Chapter 375 Tonsils and Adenoids
Anatomy
Waldeyer ring refers to the lymphoid tissue that surrounds the opening of the oral and nasal cavities into the pharynx. It is composed of the palatine tonsils, the pharyngeal tonsil or adenoid, lymphoid tissue surrounding the eustachian tube orifice in the lateral walls of the nasopharynx, the lingual tonsil at the base of the tongue, and scattered lymphoid tissue throughout the remainder of the pharynx, particularly behind the posterior pharyngeal pillars and along the posterior pharyngeal wall. Lymphoid tissue located between the palatoglossal fold (anterior tonsillar pillar) and the palatopharyngeal fold (posterior tonsillar pillar) forms the palatine tonsil. This lymphoid tissue is separated from the surrounding pharyngeal musculature by a thick fibrous capsule. The adenoid is a single aggregation of lymphoid tissue that occupies the space between the nasal septum and the posterior pharyngeal wall. A thin fibrous capsule separates it from the underlying structures; the adenoid does not contain the complex crypts that are found in the palatine tonsils but rather more simple crypts. Lymphoid tissue at the base of the tongue forms the lingual tonsil that also contains simple tonsillar crypts.
Normal Function
Situated at the opening of the pharynx to the external environment, the tonsils and adenoid are in a position to provide primary defense against foreign matter. The immunologic role of the tonsils and adenoids is to induce secretory immunity and to regulate the production of the secretory immunoglobulins. Deep crevices within tonsillar tissue form tonsillar crypts that are lined with squamous epithelium but have a concentration of lymphocytes at their bases. Lymphoid tissue of Waldeyer ring is most immunologically active between 4 and 10 yr of age, with a decrease after puberty. No major immunologic deficiency has been demonstrated after removal of either or both of the tonsils and adenoid.
Pathology
Acute Infection
Most episodes of acute pharyngotonsillitis are caused by viruses (Chapter 373). Group A β-hemolytic streptococcus (GABHS) is the most common cause of bacterial infection in the pharynx (Chapter 176).
Chronic Infection
The tonsils and adenoids can be chronically infected by multiple microbes, which can include a high incidence of β-lactamase–producing organisms. Both aerobic species, such as streptococci and Haemophilus influenzae, and anaerobic species, such as Peptostreptococcus, Prevotella, and Fusobacterium, predominate. The tonsillar crypts can accumulate desquamated epithelial cells, lymphocytes, bacteria, and other debris, causing cryptic tonsillitis. With time, these cryptic plugs can calcify into tonsillar concretions or tonsillolith. There is growing evidence that biofilms might also play a role in chronic inflammation of the tonsils.
Airway Obstruction
Both the tonsils and adenoids are a major cause of upper airway obstruction in children. Airway obstruction in children is typically manifested in sleep-disordered breathing, including obstructive sleep apnea, obstructive sleep hypopnea, and upper airway resistance syndrome (Chapter 17). Sleep-disordered breathing secondary to adenotonsillar breathing is a cause of growth failure (Chapter 38).
Clinical Manifestations
Acute Infection
Symptoms of GABHS infection include odynophagia, dry throat, malaise, fever and chills, dysphagia, referred otalgia, headache, muscular aches, and enlarged cervical nodes. Signs include dry tongue, erythematous enlarged tonsils, tonsillar or pharyngeal exudate, palatine petechiae, and enlargement and tenderness of the jugulodigastric lymph nodes (Fig. 375–1; Chapters 176 and 373).
Figure 375–1 Pharyngotonsillitis. This common syndrome has a number of causative pathogens and a wide spectrum of severity. A, The diffuse tonsillar and pharyngeal erythema seen here is a nonspecific finding that can be produced by a variety of pathogens. B, This intense erythema, seen in association with acute tonsillar enlargement and palatal petechiae, is highly suggestive of group A β-streptococcal infection, though other pathogens can produce these findings. C, This picture of exudative tonsillitis is most commonly seen with either group A streptococcal or Epstein-Barr virus infection. (B, Courtesy of Michael Sherlock, MD, Lutherville, MD.)
(From Yellon RF, McBride TP, Davis HW: Otolaryngology. In Zitelli BJ, Davis HW, editors: Atlas of pediatric physical diagnosis, ed 4, Philadelphia, 2002, Mosby, p 852.)
