key: cord-0059352-kdz6hb9h authors: Elhakeem, Amr A. title: Adenoid and Tonsils date: 2020-07-07 journal: Textbook of Clinical Otolaryngology DOI: 10.1007/978-3-030-54088-3_56 sha: 6e0c019aeb813f20f0a53ab594b1d0a62037e537 doc_id: 59352 cord_uid: kdz6hb9h The tonsils and adenoids are part of the lymphoid tissues that circle the pharynx known as Waldeyer’s ring. Adenotonsillar disease (adenoiditis and recurrent tonsillitis) is a prevalent otolaryngologic disorder. This chapter discusses the aetiology, manifestations, diagnosis and treatment of common adenotonsillar disease. They are part of the Waldeyer's ring of lymphoid tissues which have no afferent lymphatic. Their lymphoid follicles are similar to that of other lymph nodes but they also have specialised endothelium covered channels that facilitate antigen uptake directly into the tissues which in turn maximise the development of immunological memory. They contain T, B lymphocyte and few mature plasma cells. In addition to their role in antigen processing and immune surveillance, they play part in mucociliary clearance (adenoid). Removal of either or both has not been found to be clinically or epidemiologically significant in reduction of immunity against polio or increase in incidence of Hodgkin's disease. Tissues (Fig. 56 .1) Waldeyer's tonsillar ring (pharyngeal lymphoid ring) is a ringed arrangement of lymphoid tissue in the pharynx. Waldeyer's ring surrounds the naso-and oropharynx, with some of its tissue located above and some below the soft palate. The ring consists of: the adenoid, the tubal tonsils around the openings of Eustachian tubes, the palatine tonsils and the lingual tonsils. Waldeyer's ring grows throughout childhood until the age of 11 years and after that decreases spontaneously. Waldeyer's ring tissue serves as a defence against infection and plays an important role in the development of the immune system, comprising the first organs in the lymphatic system that analyse and react to airborne and alimentary antigenic stimulation. They are situated at the junction of roof and posterior aspect of nasopharynx (exit of nose). This anatomic position is important to understand their effects on nasal obstruction and orofacial growth and development ( Fig. 56 .2). The frequent question of whether the adenoids are too large for a normal size nasopharynx or the nasopharynx size is smaller in children who develop nasal obstruction remains unresolved. They are present at birth and reach the maximum period of growth at the age between 3 and 5 years (usually), they then start to regress by the age of 9 years to the age of early adulthood. (Table 56.1) Difficult to differentiate from upper respiratory tract infection (URTI) and are usually associated with it and with rhinosinusitis. (Table 56. 2) The occurrence of four or more episodes of acute adenoiditis in 6 months period, with complete resolution of symptoms in-between the attacks. (Table 56. 3) The persistence of one or more symptoms (including nasal discharge, bad breath and ear symptoms) for a minimum of 3 months. Chronic adenoiditis is based on chronic inflammation triggered by a persistent bacterial infection. These bacteria, mostly Staphylococcus aureus, Haemophilus sp. and Streptococcus sp., persist predominantly intracellular and within mucosal biofilms. The recurrent or chronic inflammation of the adenoids leads to chronic activation of the cell-mediated and humoral immune response, resulting in hypertrophy of the adenoid lymphoid tissue. This hypertrophic tissue is the cause for the prominent clinical symptoms: obstruction of the upper airways, snoring and sleep apnea. Persistence of nasal obstruction during early childhood (from obstructing adenoid and/or tonsils) results in abnormal development of characteristic facial appearance. Is usually based on clinical symptoms (most important), nasopharyngeal endoscopy and radiology (nasopharyngeal X-ray) may be used in addition. CT or MRI may be useful if other diagnoses are expected or to be excluded (meningeoenchalocoele). (Table 56 .4) Treatment strategies should target the persisting bacteria within their biofilm. Surgical removal of the hypertrophic tissue eliminates not only a mechanical obstacle of the airways, it removes also the basis for the aetiologic cause, the "biofilm carrier". No good evidence to support curative medical treatment for chronic adenoiditis but surgical removal (Recommendation). Recommendations are against long-term antibiotic treatment. The use of local nasal steroid for the treatment to reduce inflammatory changes and the size of the adenoid are optional. The use of symptomatic treatment is an important tool in the management. Multiple descriptions have been used to describe the tonsil size, the commonly used is the Brodsky grading. ( Fig. 56 . Ratio of the tonsils to the oropharynx in the medial to lateral plane as measured between the anterior pillars (Table 56 .5). Tonsillitis is a term used to describe an acute inflammation of the palatine tonsils. Sore Throat is used to describe any causes of inflammation of the throat. • Bacterial infection: The most common bacterial cause is Group A beta-haemolytic streptococcus (GABHS) also known as Streptococcus pyo- For the majority of patients, the following apply: If caused by a viral or bacterial infection, symptoms resolve within 3 days in 40% of patients and in 1 week in 85% of patients. Infectious mononucleosis (glandular fever) symptoms usually resolve within 1-2 weeks although mild causes may resolve within days; however, lethargy may continue for months or years in rare cases. • Suppurative (Table 56 .6). • Non-suppurative. -Rheumatic fever -Post-streptococcal glomerulonephritis Tonsils fill less than 25% of the transverse oropharyngeal space between the anterior tonsillar pillars 2+ 25-49% Tonsils fill less than 50% of the transverse oropharyngeal space 3+ 50-74% Tonsils fill less than 75% of the transverse oropharyngeal space 4+ 75% or more Tonsils fill 75% or more than the transverse oropharyngeal space • 7 or more episodes in the preceding 1 year. • 5 or more episodes in each of the preceding 2 years (consecutive). • 3 or more episodes in each of the preceding 3 years (consecutive). Sore Throat plus one or more of 1. Temperature >38.3 °C. 2. Cervical lymphadenopathy (tender lymph nodes or >2 cm). 