Hypertrophic Tonsil

WONG Yee Hang Birgitta, HUI Yau
Department of Surgery, The University of Hong Kong, HKSAR

Diseases of the tonsil and adenoid remain the commonest paediatric ENT diagnosis, while tonsillectomy and adenoidectomy are currently the top ten paediatric surgical procedures performed. The impact of the disease on a child's health does not localized just to the organ itself, but has significant ill-effects on the whole upper respiratory tract and the anatomical development of the facial complex. Thus, it is important for all primary care physicians, paediatricians and otorhinolaryngologists to have a clear knowledge on adenotonsillar disorder [1].

Anatomy

Tonsils are lymphoepithelial organs at the opening of the upper aerodigestive tract. From above downwards, they can be divided into [2]:

  1. pharyngeal tonsil, adenoid, which lies on the roof and posterior wall of the nasopharynx
  2. tubal tonsil which lies around the eustachain tube
  3. palatine tonsil which lies between the anterior and posterior faucial pillars
  4. lingual tonsil which lies at the base of the tongue

These lymphoid organs developed from the epithelium of the primitive oronasal cavity, the mesenchymal stroma and lymphoid cells then infiltrate these areas. Although the tonsils are present at embryonal stage, they only acquire their typical structure in the postnatal period. They begin increasing rapidly in size between the first and third year of life, with peaks in the third and seventh year. They involute slowly at early puberty. In contrast to other lymphoid aggregates, tonsils do not filter lymph [3].

The palatine tonsil is supplied by the facial artery, ascending pharyngeal artery, lingual artery and the maxillary artery. Venous drainage is by the lingual and pharyngeal veins [3].

Immunology

Tonsils are composed primarily of B-lymphocytes. T-cell lymphocytes constitute 40% of total volume in contrast to 70% in circulating plasma. According to present knowledge, tonsils are involved in production of antibodies, interferon-gamma and lymphokines and in inducing secretory immunity [3]

Clinical Aspect of tonsils

The most common problems encountered in paediatric age group are obstructive hypertrophy and infection.

Adenotonsillar hypertrophy and hyperplasia

Tonsillar hypertrophy has become the most frequent indication for tonsillectomy in children. Hyperplasia itself is not a disease, but only a result of increased immunologic activity. It does not necessary be due to inflammation or tonsillitis. Those hypertrophic tonsils with acute upper airway obstruction are usually associated with acute infection but not with the chronic type [1]. Chronic tonsillar hypertrophy can be asymptomatic and may not lead to any problem. However, a marked increase in size of tonsil accounts for up to 80% of obstructive sleep apnoea in children. In severe form of OSA can lead to cor pulmonale, pulmonary hypertension, pneumonia, chronic hypercapnia or hypoxia and eventually right heart failure [3].

Tonsillar hypertrophy usually accompanied hypertrophy of adenoid. Besides obstructive sleep apnoea and its complication, it can also lead to other diseases [2]:

  1. Acute and chronic otitis media due to obstruction of Eustachian tube.
  2. Sinusitis and rhinitis
  3. Maldevelopment of upper jaw, arched or gothic palate due to persistent opening of mouth during childhood.
  4. Poor mental development due to chronic hypoxia.

Assessment of tonsils should begin with a good history taking. Symptoms suggestive of adenotonsillar hypertrophy include difficulty in feeding in small children, mouth breathing, noisy respiration, loud snoring, frequent awakening during the night, hypersomnolence, secondary enuresis, night terrors, changes in behaviour pattern and poor school performance. On physical examination, affected children may present with adenoid facies with dull facial expression, flattened nasolabial fold, open mouth and protruding upper incisors. In severe cases, congestive heart failure may be found. The child may be found to sleep in an unusual position i.e. the sniff position or with the neck hyperextended. Growth disturbance and failure to thrive can occur. Therefore a complete assessment is needed. Growth curve should be recorded for future comparison. One should look out for underlying medical problems and craniofacial deformity which can aggravates the obstructive symptoms [1,2].

Examination of oral cavity should be done properly. Very often, the size of tonsils may be exaggerated during gagging and pressing hard with the use of a tongue depressor. The proper way is to gently place the tongue depressor anterior to the circumvallate papillae or if possible, just by inspection without the use of tongue depressor. The size and percentage of the obstruction should be recorded using the scale 0 to +4. 0 means the tonsil is in the fossa; +1 means less than 25% obstruction; +2 is less than 50%; +3 is less than 75% and +4 is more than 75% obstruction [1,2].

Imaging is important in paediatric assessment as children may be difficult to examine. A lateral soft tissue x-ray film of the head and neck region will show up the hypertrophic tonsils and adenoid together with associated narrowing of naso and oropharynx [2].

A formal sleep study i.e. polysomnography may be used as an objective measure but is expensive and not readily available. It is reserved for those in which the diagnosis is in doubt, unclear history and for documentation prior to surgery [1].

ECG, echocardiogram and CXR are necessary for those suspected to have heart failure.

Currently, children with hypertrophic tonsils associated with symptom of obstruction warrant tonsillectomy as the main treatment as only 30% of hypertrophic tonsil have improved obstructive symptoms after taken antibiotics for 3 to 6 weeks. Besides, the relapse rate is high, up to 50%. With tonsillectomy, symptoms resolve rapidly and prognosis is very good. No significant immunological consequences has ever been documented. With present advancement and new techniques, complications are rare. Postoperative haemorrhage ranges from 0.5-2%. Changes in speech or velopharyngeal insufficiency are mainly temporary. In general, nearly all our patients can be discharged safely from hospital two days after the operation.

