Tonsils and Adenoids
Ralph F. Wetmore
Anatomy
The Waldeyer ring (the lymphoid tissue surrounding the opening of the oral and nasal cavities into the pharynx) comprises the palatine tonsils, the pharyngeal tonsil or adenoid, lymphoid tissue surrounding the eustachian tube orifice in the lateral walls of the nasopharynx, the lingual tonsil at the base of the tongue, and scattered lymphoid tissue throughout the remainder of the pharynx, particularly behind the posterior pharyngeal pillars and along the posterior pharyngeal wall. The palatine tonsil consists of lymphoid tissue located between the palatoglossal fold (anterior tonsillar pillar) and the palatopharyngeal fold (posterior tonsillar pillar) forms. This lymphoid tissue is separated from the surrounding pharyngeal musculature by a thick fibrous capsule. The adenoid is a single aggregation of lymphoid tissue that occupies the space between the nasal septum and the posterior pharyngeal wall. A thin fibrous capsule separates it from the underlying structures; the adenoid does not contain the complex crypts that are found in the palatine tonsils but rather more simple crypts. Lymphoid tissue at the base of the tongue forms the lingual tonsil that also contains simple tonsillar crypts.
Normal Function
Located at the opening of the pharynx to the external environment, the tonsils and adenoid are well situated to provide primary defense against foreign matter. The immunologic role of the tonsils and adenoids is to induce secretory immunity and to regulate the production of the secretory immunoglobulins. Deep crevices within tonsillar tissue form tonsillar crypts that are lined with squamous epithelium and host a concentration of lymphocytes at their bases. The lymphoid tissue of the Waldeyer ring is most immunologically active between 4 and 10 yr of age, with a decrease after puberty. Adenotonsillar hypertrophy is greatest between ages 3 and 6 yr; in most children tonsils begin to involute after age 8 yr. No major immunologic deficiency has been demonstrated after removal of either or both of the tonsils and adenoid.
Pathology
Acute Infection
Most episodes of acute pharyngotonsillitis are caused by viruses (see Chapter 409 ). Group A β-hemolytic streptococcus (GABHS) is the most common cause of bacterial infection in the pharynx (see Chapter 210 ).
Chronic Infection
The tonsils and adenoids can be chronically infected by multiple microbes, which can include a high incidence of β-lactamase–producing organisms. Both aerobic species, such as streptococci and Haemophilus influenzae, and anaerobic species, such as Peptostreptococcus, Prevotella, and Fusobacterium, contribute. The tonsillar crypts can accumulate desquamated epithelial cells, lymphocytes, bacteria, and other debris, causing cryptic tonsillitis. With time, these cryptic plugs can calcify into tonsillar concretions or tonsillolith. Biofilms appear to play a role in chronic inflammation of the tonsils.
Airway Obstruction
Both the tonsils and adenoids are a major cause of upper airway obstruction in children. Airway obstruction in children is typically manifested in sleep-disordered breathing, including obstructive sleep apnea, obstructive sleep hypopnea, and upper airway resistance syndrome (see Chapter 31 ). Sleep-disordered breathing secondary to adenotonsillar breathing is a cause of growth failure (see Chapter 59 ).
Tonsillar Neoplasm
Rapid enlargement of one tonsil is highly suggestive of a tonsillar malignancy, typically lymphoma in children.
Clinical Manifestations
Acute Infection
Symptoms of GABHS infection include odynophagia, dry throat, malaise, fever and chills, dysphagia, referred otalgia, headache, muscular aches, and enlarged cervical nodes. Signs include dry tongue, erythematous enlarged tonsils, tonsillar or pharyngeal exudate, palatine petechiae, and enlargement and tenderness of the jugulodigastric lymph nodes (Fig. 411.1 ; see Chapter 210 ).
Chronic Infection
Children with chronic or cryptic tonsillitis often present with halitosis, chronic sore throats, foreign-body sensation, or a history of expelling foul-tasting and foul-smelling cheesy lumps. Examination reveals tonsils of a range of sizes, often containing copious debris within the crypts. The offending organism is not usually GABHS.
Airway Obstruction
The diagnosis of airway obstruction (see Chapter 31 ) can frequently be made by history and physical examination. Daytime symptoms of airway obstruction, secondary to adenotonsillar hypertrophy, include chronic mouth breathing, nasal obstruction, hyponasal speech, hyposmia, decreased appetite, poor school performance, and, rarely, symptoms of right-sided heart failure. Nighttime symptoms consist of loud snoring, choking, gasping, frank apnea, restless sleep, abnormal sleep positions, somnambulism, night terrors, diaphoresis, enuresis, and sleep talking. Large tonsils are typically seen on examination, although the absolute size might not indicate the degree of obstruction. The size of the adenoid tissue can be demonstrated on a lateral neck radiograph or with flexible endoscopy. Other signs that can contribute to airway obstruction include the presence of a craniofacial syndrome or hypotonia.
Tonsillar Neoplasm
The rapid unilateral enlargement of a tonsil, especially if accompanied by systemic signs of night sweats, fever, weight loss, and lymphadenopathy, is highly suggestive of a tonsillar malignancy. The diagnosis of a tonsillar malignancy should also be entertained if the tonsil appears grossly abnormal. Among 54,901 patients undergoing tonsillectomy, 54 malignancies were identified (0.087% prevalence); all but 6 malignancies had been suspected based on suspicious anatomic features preoperatively.