3. Tonsillar exudates. Positive culture for group A beta-hemolytic streptococcus or treatment with antibiotics (conventional dosage for proved or suspected streptococcal episodes). Persistence of symptoms in-between the attacks of tonsillitis or presence of tonsillolith. Throat cultures or rapid antigen testing, neither is able to differentiate between carrier states and an invasive infection. The asymptomatic carrier rate for GABHS is up to 40%, and they have low infectivity and are not at risk of developing complications. Monospot testing is not routinely recommended. Features indicative of a viral sore throat include malaise, cough, pharynx looks normal or mild erythema and oedema and presence of nasal symptoms or signs. Features indicative of a streptococcal sore throat include: Odynophagia, nausea, vomiting, abdominal pain (common in children), exudates present on the tonsils, cervical lymph nodes are enlarged and tender and rash characteristic of scarlet fever. Scarlet fever: Caused by streptococcal infection, associated with characteristic erythematous rash which later desquamates with the tongue initially covered with a white coat and enlarged red papillae (strawberry tongue) may be seen. Acute herpetic pharyngitis: Primary infection with herpes simplex virus may present as acute sore throat. Pain is moderate to severe with possible cervical lymphadenopathy, fever, and exudates and vesicles and shallow ulcers on the palate with gingivostomatitis may be seen. The natural history of the illness is self-limiting and most cases last for an average of one week. During this period, patients should be managed through symptom control. Antibiotics should only be used in severe cases. Categorise a patient's risk for Group A betahaemolytic streptococcus (GABHS) to prescribe antibiotics. One point is awarded for each of the following: 1. Tonsillar exudates. 2. Tender anterior cervical lymph nodes. 3. Fever. 4. Absence of cough. • Score of 3-4 suggests a 40-60% likelihood of GABHS. • Score <3 indicates infection with GABHS is unlikely. It is not a diagnostic tool, not valid for children younger than age 3 years with low specificity for bacterial infection. Antibiotic treatment: Antibiotics should only be used in severe cases. Antibiotics should not be used for: 1. Patients with a Centor score of <3. 2. Symptomatic relief of sore throat. 3. To prevent suppurative complications. 4. Prophylaxis for recurrent sore throat. 5. Treatment of sore throat specifically to prevent the development of rheumatic fever and acute glomerulonephritis. 6. To prevent cross infection with Group A betahaemolytic streptococcus (GABHS) in the general community. First-line treatment: -Phenoxymethylpenicillin (penicillin V) for 10 days. -Ampicillin-based antibiotics, including coamoxiclav, can be used for 10 days, as alternatives to penicillin V as first line; however, there is a risk of rash when used in the presence of glandular fever. -Cephalosporin as second-line treatment. Clarithromycin for 10 days is recommended. Close contacts of patients with invasive Group A streptococcal disease should be treated with antibiotics if they have symptoms of localised infection which may include sore throat, fever and skin infection. • Sore throat including tonsillitis is primarily a condition that should be recognised and managed in primary care. • Significant complications of sore throat or serious systemic illness should be managed in secondary care. • Throat swabs and rapid antigen testing are of limited benefit in the diagnosis and management of sore throat. • Routine treatment of tonsillitis should be symptomatic, with antibiotic use reserved for those most likely to have either: -Bacterial infection -Complication of tonsillitis -Significant risk factors for developing a complication • Watchful waiting rather than tonsillectomy is a reasonable management approach where the severity of symptoms or frequency of episodes is unclear. • Recurrent acute tonsillitis and chronic tonsillitis are an indication for tonsillectomy. Glenis • Waldeyer's ring grows throughout childhood until the age of 11 years and after that decreases spontaneously. • Waldeyer's ring tissue serves as a defence against infection and plays an important role in the development of the immune system. • Removal of either or both doesn't reduce immunity or increase incidence of Hodgkin's disease. • Treatment of chronic adenoiditis is surgical removal. • Acute tonsillitis in children is most commonly viral and self-limiting. • Acute bacterial tonsillitis is most commonly the result of beta-haemolytic streptococcus and is best treated with oral penicillin V. Handbook of pediatric otolaryngology: a practical guide for evaluation and management of pediatric ear, nose, and throat disorders Pediatric otolaryngology: principles and practice pathways