71.1 Anatomy

71.1.1 Waldeyer Ring

• Lymphoid tissue encircling the pharynx

• Consists of palatine tonsils (the tonsils), pharyngeal tonsils (the adenoids), lingual tonsils, and tubal tonsils

• Constantly exposed to new antigens

• Part of the MALT, which processes antigens and presents them to T_H cells and B cells

• Secretes IgA and IgG

71.1.2 Palatine Tonsils

• Boundaries:

Anterior: palatoglossus

Posterior: palatoglossus

Lateral: superior constrictor

• Vascular supply:

Tonsillar a

Ascending pharyngeal a

Tonsil branch of facial a

Dorsal lingual branch of lingual a

Ascending palatine branches of facial a

• Venous drainage:

Peritonsillar plexus to lingual and pharyngeal vv to internal jugular v

• Nerve supply:

Tonsillar branches of maxillary n and glossopharyngeal n

• Lymphatic drainage:

Directly to jugulodigastric nodes and upper deep cervical LNs and indirectly through retropharyngeal LNs

71.1.3 Adenoids

• Boundaries:

Posterosuperior: posterior pharyngeal wall and base of skull

• Vascular supply:

Ascending pharyngeal a

Ascending palatine a

Tonsillar branch of facial a

Pharyngeal branch of maxillary a

A of pterygoid canal

Basisphenoid a

• Venous drainage:

Peritonsillar plexus in conjunction with pterygoid plexus to internal jugular and facial vv

• Nerve supply:

Pharyngeal plexus

• Lymphatic drainage:

Retropharyngeal and pharyngomaxillary space LNs

71.2 Histology

• Tonsils: lymphoid tissue covered with nonkeratinizing stratified squamous epithelium

• Adenoids: lymphoid tissue covered with pseudostratified ciliated columnar epithelium

• Only the tonsils lie in a capsule, this is formed from a specialized condensation of pharyngobasilar fascia

71.3 Tonsil Pathology

71.3.1 Tonsillitis

• Viral tonsillitis: adenovirus, rhinovirus, reovirus, RSV, influenza, parainfluenza, CMV

• Bacterial tonsillitis is usually due to group A β-haemolytic streptococcus (GABHS) but may also be due to staphylococcus, nonhaemolytic streptococci, Lactobacillus, Bacteroides, and Actinomyces

• Other forms of tonsillitis include fungal tonsillitis (due to candidiasis, usually in immunocompromised patients), mycoplasmal tonsillitis, parasitic tonsillitis (toxoplasma), and tonsillitis due to chlamydia

• Rare forms of tonsillitis include Vincent angina, caused by Treponema vincentii and Spirochaeta denticulata

Types

• Acute parenchymatous: the whole tonsil is infected but no exudative pus

• Acute follicular: the crypts are filled with infected fibrin

• Chronic forms: chronic parenchymatous and chronic follicular; these are sometimes associated with tonsillolith formation

• Suppurative

Peritonsillar abscess (quinsy)

Deep neck infections: parapharyngeal and retropharyngeal esses

Thrombophlebitis: Lemierre disease (Fusobacterium necrophorum)

Chronic adenotonsillar hypertrophy

• Nonsuppurative

Scarlet fever

Acute rheumatic fever

Poststreptococcal glomerulonephritis

71.3.2 Glandular Fever

• Infectious mononucleosis

• Usually due to EBV, 10% of cases due to CMV

• Transmitted by oral contact

• Fever, generalized malaise, lymphadenopathy, hepatosplenomegaly, and pharyngitis

• 10% become jaundiced

• Blood count: lymphocytosis with atypical lymphocytes (activated T cells)

• Sheep RBC agglutination in the presence of heterophile antibodies is the basis for the Paul–Bunnell test

• Horse RBC agglutination in the presence of heterophile antibodies is the basis for the Monospot test

This test is 100% specific and 85% sensitive, but more sensitive than the Paul–Bunnell test

This test may be negative early in the course of EBV infectious mononucleosis

Complications

• Airway obstruction

• Myocarditis

• Splenic rupture

• Haemolytic anaemia

• Acute interstitial nephritis, glomerulonephritis

• Fatigue, depression

• Neurological: optic neuritis, transverse myelitis, aseptic meningitis, encephalitis, meningoencephalitis, CN palsy or Guillain–Barré syndrome

• Maculopapular rash develops with amoxicillin

• Patients to avoid strenuous exercise for the first 3 weeks of illness

• Prevent spread by avoiding close contact with body fluid secretions

71.3.3 Obstructive Sleep Apnoea Syndrome

• Due to adenotonsillar hypertrophy

• Association between OSAS and households where adults smoke

• Complications: pulmonary hypertension, cor pulmonale, alveolar hypoventilation causing chronic CO₂ retention

• May result in craniofacial abnormalities over time

71.3.4 Neoplasms

• Benign: lipomas, fibromas, schwannomas

• Malignant: lymphoma, SCC

71.3.5 Post-transplant Lymphoproliferative Disorder

• Not a true neoplasm

• Life-threatening complication of immunosuppression

• Proliferative B-cell disorder associated with EBV in an immunocompromised host

• Tonsillectomy is required to restore an airway and to provide tissue for diagnosis

71.4 Adenoid Pathology

• Adenoiditis

• OSAS as a consequence of their hypertrophy in conjunction with enlarged tonsils

• Nasal obstruction

• Contribution to recurrent or persistent otitis media

• Contribution to recurrent acute sinusitis or chronic sinusitis

71.5 Tonsillectomy

71.5.1 Indications

• Enlarged tonsils resulting in upper airway obstruction/OSAS

• Recurrent acute tonsillitis

7 or more episodes in the preceding year

5 or more episodes in each of the 2 preceding years

3 or more episodes in each of the 3 preceding years

Other reported indications:

– Swallowing difficulties

– Tonsillar crypt debris (tonsilloliths)

– Enlarged cervical LNs

– Guttate psoriasis

71.5.2 Brodsky Tonsil Classification