Tonsils, Adenoids and Glue Ear

Question 1

summarise the development of the tonsils

Answer 1

tonsillar fossa and palatine tonsils develop from dorsal wing of 1st palatine pouch and ventral wing of 2nd pouch @ 8 weeks
crypts 3-6 months

16 weeks adenoids develop as a sub epithelial infiltration of lymphocytes

Question 2

what is the main function of the adenoids and tonsils

Answer 2

trap bacterial and viruses on inhalation

expose these to immune system

Question 3

what happens to tonsil size throughout life

Answer 3

singificant adenotonsilar enlargement unusual under 2

after teens tonsils and adenoids decrease in size

Question 4

what is waldeyers ring

Answer 4

ring of lymphoid aggregation in the subepthelial layer of oropharynx and nasopharynx

made up of tonsils (palatine tonsil), adenoids (pharyngeal tonsil) and lingual tonsils (on tongue)

Question 5

what does the tonsil sit in

Answer 5

in a fossa formed by the muscular anterior and posterior tonsillar pillars (palatoglossus and palatopharyngeus)

Question 6

describe the histology of the tonsils

Answer 6

Lymphoid tissues covered with specialised stratified squamous epithelium
deep cysts
base separated from muscles by dense collagenous hemi-capsule
lymphoid follicles in parenchyma

Question 7

describe the histology of the adenoids

Answer 7

ciliated pseudostratified columnar
stratified squamous
deep folds
transitional

Question 8

what epithelium lines the oral cavity, pharyngeal, vocal cords, oesophagus

Answer 8

squamous epithelium

Question 9

what epithelium where air goes (nose, PNS, larynx, trachea)

Answer 9

columnar

Question 10

what usually causes acute tonsillitis

Answer 10

majority viral - EBV, rhinovirus, parainfluenza, enterovirus, adenovirus

bacterial- strep pyogenes (group A beta-haemolytic strep), H influenza, S. aureus, strep pneumoniae

Question 11

when should you suspect mono in a patient previously diagnosed with tonsilitis

Answer 11

if persists despite antibacterial treatment

Question 12

what malignancies can be mistaken for acute tonsilitis

Answer 12

lymphoma, leukemia, carcinoma

Question 13

what are the symptoms of viral tonsilitis

Answer 13

not a severe as bacterial:

• malaise
• sore throat
• temp
• able to work and do normal activities
• possible lymphadenopathy
• lasts 3-4 days

Question 14

what are the symptoms of bacterial tonsilitis

Answer 14

more severe than viral:

• systemic upset
• fever
• odynophagia
• halitosis
• unable to work/school
• lymphadenopathy
• lasts 1 week

Question 15

how do you differentiate between bacterial and viral tonsilitis

Answer 15

bacterial infection:

• history of fever
• tonsillar exudates
• tender anterior cervical adenopahty
• absence of cough

Question 16

when should you give antibiotics in tonsilitis

Answer 16

centor
0-1 no
2/3 - yes if symptoms progress
4/5 - treat empirically with an antibiotic

Question 17

what does the centor criteria assess

Answer 17

the risk of group A strep infection and hence the need for antibiotics

Question 18

is puss on tonsils more/less likely to make it bacterial tonsillitis

Answer 18

more likely

Question 19

what is the treatment for tonsilitis

Answer 19

supportive: eat and drink, rest, analgesia (paracetamol, NSAID)
antibiotic- penicillin 500 mg quid for 10 days, clarithromycin if allergic
hospital- IV fluids and antibiotics, steroids
surgery

Question 20

what are the negatives of surgical management of tonsilectomy

Answer 20

very painful

risk of haemorrhage- 1 person dies every year

Question 21

what are the possible complications of tonsillitis

Answer 21

peritonsilar abscess (quinsy) 
infective mononucleosis (when caused by EBV)

Question 22

what is a peritonisilar abscess

Answer 22

complication of acute tonsilitis- when the bacteria between muscle and tonsil produce pus

Question 23

what are the features of a peritonsilar abscess

Answer 23

unilateral throat pain and odynophagia
trismus
3-7 days of preceding acute tonsilitis

medial displacement of tonsil and uvula
concavity of palate lost

Question 24

what is the treatment for a peritonsilar abscess (qunisy)

Answer 24

aspiration and antibiotics

Question 25

what is infective mononucleosis (glandular fever) caused by

Answer 25

ebstein-barr virus

Question 26

what are the signs of infective mononucleosis

Answer 26

``` gross tonsilar enlargement with membranous exudate marked cervical lymphadenopathy palatal petechial haemorrhages generalised lymphadenopathy hepatosplenomegaly ```

Question 27

what tests to diagnose infective mononucleosis

Answer 27

atypical lymphocytes in peripheral blood, paul-bunnell test or monospot, low CPR, can cause deranged LFTs

Question 28

what is the management of infective mononucleosis

Answer 28

symptomatic antibiotics if they get secondary bacterial infection steroids if patient struggling avoid contact sport to avoid spleen rupture avoid alcohol

Question 29

is chronic tonsillitis a thing

Answer 29

probs not

Question 30

what are the features of obstructive hyperplasia of the adenoids

Answer 30

obligate mouth breathing hyponasal voice snoring and sleep disturbance (*reason to remove them) AOM/OME*

Question 31

what are the features of obstructive hyperplasia of the tonsils

Answer 31

snoring and sleep disturbance muffled voice (transient as tonsils decrease in size) ?dysphagia

Question 32

what are the causes of unilateral tonsilar enlargment

Answer 32

acute/chronic infection hypertrophy congenital neoplastic

Question 33

what is glue ear/ otitis media with effusion/ serous otitis media

Answer 33

inflammation of the middle ear accompanied by accumulation of fluid without the symptoms and signs of acute inflammation - hearing loss - fluid seen in TM and has impaired mobililty

Question 34

what is acute otitis media

Answer 34

inflammation of the middle ear accompanied by the symptoms and signs of acute inflammation with/ without an accumulation of fluid - may have hearing loss not always (inc: fever, earache, irritability, opaque TM- may be bulging or have impaired mobility)

Question 35

who gets OME

Answer 35

``` children, boys more esp if: in day care, have older siblings, smoking household (affects cililary function), history of recurrent URTI/AOM, if premature, craniofacial/genetic abnormalities, immunodeficient, bottle fed, allergy, seasonal ```

Question 36

why do children get OME

Answer 36

as eustachian tube short- gets congested

Question 37

what are the symptoms of OME

Answer 37

``` deafness, poor school performance and behavioural problems, speech delay, balance problems, loud TV ``` will NOT have otalgia

Question 38

how do you diagnose OME

Answer 38

``` history, otoscope, tuning fork tests, audiometry tympanometry ```

Question 39

what are the signs of OME

Answer 39

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

Question 40

what will cause a tympanomtery test to produce a flat line

Answer 40

fluid in the middle ear

Question 41

what is the hearing range in glue ear

Answer 41

roughly around 30dB

Question 42

what is the management of glue ear

Answer 42

watchful waiting most resolve review at 3 months otoscopy, PTA, tympanometry manage educational needs if persistent for >3 months, symptoms of deafness and speech/language problems, CHL>25 dB or developmental behavioural problems then refer

Question 43

what are the surgical management options of OME

Answer 43

<3 years= grommets | >3 years grommets, then adenoidectomy (considered earlier if nasal problems early), hearing aids

Question 44

how long to grommets last

Answer 44

can fall out in few days or in 18 months

Question 45

what are the complications of grommets

Answer 45

``` infection/ discharge early extrusion retention persistent perforation, swimming/bathing issues (cant swim as will get severe vertigo due to cold water) ```