Tonsils, Glue Ear and the Adenoids Flashcards by Joanne McEwan

what happens at 8 weeks development?

tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch
tonsillar pillars originate from the 2nd/3rd arches

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what happens at 6 weeks development?

adenoids develop as a subepithelial infiltration of lymphcytes

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what are the 4 functions of the tonsils?

trap bacteria and viruses on inhalation
expose to immune system
antibodies produced by the immune cells in the tissue
help to prime immune system and help to prevent subsequent infections

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how does the size of the tonsils change in growth?

smaller <2 yrs
- significant enlargement <2 y/o is rare
tonsils and adenoids decrease in bulk after early teenage years

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what is waleyer’s ring?

ring of lymphoid aggregation in the subepithelial layer of oropharynx and nasopharynx
comprised of
- tonsils (palatine tonsil)
- adenoids (pharyngeal tonsil)
- lingual tonsil

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describe the histological features of the tonsils

specialized squamous
deep crypts
lymphoid follicles
posterior capsule

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describe the histological features of the adenoids

ciliated pseudostratified columnar
stratified squamous
transitional
deep folds

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general histology of upper aerodigestive tract?

ciliated columnar respiratory type mucosa

squamous epithelium

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general histology of where food goes/high use/trauma?

squamous

oral, pharyngeal, vocal cords, oesophagus

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general histology of where air goes?

columnar

nose, PNS, larynx, trachea

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what most commonly causes acute tonsillitis?

most are viral (EBV, rhinovirus, influenza, enterovirus, adenovirus)
5-30% are bacterial
group A beta haemolytic strep = most important pathogen

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are throat swabs used in tonsillitis?

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what are the most common organisms cultures from chronic tonsillar disease?

strep pyogenes
H influenza
staph aureus
strep pneumonia
beta lactamase producing

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differential diagnoses of acute tonsilitis?

viral URTI
glandular fever
peritonsillar abscess
candida infection
malignancy
diptheria
scarlet fever

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symptoms of viral tonsillitis?

malaise
sore throat, mild analgesia requirement
temperature
able to go about normal activities
possible lymphadenopathy
lasts 3-4 days

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symptoms of bacterial tonsillitis?

systemic upset
fever
odynophagia
halitosis
unable to work/school
lymphadenopathy
lasts 1 week, requires antibiotics to settle

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centor criteria?

differentiates viral from bacterial tonsillitis
fever
tonsillar exudate
tender anterior cervical lymphadenopathy
absence of cough
0-1 = no antibiotic
2-3 = should get antibiotic if symptoms progress
4-5 = treat empirically with antibiotic

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treatment of tnsilitis?

supportive (rest, eat and drink, analgesia)
antibiotic (penicillin 500g for 10 days, clarithromycin if allergic)
hospital if cant eat and drink (IV fluids and antibiotic, steroids)
surgery

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problem with clarithromycin?

makes you sick

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guidelines for tonsillectomy?

watch and wait more appropriate for children with mild sore throats
tonsillectomy is recommended for recurrent severe sore throats
- sore throats must be due to acute tonsillitis
- episodes os sore throats are disabling and prevent normal functioning
- seven or more well documented, clinically significant, adequately treated sore throats in preceeding year
or
- five or more per year in past 2 years
or
- three or more per year in past 3 years

features of post tonsillectomy?

very painful
strong opiates required
daycase
pain worst at day 5
5% risk of haemorrhage

what is a peritonsillar abscess?

complications of acute tonsillitis where bacteria between muscle and tonsil produce pus

features of peritonsillar abscess?

unilateral throat pain and odynophagia
trismus
3-7 days of preceeding acute tonsillitis
medial displacement of tonsil and uvula
concavity of palate is lost

how is peritonsillar abscess managed?

aspiration/drainage

antibiotics

what are the signs of glandular fever?

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

how is glandular fever diagnosed?

atypical lymphocytes in peripheral blood (different to neutrophilia seen in tonsillitis) +ve monospot or paul bunnel test EBV IgE? low CRP

how is glandular fever managed?

symptomatic supportive treatment do not prescribe ampicillin?/amoxicillin? antibiotics - penicillin steroids

"chronic tonsillitis" included what?

``` chronic sore throat malodourous breath presence of tonsilliths peritonsillar erythema persistent tender cervical lymphadenopathy ```

features of obstructive hyperplasia due to adenoids?

obligate mouth breathing hyponasal voice snoring and other signs of sleep disturbance AOM/OME (acute otitis media/otitis media with effusion)

features of obstructive hyperplasia due to tonsils?

snoring and other symptoms of sleep disturbance muffled voice dysphagia

is large tonsils always a pathological symptoms?

no | only when associated with other symptoms

causes of true unilateral tonsillar enlargement?

``` acute infection chronic infection hypertrophy congenital neoplasm ```

glue ear, otitis media with effusion and serous otitis media are interchangeable terms for what?

inflammation of the middle ear accompanied by accumulation of fluid without symptoms and signs of acute inflammation

what is acute otitis media?

inflammation of the middle ear accompanied by symptoms and signs of acute inflammation with/without accumulation of fluid

AOM vs OME?

hearing loss and fluid only in OME | earache, fever, irritability and opaque only in AOM

who is OME more common in?

children(30% < 4 yrs old) males > female increased incidence in day care, older siblings, smoking household, recurrent URTI

patient risk factors for OME?

``` recurrent URTI recurrent AOM prematurity craniofacial/genetic abnormalities - eustachian tube dysfunction immunodeficiency ```

environmental risk factors for OME?

``` household smoking day care allergy nutrition bottle feeding seasonal ```

what are the symptoms of chronic OM?

``` hearing loss poor school performance bad behaviour speech delay balance problems TV volume NOT OTALGIA ```

how is chronic otitis media diagnosed?

``` history otoscopy tuning fork test audiometry tympanometry ```

signs of chronic otitis media?

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

how is hearing investigated?

``` age appropriate hearing assessment audiometry - distraction testing (kids) - bone conduction - OAE (otoacoustic emissions) - pure tone audiometry tympanometry ```

how does tympanometry work?

measures vibration of tympanic membrane | TM cant vibrate much if middle ear is filled with fluid

how is chronic otitis media managed?

watchful waiting - 60% resolve in 1 month - 90% resolve in 3 months can insert grommet if still present at 6-8 months review at 3 months for otoscopy, PTA and tympanometry explain that is wont cause long term hearing problems

how is chronic otitis media (glue ear) managed if present for more than 3 months?

referral | no evidence for antibiotics, decongestants, steroids or antihistamines etc

how can glue ear be managed surgically if persistent?

<3 yrs = grommet >3 yrs, first intervention = grommet >3 yrs, second intervention = grommets and removal of adenoids - adenoidectomy may be considered earlier if nasal symptoms present

possible complications of glue ear?

short term speech, language and behavioural development problems (possibly) no long term problems

complications of grommets?

``` infection/discharge early extrusion retention persistent perfusion swimming/bathing issues ```