Chronic Infection
Children with chronic or cryptic tonsillitis often present with halitosis, chronic sore throats, foreign body sensation, or a history of expelling foul-tasting and foul-smelling cheesy lumps. Examination can reveal tonsils of almost any size and often they contain copious debris within the crypts. Because the offending organism is not usually GABHS, streptococcal culture is usually negative.
Airway Obstruction
In many children, the diagnosis of airway obstruction (Chapters 17 and 365) can be made by history and physical examination. Daytime symptoms of airway obstruction, secondary to adenotonsillar hypertrophy, include chronic mouth breathing, nasal obstruction, hyponasal speech, hyposmia, decreased appetite, poor school performance, and, rarely, symptoms of right-sided heart failure. Nighttime symptoms consist of loud snoring, choking, gasping, frank apneas, restless sleep, abnormal sleep positions, somnambulism, night terrors, diaphoresis, enuresis, and sleep talking. Large tonsils are typically seen on examination, although the absolute size might not indicate the degree of obstruction. The size of the adenoid tissue can be demonstrated on a lateral neck radiograph or with flexible endoscopy. Other signs that can contribute to airway obstruction include the presence of a craniofacial syndrome or hypotonia.
Tonsillar Neoplasm
The rapid unilateral enlargement of a tonsil, especially if accompanied by systemic signs of night sweats, fever, weight loss, and lymphadenopathy, is highly suggestive of a tonsillar malignancy. The diagnosis of a tonsillar malignancy should also be entertained if the tonsil appears grossly abnormal. Among 54,901 patients undergoing tonsillectomy, 54 malignancies were identified (0.087% prevalence); all but 6 malignancies had been suspected based on suspicious anatomic features preoperatively.
Treatment
Medical Management
The treatment of acute pharyngotonsillitis is discussed in Chapter 373 and antibiotic treatment of GABHS in Chapter 176. Because co-pathogens such as staphylococci or anaerobes can produce β-lactamase that can inactivate penicillin, the use of cephalosporins or clindamycin may be more efficacious in the treatment of chronic throat infections. Tonsillolith or debris may be expressed manually with either a cotton-tipped applicator or a water jet. Chronically infected tonsillar crypts can be cauterized using silver nitrate.
Tonsillectomy
Tonsillectomy alone is usually performed for recurrent or chronic pharyngotonsillitis. Indications for surgery remain uncertain; there are large variations in surgical rates among children across countries: 144/10,000 in Italy; 115/10,000 in the Netherlands; 65/10,000 in England; and 50/10,000 in the United States. Rates are generally higher in boys. Potential but nonevidenced based indications include 7 or more throat infections treated with antibiotics in the preceding yr, 5 or more throat infections treated in each of the preceding 2 yr, or 3 or more throat infections treated with antibiotics in each of the preceding 3 yr. The American Academy of Otolaryngology—Head and Neck Surgery offers guidelines of 3 or more infections of tonsils and/or adenoids per yr despite adequate medical therapy; the Scottish Intercollegiate Tonsillectomy Guidelines Network recommends 5 or more episodes per yr of tonsillitis with disabling symptoms and lasting for longer than 1 yr. Tonsillectomy has been shown to be effective in reducing the number of infections and the symptoms of chronic tonsillitis such as halitosis, persistent or recurrent sore throats, and recurrent cervical adenitis. In resistant cases of cryptic tonsillitis, tonsillectomy may be curative. Rarely in children, tonsillectomy is indicated for biopsy of a unilaterally enlarged tonsil to exclude a neoplasm or to treat recurrent hemorrhage from superficial tonsillar blood vessels. Tonsillectomy has not been shown to offer clinical benefit over conservative treatment in children with mild symptoms.
Adenoidectomy
Adenoidectomy alone may be indicated for the treatment of chronic nasal infection (chronic adenoiditis), chronic sinus infections that have failed medical management, and recurrent bouts of acute otitis media, including those in children with tympanostomy tubes who suffer from recurrent otorrhea. Adenoidectomy may be helpful in children with chronic or recurrent otitis media with effusion. Adenoidectomy alone may be curative in the management of patients with nasal obstruction, chronic mouth breathing, and loud snoring suggesting sleep-disordered breathing. Adenoidectomy may also be indicated for children in whom upper airway obstruction is suspected of causing craniofacial or occlusive developmental abnormalities.
