Adenotonsillar Disease

Question 1

When do the tonsils begin to develop?

Answer 1

8 weeks gestation = tonsillar fossa and palatine tonsils develop from dorsal wing of 1st pharyngeal pouch and the ventral wing of the 2nd pouch, tonsillar pillars originate from second/third arches

Question 2

When do the adenoids begin to develop?

Answer 2

16 weeks gestation = develop as subepithelial infiltration of lymphocytes

Question 3

What are some other important embryological developments related to the tonsils and adenoids?

Answer 3

Crypts develop from 3-6 months gestation, capsule develops in 5th month, germinal centres develop after birth

Question 4

What are the main functions of the tonsils and the adenoids?

Answer 4

Trap bacteria/viruses on inhalation and expose them to immune system, production of antibodies by tissue immune cells, help prime immune system and prevent subsequent infections

Question 5

When is it unusual to have significant adenotonsilar enlargement?

Answer 5

Before the age of 2

Question 6

What happens to the adenoids and the tonsils after the early teenage years?

Answer 6

Decrease in bulk

Question 7

What is Waldeyer’s ring?

Answer 7

Ring of lymphoid aggregation in the subepithelial layer of the oropharynx and nasopharynx

Question 8

What structures make up Waldeyer’s ring?

Answer 8

Tonsils (palatine tonsils), adenoids (pharyngeal tonsils) and lingual tonsil

Question 9

What are the histological features of the tonsils?

Answer 9

Specialised squamous, deep crypts, lymphoid follicles, posterior capsule

Question 10

What are the histological features of the adenoids?

Answer 10

Ciliated pseudostratified columnar, stratified squamous, transitional, deep folds

Question 11

What cell types are present in the upper aerodigestive parts of the tonsils and adenoids?

Answer 11

Ciliated columnar respiratory type mucosa, squamous epithelium

Question 12

Where are some areas that would have squamous epithelium?

Answer 12

Areas where food goes in/high use/trauma = oral, pharyngeal, vocal cords, oesophagus

Question 13

What are some examples of areas with columnar epithelium?

Answer 13

Areas where air goes = nose, PNS, trachea

Question 14

What are some common pathologies of the tonsils and adenoids?

Answer 14

Acute tonsillitis, recurrent/chronic tonsillitis/adenoiditis, obstructive hyperplasia, malignancy, tonsil crypt debris/tonsiliths, glue ear

Question 15

What are the majority of acute tonsillitis cases due to?

Answer 15

Viral aetiology = EBV, rhinovirus, influenza, parainfluenza, enterovirus, adenovirus

Question 16

How common are bacterial causes of acute tonsillitis?

Answer 16

About 5-30% = group A strep important because of potential sequalae

Question 17

Are throat swabs taken in patients with acute tonsillitis?

Answer 17

No

Question 18

What are the most common bacteria that cause acute tonsillitis?

Answer 18

Group A strep, h. influenzae, staph aureus, strep pneumoniae, 39% are beta lactamase producing (BLPO)

Question 19

What are the differentials of acute tonsillitis?

Answer 19

URT viral infection, glandular fever, peritonsillar abscess, candida infection, lymphoma, leukaemia, carcinoma, diphtheria, scarlet fever

Question 20

What are the symptoms of a viral case of acute tonsillitis?

Answer 20

Malaise, temperature, sore throat (needs mild analgesia), able to undertake near normal activity, possible lymphadenopathy, lasts 3-4 days

Question 21

What are the symptoms of bacterial acute tonsillitis?

Answer 21

Systemic upset, fever, odynophagia, halitosis, unable to work/school, lymphadenopathy, lasts about 1 week (need antibiotics to settle)

Question 22

What is the purpose of the modified Centor criteria for acute tonsillitis?

Answer 22

Differentiates between viral and bacterial causes

Question 23

What criteria make up the modified Centor criteria?

Answer 23

History of fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough

Question 24

How does the modified Centor criteria dictate how a patient will be treated for acute tonsillitis?

Answer 24

0-1 point = no antibiotics (<10% risk of bacterial cause)
2-3 points = antibiotic only if symptoms progress (risk 15% if 2, 32% if 3)
4-5 points = treat empirically with antibiotic (56% risk)

Question 25

What are the treatment options for acute tonsillitis?

Answer 25

Supportive = eat/drink, rest, paracetamol/NSAIDs | Antibiotics, hospital (IV fluid/antibiotics, steroids), surgery

Question 26

What antibiotics are used to treat acute tonsillitis?

Answer 26

500 mg penicillin qid for 10 days, clarithromycin if allergic

Question 27

When are tonsillectomies recommended to treat acute tonsillitis?

Answer 27

Recurrent severe throats in adults, recurrent sore throats due to acute tonsillitis, episodes of sore throats that are disabling and prevent normal function

Question 28

How often would a patient need to have acute tonsillitis to qualify for a tonsillectomy?