Acute and Chronic Tonsillitis

The most active phase of tonsils is between age 3 to 10 years and after that involution begins. Although hyperplasia of tonsils is not a disease, these organs are found to have a higher incidence of pathogenic bacteria around the poorly-drained tonsillar crypts resulting in tonsillitis. Majority of childhood tonsillitis are caused by group A £]-haemolytic streptococcus (GABHS). Its frequency and serious consequences such as acute rheumatic fever and glomerulonephritis make this an important infection. Viral causes are also common including coxsackievirus, herpesvirus and Epstein-Barr virus [4,5]. However, it was found that with recurrent attacks of tonsillitis, the type and number of organisms changes from a commensal to greater varieties of bacteria and thus requiring different broad-spectrum antibiotics [1]. Therefore the use of throat culture to arrive at the diagnosis is inaccurate.

Clinically, the patients presented with sorethroat, fever and malaise. Physical examination may nor may not show enlarged tonsils, but exudates, erythema are seen. Cervical lymph nodes may be enlarged and tender.

Definition of recurrent acute tonsillitis is varible. We take more than 4 episodes in one year or 7 episodes in 1 year, 5 episodes per year for 2 years or 3 episodes per year for 3 years [1].

Recurrent acute tonsillitis and chronic tonsillitis can give rise to peritonsillar abscess. Further spread of the infection beyond the peritonsillar space and lateral aspect of tonsillar fossa can lead to parapharyngeal space abscess. In addition, children under age 3 with tonsillitis are more susceptible to retropharyngeal space infection. Affected children will present as irritability, fever, difficulty in breathing and torticollis [3].

The most common drug used to treat tonsillitis is amoxicillin [5]. But with increasing resistance, the use of beta-lactamase inhibitor i.e. augmentin or unasyn may be needed [3]. Only 32% responds to medical treatment with 6 months prophylaxis or a prolonged course of 30-days antibiotics [1].

Decision for surgical intervention in patients with recurrent tonsillitis should be individualized. When treating paediatric patients, surgeon should have good communication with parents and provide full explanation of the procedure. Always ask for family history of bleeding tendency and other medical problems. Cervical XR should be done for children with Down's syndrome.

Tonsillectomy

Recently, the surgical indications for tonsillectomy are as follows[3]:

  1. Infection:

    Recurrent, acute tonsillitis (>6 episodes per year or 3 episodes per year >2 years)
    Recurrent acute tonsillitis associated with other conditions
    Cardiac valvular disease associated with recurrent streptococcal tonsillitis
    Recurrent febrile seizures
    Chronic tonsillitis that is unresponsive to medical therapy associated with
    Halitosis
    Persistent sore throat
    Tender cervical adenitis
    Streptococcal carrier state unresponsive to medical therapy
    Peritonsillitis abscess
    Tonsillitis associated with abscessed cervical nodes
    Mononucleosis with severely obstructing tonsils that is unresponsive to medical therapy

  2. Obstruction

    Excessive snoring and chronic mouth breathing
    Obstructive sleep apnoea or sleep disturbances
    Adenotonsillar hypertrophy associated with
    Cor pulmonale
    Failure to thrive
    Dysphagia
    Speech abnormalities
    Craniofacial growth abnormalities
    Occlusion abnormalities

  3. Other
    Suspected neoplasia-asymmetric tonsillar hypertrophy
  4. There are different methods of tonsillectomy including the use of a cold knife, hot knife, diathermy, laser and harmonic scalpel [1]. The operation lasts for about one hour. Postop, the patients recover rapidly and can resume tonsillar diet immediately. Most important is to look out for post-op bleeding. Postoperative haemorrhage ranges from 0.5-2% [3]. No significant immunological consequence has ever been documented. Changes in speech or velopharyngeal insufficiency are mainly temporary. In general, nearly all our patients can be discharged safely from hospital three days after the operation.

Unilateral tonsillar hypertrophy

It is uncommon for a child to present with a true asymmetrically enlarged tonsil. If it happens, the differential diagnosis include lymphoma, maliganacy and unusual infections like atypical mycobacterium infection, actinomycosis and fungal infection. Excisional biopsy must be done. For suspicious case, CT neck with contrast and MRI are warranted.

Local Statistics

In Queen Mary Hospital, Hong Kong, diseases of the tonsil and adenoid remain the commonest paediatric ENT diagnosis. We observed that among the total paediatric admissions from 1995 to 1998, the trend for obstructive tonsillar disease like obstructive sleep apnoea is increasing; while in contrary, infective tonsillar disease i.e. tonsillitis is decreasing.

The following are the percentage of infective and obstructive tonsillar diseases among the total paediatric admissions in QMH:

  1995 1996 1997 1998
Infective tonsillar disease 62% 49% 43% 34%
Obstructive tonsillar disease 19% 39% 28% 68%

 

Conclusion

Diseases of the tonsils are commonly encountered in the management of children. A clear understanding of the anatomy, physiology, pathology and treatment are essential for management.

References

  1. L. Brodsky, Adenotonsillar disease in children, Practical Paediatric Otolaryngology. Ch 2, 15-39
  2. W. Becker, Ear, Nose, and Throat Diseases. Ch 3, 307-9, 322-24
  3. M.A. Richardson, Sore throat, tonsillitis, and adenoiditis, Medical Clinics of North America. 83 (1999) 75-83
  4. J.L. Paradise, Etiology and management of pharyngitis and pharyngotonsillitis in children: a current review, Ann Otol Rhinol Laryngol. 101 (1992) 51-57
  5. C.D. Bluestone, Current indications for tonsillectomy and adenoidectomy, Ann Otol Rhinol Laryngol 101 (1992) 58-64

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