Tonsillectomy and Adenoidectomy
The criteria for both tonsillectomy and adenoidectomy for recurrent infection are the same as those for tonsillectomy alone. The other major indication for performing both procedures together is upper airway obstruction secondary to adenotonsillar hypertrophy that results in sleep-disordered breathing, failure to thrive, craniofacial or occlusive developmental abnormalities, speech abnormalities, or, rarely, cor pulmonale. A high proportion of children with failure to thrive in the context of adenotonsillar hypertrophy resulting in sleep disorder experience significant growth acceleration after adenotonsillectomy.
Complications
Acute Pharyngotonsillitis
The 2 major complications of untreated GABHS infection are post-streptococcal glomerulonephritis and acute rheumatic fever (Chapters 176 and 505.1).
Peritonsillar Infection
Peritonsillar infection can occur as either cellulitis or a frank abscess in the region superior and lateral to the tonsillar capsule (Chapter 374). These infections usually occur in children with a history of recurrent tonsillar infection and are polymicrobial, including both aerobes and anaerobes. Unilateral throat pain, referred otalgia, drooling, and trismus are presenting symptoms. The affected tonsil is displaced down and medial by swelling of the anterior tonsillar pillar and palate. The diagnosis of an abscess can be confirmed by CT or by needle aspiration, the contents of which should be sent for culture.
Retropharyngeal Space Infection
Infections in the retropharyngeal space develop in the lymph nodes that drain the oropharynx, nose, and nasopharynx. (See Chapter 374).
Parapharyngeal Space Infection
Tonsillar infection can extend into the parapharyngeal space, causing symptoms of fever, neck pain and stiffness, and signs of swelling of the lateral pharyngeal wall and neck on the affected side. The diagnosis is confirmed by contrast medium–enhanced CT, and treatment includes intravenous antibiotics and external incision and drainage if an abscess is demonstrated on CT (Chapter 374). Septic thrombophlebitis of the jugular vein, Lemierre syndrome, manifests with fever, toxicity, neck pain and stiffness, and respiratory distress due to multiple septic pulmonary emboli and is a complication of a parapharyngeal space or odontogenic infection from Fusobacterium necrophorum. Concurrent Epstein-Barr virus mononucleosis can be a predisposing event before the sudden onset of fever, chills, and respiratory distress in an adolescent patient. Treatment includes high-dose intravenous antibiotics (ampicillin-sulbactam, clindamycin, penicillin, or ciprofloxacin) and heparinization.
Chronic Airway Obstruction
Although rare, children with chronic airway obstruction from enlarged tonsils and adenoids can present with cor pulmonale.
The effects of chronic airway obstruction (Chapter 17) and mouth breathing on facial growth remain a subject of controversy. Studies of chronic mouth breathing, both in humans and animals, have shown changes in facial development, including prolongation of the total anterior facial height and a tendency toward a retrognathic mandible, the so-called adenoid facies. Adenotonsillectomy can reverse some of these abnormalities. Other studies have disputed these findings.
Tonsillectomy and Adenoidectomy
The risks and potential benefits of surgery must be considered (Table 375–1). Bleeding can occur in the immediate postoperative period or be delayed after separation of the eschar. Bleeding is more common after high dose dexamethasone (0.5 mg/kg), although postoperative nausea and emesis is reduced. The risk of bleeding is lower with lower-dose dexamethasone (0.15 mg/kg), which also has a lowered risk of postoperative nausea and emesis. Swelling of the tongue and soft palate can lead to acute airway obstruction in the 1st few hours after surgery. Children with underlying hypotonia or craniofacial anomalies are at greater risk for suffering this complication. Dehydration from odynophagia is not uncommon in the 1st postoperative week. Rare complications include velopharyngeal insufficiency, nasopharyngeal or oropharyngeal stenosis, and psychologic problems.
Table 375-1 RISKS AND POTENTIAL BENEFITS OF TONSILLECTOMY OR ADENOIDECTOMY OR BOTH
RISKS
POTENTIAL BENEFITS
* Cost for tonsillectomy alone and adenoidectomy alone are somewhat lower.
Modified from Bluestone CD, editor: Pediatric otolaryngology, ed 4, Philadelphia, 2003 Saunders, p. 1213.
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