Answer 28

``` >= 7 episodes in previous year >= 5 episodes in each of previous two years >= 3 episodes in each of previous three years ```

Question 29

What are some features of surgery for acute tonsillitis?

Answer 29

Very sore afterwards, worst day is the 5th one post surgery, may need strong opiates, daycase surgery, 5% risk of haemorrhage

Question 30

How do peritonsillar abscesses normally occur?

Answer 30

As a complication of acute tonsillitis = bacteria between muscle and tonsils produces pus

Question 31

How do peritonsillar abscesses present?

Answer 31

Unilateral throat pain and odynophagia, trismus, 3-7 days of preceding acute tonsillitis

Question 32

What are some signs that a patient may have a peritonsillar abscess?

Answer 32

Medial displacement of tonsil and uvula, concavity of palate lost

Question 33

How are peritonsillar abscesses treated?

Answer 33

Aspiration and antibiotics

Question 34

What causes glandular fever?

Answer 34

Epstein Barr virus

Question 35

What are the signs of glandular fever?

Answer 35

Gross tonsillar enlargement with membranous exudate, marked cervical lymphadenopathy, palatal petechial haemorrhage, generalised lymphadenopathy, hepatosplenomegaly

Question 36

How is glandular fever diagnosed?

Answer 36

Atypical lymphocytes in peripheral blood, positive Monospot or Paul-Bunnell test, low CRP (<100)

Question 37

How is glandular fever treated?

Answer 37

Symptomatic treatment, antibiotics, steroids

Question 38

What antibiotics should never be given to a patient with glandular fever?

Answer 38

Ampicillin or amoxicillin = will cause a rash

Question 39

How would chronic tonsillitis present?

Answer 39

Chronic sore throat, malodorous breath, presence of tonsillitis, peritonsillar erythema, persistent tender cervical lymphadenopathy

Question 40

What is a controversial treatment option for chronic tonsillitis?

Answer 40

Surgery = rarely offered

Question 41

How does obstructive hyperplasia of the adenoids present?

Answer 41

Obligate mouth breathing, hyponasal voice, snoring and other symptoms of sleep disturbance, acute otitis media/otitis media with effusion

Question 42

How would obstructive hyperplasia of the tonsils present?

Answer 42

Snoring and other symptoms of sleep disturbance, muffled voice, dysphagia

Question 43

What must be differentiated between in unilateral tonsillar enlargement?

Answer 43

Apparent enlargement vs true enlargement

Question 44

What are some causes of unilateral tonsillar enlargement?

Answer 44

Non-neoplastic = acute/chronic infection, hypertrophy, congenital Neoplasm

Question 45

What are other terms used to describe glue ear?

Answer 45

Otitis media with effusion, serous otitis media

Question 46

Is acute otitis media the same as glue ear?

Answer 46

No = they are different

Question 47

What is glue ear?

Answer 47

Inflammation of the middle ear with accumulation of fluid but no symptoms of acute inflammation

Question 48

What is acute otitis media?

Answer 48

Inflammation of the middle ear with symptoms of acute inflammation that may also have an accumulation of fluid

Question 49

What is the epidemiology of otitis media with effusion?

Answer 49

May occur in any child but less common as age increases, more common in males, present in 30% of children <4 years old at any time

Question 50

What are the risk factors for developing otitis media with effusion?

Answer 50

Day care, older sibling, smoking household, recurrent URTI/acute otitis media, prematurity, craniofacial/genetic abnormalities, immunodeficiency, bottle feeding

Question 51

What are some associations of otitis media with effusion?

Answer 51

May be seasonal, linked with allergy and nutrition

Question 52

What is not a symptom of glue ear?

Answer 52

Otalgia

Question 53

What are the symptoms of glue ear?

Answer 53

Deafness, poor school/behaviour problems, speech delay, balance problems, TV volume

Question 54

What is used to diagnose glue ear?

Answer 54

History, otoscopy, tuning fork test, audiometry, tympanometry

Question 55

What are some signs of glue ear?

Answer 55

TM retraction, reduced TM motility, altered TM colour, visible ME fluid/bubbles, CHL tuning fork tests

Question 56

What investigations may be done for glue ear?

Answer 56

Age appropriate hearing assessment Audiometry = OAE, distraction testing, COR, PTA Tympanometry

Question 57

How is simple glue ear treated?

Answer 57

Watchful waiting = 60% resolved by 1 month, 90% resolved by 3 months Review at 3 months = otoscopy, PTA, tympanometry

Question 58

How is glue ear treated if it lasts over 3 months with symptoms?

Answer 58

No evidence to support antibiotics, decongestants, mucolytics, steroids or antihistamines Autoinflation may be beneficial

Question 59

When should a patient be referred for glue ear?

Answer 59

Persistent (.3 months) and bilateral, CHL > 25dB, speech/language problems, developmental behaviour problems

Question 60

What surgery is done to treat a child <3 years old with glue ear?

Answer 60

Grommets

Question 61

What is the surgical management of a child >3 years old?

Answer 61

1st intervention = grommets | 2nd intervention = grommets and adenoidectomy

Question 62

When may an adenoidectomy be considered earlier than normal in a patient with glue ear?

Answer 62

If they have nasal symptoms

Question 63

What are some complications of glue ear?

Answer 63

Some evidence of short term speech, language and behaviour problems, no evidence of long term complications

Question 64

What are some complications of grommets?

Answer 64

Infection/discharge, early extrusion, retention, persistent perforation, swimming/bathing issues