Anatomy of Tonsil and Acute Tonsillitis

1. Anatomy of Tonsil and Acute Tonsillitis Dr. Mubeena

2. Anatomy of tonsil

3. Palatine (Faucial tonsil) • 2 • Lymphoid tissue • Location

4. Palatine tonsil • Medial surface- non keratinising stratified squamous epithelium • Crypts – Crypta magna • Lateral surface – fibrous capsule • Loose areolar tissue

5. Palatine tonsil • Upper pole – semilunar fold – supratonsillar fossa • Lower pole – attached to tongue • Tonsillolingual sulcus

6. Relations of tonsillar bed

7. Relations of tonsillar bed 1. Tonsillar capsule 2. Peritonsillar space with paratonsillar vein 3. Pharyngo-basilar fascia, Superior constrictor 4. Bucco-pharyngeal fascia 5. Styloid process, muscles, glossopharyngeal nv. 6. Facial artery 7. Medial pterygoid, submandibular salivary gland 8. Mandible

8. Arterial supply of tonsil

9. Anatomy of tonsil • Venous drainage:Para tonsillar vein -> common facial vein  pharyngeal venous plexus • Lymphatic drainage:jugulo-digastric • Nerve supply:Glossopharyngeal nerve & Lesser palatine nerve

10. Adenoid Tonsil 1. Ciliated columnar 1. Non-keratinizing epithelium squamous epithelium 2. No capsule 2. Partly encapsulated 3. Has furrows 3. Has crypts 4. Peak growth: 6 yr 4. Peak growth: 8 yr 5. Growth stops: 12 yr 5. Growth stops: 15 yr 6. Disappears: 20 yr 6. Partial regression:18 yr

11. FUNCTIONS OF TONSILS • 1. LOCAL IMMUNITY • Epithelium • M cells, antigen processing cells  antigen brought in contact with subepithelial lymphoid follicles  B cell stimulation  Plasma cells  antibodies

12. 2. Surveillance mechanism • Identifies intruder • Prepares the entire body for defense mechanism

13. ACUTE TONSILLITIS

14. Types of acute tonsillitis 1. Superficial / catarrhal: part of generalized pharyngitis 2. Follicular:crypts filled with pus, visible as yellow-white dots 3. Membranous: multiple follicles join to form a yellow-white membrane 4. Parenchymatous:infection of lymphoid parenchyma  tonsil enlargement

15. Superficial Tonsillitis

16. Follicular Tonsillitis

17. Membranous Tonsillitis

18. Parenchymatous tonsillitis

19. Aetiology • Children • Haemolytic streptococcus • Others – Staphylococci, pneumococci, H influenzae

20. Symptoms • Sore throat • Dysphagia • Fever • Earache • Constitutional symptoms

21. Signs of tonsillitis 1. Congested tonsil & tonsillar pillars 2. Enlarged tonsil (except chronic fibrotic type) • Follicles over surface of tonsil • White patch/membrane over tonsil 4. Jugulo-digastric lymph node enlarged. Tender jugulo-digastric node seen in acute tonsillitis.

22. Tonsillar enlargement Grade 1 = tonsil within tonsillar fossa Grade 2= tonsil come outside tonsillar fossa Grade 3 = Significant tonsillar hypertrophy but not touching in midline Grade 4= Kissing tonsils

23. Grade 1 enlargement

24. Grade 2 enlargement

25. Grade 3 enlargement

26. Grade 4 enlargement

28. Complications of acute tonsillitis Local 1. Recurrent tonsillitis 2. Intra-tonsillar abscess 3. Peri-tonsillar abscess (Quinsy) 4. Parapharyngeal abscess 5. Retropharyngeal abscess

29. Complications of acute tonsillitis Systemic Focal 1. Rheumatic fever 1. Otitis media 2. Endocarditis (SABE) 2. Cervical abscess 3. Glomerulonephritis due to lymph node 4. Urticaria, erythema enlargement 5. Septicemia

30. Treatment of tonsillitis • Bed rest + plenty of fluids • Systemic antibiotic: Cefadroxil, Cefuroxime • Antihistamine – Decongestant tablet • Analgesics • Antiseptic gargle • Treatment of focus of infection

31. Membrane over the tonsil tonsil  Membranous tonsillitis  Faucial diphtheria  Infectious mononucleosis  Candidiasis (throat swab  Candida albicans)  Vincent's angina (fusiform bacilli, spirochaete)

32. Membrane over the tonsil • Aphthous ulcer (red margin, yellow centre) Agranulocytosis (peripheral blood smear) • Leukemia (peripheral blood smear)  Neoplasm (excision biopsy)  Traumatic ulcer (history of trauma)

33. Membranous tonsillitis

34. Post - Tonsillectomy scab

35. Vicent’s angina • Insidious onset • Membrane on one side • Fusiform bacilli, spirochaetes

36. Infectious Mononucleosis • Young adults • Posterior triangle lymph nodes and splenomegaly • >50 % lymphocytes – 10% atypical • Paul Bunnet test

37. Oral Candidiasis

38. Keratosis pharyngis

39. Faucial Diphtheria

40. Faucial diphtheria • Corynebacterium diphtheriae • Droplet infection • Incubation period – 2- 6 days

41. More in children • Greyish white membrane in oropharynx – bleeds on removal • Jugulodigasric node enlargement – bull neck appearance • Toxaemic

42. Complications • Due to exotoxins • Myocarditis, arrhythmias, acute circulatory failure • Paralysis of soft palate, diaphragm, ocular muscles • Larynx – airway obstruction

43. Treatment of faucial diphtheria • Isolation + bed rest • I.V. benzyl penicillin 600 mg q6h 3. Diphtheritic anti - toxininfusion in saline • 20,000 – 40,000 U:  48 hrs duration, tonsillar • 40,000 – 80,000 U: nasopharynx / larynx • 80,000 – 120,000 U:  48 hrs, neck edema 4. Emergency tracheostomy required for stridor

44. Keratosis pharyngis • Benign self – limiting condition • Etiology: smoking, alcohol, vitamin A deficit • O/E:yellowish, horn-like outgrowths from mucosa of tonsil. Cannot be wiped off. • H.P.E.:Absence of inflammation; hyper-trophy & hyperkeratinization of epithelium.

45. Keratosis pharyngis Treatment:Reassurance. Tonsillectomy in severe cases.

46. Diagnosis of membrane over tonsil • History • Physical examination • Total and differential count • Blood smear • Throat swab • Bone marrow aspiration • Paul Bunnet test, biopsy of the lesion

47. Unilateral tonsillar enlargement Tonsillar causes: 1. Tonsillar malignancy 2. Peri-tonsillar abscess 3. Intra-tonsillar abscess 4. Tonsillolith 5. Tonsillar cyst 6. Tonsillar artery aneurysm 7. Vincent's angina

48. Unilateral tonsillar enlargement Extra-tonsillar causes:  Parapharyngeal abscess  Parapharyngeal tumours  Tumours of deep parotid lobe  Internal carotid art. aneurysm  Cervical lymphadenopathy

49. Thank You