharyngeal wall (the sup., middle & inferior constrictors of the pharynx) & the prevertebral fascia, its divided into:
         Acute retropharyngeal abscess: its more common in infants & young children up to 5-yr. old, usually unilateral swelling in the posterior pharyngeal wall caused by (retropharyngeal L.N. infection, FB & rarely acute otitis media or mastoiditis).
              Clinically the child looks ill, feverish, irritable & pushes his head backward to relieve the pain. If the swelling is large enough it may cause dysphagia & airway obstruction.
               Diagnosis is by clinical features & lateral x-ray of the neck in which we see widening of the prevertebral tissues & fluid level could be seen.
               Treatment is done preferably under local anesthesia & midline incision of the abscess & suction of the pus or putting the child in a depending position to prevent inhalation of pus into the respiratory tract.
        Chronic retropharyngeal abscess: it’s more common in adolescents & adults due to tuberculous infection of the cervical spine. It’s always blood born infection.
               Clinically the patient is a symptomatic at early stages then a slight dysphagia, pain, fever, sore throat, cough & there may be bulging of the posterior pharyngeal wall, in advanced cases neurological symptoms appear due to spinal cord affection.
               Diagnosis is by clinical features, cervical spine X-ray & fine needle aspiration biopsy for acid-fast bacilli.
               Treatment is by drainage of abscess (which is not normally necessary & if done it should be through the neck). The usual anti-tuberculosis drugs & finally an advice of an expert about the stability of the cervical spine is necessary.
7.	Peri-tonsilar abscess (quinsy): it’s a collection of pus between the fibrous capsule of the tonsil & the superior constrictor muscle of the pharynx. It’s a disease of young adults & rarely occur in children.
                The causative organisms are usually mixed bacteria (aerobic & anaerobic bacteria) & usually follows acute tonsillitis also could occur in a remnant of tonsilar tissue after tonsillectomy, it’s usually unilateral & lies above the tonsil medially.
                 Clinically the patient is ill, preceding history of sore throat, high fever (40 c), sever throat pain associated with drooling of saliva, referred otalgia, plummy voice, trismus, a symmetry of the pharynx & cervical lymph node enlargement.
                 Treatment is by admission, analgesia, fluid diet, IV fluid if needed, antibiotics (benzyl penicillin 600 mg/6 hr. if there is no response to medical treatment or there is marked bulging of the soft palate incision & drainage of the abscess is done.
B.    General complications  
1.	Glomerulonephritis:
2.	Rheumatic fever: 
           Both above complications are of unknown etiology & follows infection with B-hemolytic streptococcus of lancefield group.
3.	Septicemia:  
                Untreated acute tonsillitis can lead to septicemia with septic abscesses, septic arthritis & meningitis, they are rare in adults but more common in children & immuncompromized patients.  

 
Tonsillectomy

Indications of tonsillectomy:
a. Absolute indications:
1.	Recurrent episodes of acute tonsillitis:
          In adults, 3-4 attacks/yr. for 2-3 successive years.
          Inchildren, 6 attacks/yr. for 2 successive years.
          Signes of unhealthy tonsil are : enlarged cervical lymph nodes, congested anterior pillars & presence of purulent material in the tonsils.

2.	Peritonsillar abscess (quinsy): if the patient had repeated attacks of tonsillitis, or after the second attack of quinsy.
3.	Tonsillectomy for biopsy purposes: if there is a suscpesion of a neoplasm.
4.	Sleep apnea: especially in children with obstructive symptoms.
5.	As an access to other structures: in glossopharyngeal neuralgia to reach the glossopharyngeal nerve, & to reach the elongated styloid process.
b. Relative indications: 
1.	Chronic tonsillitis.
2.	Carrier state of streptococcus or diphtheria.
3.	Persistent cervical lymph nodes when suspected to be due to tuberculous infection of tonsilar origin.
4.	Recurrent attacks of acute rheumatism if associated with acute tonsillitis.
5.	Attacks of glomerulonephritis.
6.	Recurrent otitis media associated with sore throat.
7.	In children with general debility, failure to thrive & malaise thought to be due to repeated tonsillitis.

Contraindications of tonsillectomy:
1.	Bleeding disorders: cryosurgical technique may be of benefit in such patients.
2.	Recent infection: it is wise to postponed the operation for 3-weeks.
3.	Oral contraceptives: because of high risk of DVT although its rare.
4.	Epidemics: especially poliomyelitis as the virus may invade the exposed nerve endings leading to fatal bulbar type of poliomyelitis.
5.	Allergic rhinitis & asthma: not accepted by all surgeons.
 
Complications of tonsillectomy:
    A. Peri-operative: 
a.	Hemorrhage (primary): occurs at the time of the operation caused by: 
1.	Recent infection.
2.	Previous peritonsillar abscess.
3.	Sever scarring.
4.	Traumatic dissection through the muscles.
5.	Coagulation defect which is not suspected.
6.	Congenitally abnormal artery(large tonsilar branch of the facial artery & aberrant internal carotid artery).
b.	Trauma during operation: 
1.	Dental trauma.
2.	Damage to the posterior pharyngeal wall.
3.	Damage to the uvula & its blood supply.
4.	Dislocation of the temporomandibular joint.
5.	Diathermy induced fire in the presence of high oxygen concentration.
    B. Post-operative:   
a.	Immediate complication:
1.	Hemorrhage (reactionary): occurs up to 24 hrs.       postoperatively, usually due to (clot dislodgment, vasodilatation of vasoconstricted blood vessels, excessive venous pressure during coughing & slipped ligature).
2.	Anesthetic complications:  this is usually due to forgetting pack or swab or inhalation of blood clot.
    b. Intermediate complications: 
1.	Hemorrhage (secondary): any bleeding occurs after 24 hrs. postoperatively up to 6 days is usually due to infection.
2.	Hematoma & edema of the uvula: due to trauma or damage to the blood supply of the uvula.
3.	Infection: the fossa after the operation contains whitish sloughs, which is ideal culture for microorganisms.
4.	Pulmonary complications: which are very rare.
5.	Sub-acute bacterial endocarditis: usually in patients with abnormal heart valves.
6.	Pain & earache.
7.	Parapharyngeal abscesses & septicemia.
b.	Late complications: 
1.	Post-operative scarring: occurs especially in traumatic dissection & may affect voice production.
2.	Tonsilar remnant: if small it’s a symptomatic but large masses can produce acute tonsillitis.
3.	Malignancy after tonsillectomy: questionable.