Treatment
Medical Management
The treatment of acute pharyngotonsillitis is discussed in Chapter 409 and antibiotic treatment of GABHS in Chapter 210 . Because copathogens such as staphylococci or anaerobes can produce β-lactamase that can inactivate penicillin, the use of cephalosporins or clindamycin may be more efficacious in the treatment of chronic throat infections. Tonsillolith or debris may be expressed manually with either a cotton-tipped applicator or a water jet. Chronically infected tonsillar crypts can be cauterized using silver nitrate.
Tonsillectomy
Tonsillectomy alone is most commonly performed for recurrent or chronic pharyngotonsillitis. Tonsillectomy has been shown to be effective in reducing the number of infections and the symptoms of chronic tonsillitis such as halitosis, persistent or recurrent sore throats, and recurrent cervical adenitis in severely affected patients. In resistant cases of cryptic tonsillitis, tonsillectomy may be curative. Rarely in children, tonsillectomy is indicated for biopsy of a unilaterally enlarged tonsil to exclude a neoplasm or to treat recurrent hemorrhage from superficial tonsillar blood vessels. Tonsillectomy has not been shown to offer clinical benefit over conservative treatment in children with mild symptoms or in those with severe infections 2 yr after surgery.
There are large variations in surgical rates among children across countries: 144 in 10,000 in Italy; 115 in 10,000 in the Netherlands; 65 in 10,000 in England; and 50 in 10,000 in the United States. Rates are generally higher in boys. With the issuance of practice guidelines, these variations may decrease. The American Academy of Otolaryngology (AAO)–Head and Neck Surgery Taskforce on Clinical Practice Guidelines: Tonsillectomy in Children issued evidence-based guidelines in 2019 (Table 411.1 ). Table 411.2 illustrates the differences and similarities between these guidelines with those of the other major professional groups across the globe. The 2019 guidelines recommend watchful waiting for recurrent throat infections if there has been <7 episodes in the past year, <5 episodes/yr in the past 2 yr, or <3 episodes/yr in the past 3 yr.
Table 411.1
Paradise Criteria for Tonsillectomy
| CRITERION | DEFINITION |
|---|---|
| Minimum frequency of sore throat episodes | At least 7 episodes in the previous year, at least 5 episodes in each of the previous 2 yr, or at least 3 episodes in each of the previous 3 yr |
| Clinical features | |
| Treatment | Antibiotics administered in the conventional dosage for proved or suspected streptococcal episodes |
| Documentation | Each episode of throat infection and its qualifying features substantiated by contemporaneous notation in a medical record |
| If the episodes are not fully documented, subsequent observance by the physician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history* |
* Allows for tonsillectomy in patients who meet all but the documentation criterion. A 12 mo observation period is usually recommended before consideration of tonsillectomy.
Adapted from Baugh RF, Archer SM, Mitchell RB, et al: American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 144(1 Suppl):S8, 2011, Table 5.
Table 411.2
Comparison of American, Italian, and Scottish Guidelines for Tonsillectomy in Children and Adolescents
| PARAMETER | AAO-HNS GUIDELINES | ITALIAN GUIDELINES | SCOTTISH GUIDELINES |
|---|---|---|---|
| Audience | Multidisciplinary | Multidisciplinary | Multidisciplinary |
| Target population | Children and adolescents 1-18 yr of age | Children and adults | Children 4-16 yr of age and adults |
| Scope | Treatment of children who are candidates for tonsillectomy | Appropriateness and safety of tonsillectomy | Management of sore throat and indications for tonsillectomy |
| Methods | Based on a priori protocol, systematic literature review, American Academy of Pediatrics scale of evidence quality | Systematic literature review, Italian National Program Guidelines scale of evidence quality | Based on a priori protocol, systematic literature review, Scottish Intercollegiate Guidelines Network scale of evidence quality |
| Recommendations | |||
| Recurrent infection | Tonsillectomy is an option for children with recurrent throat infection that meets the Paradise criteria (see Table 411.1 ) for frequency, severity, treatment, and documentation of illness | Tonsillectomy is indicated in patients with at least 1 yr of recurrent tonsillitis (5 or more episodes per year) that is disabling and impairs normal activities, but only after an additional 6 mo of watchful waiting to assess the pattern of symptoms using a clinical diary | Tonsillectomy should be considered for recurrent, disabling sore throat caused by acute tonsillitis when the episodes are well documented, are adequately treated, and meet the Paradise criteria (see Table 411.1 ) for frequency of illness |
| Pain control | Recommendation to advocate for pain relief (e.g., provide information, prescribe) and educate caregivers about the importance of managing and reassessing pain | Recommendation for acetaminophen before and after surgery | Recommendation for adequate dose of acetaminophen for pain relief in children |
| Antibiotic use | Recommendation against perioperative antibiotics | Recommendation for short-term perioperative antibiotics* | NA |
| Steroid use | Recommendation for a single intraoperative dose of dexamethasone | Recommendation for a single intraoperative dose of dexamethasone | Recommendation for a single intraoperative dose of dexamethasone |
| Sleep-disordered breathing | Recommendation to counsel caregivers about tonsillectomy as a means to improve health in children with sleep-disordered breathing and comorbid conditions | Recommendation for diagnostic testing in children with suspected sleep respiratory disorders | NA |
| Polysomnography | Recommendation to counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography | Recommendation for polysomnography when pulse oximetry results are not conclusive in agreement with Brouillette criteria | NA |
| Surgical technique | NA | Recommendation for “cold” technique | NA |
| Hemorrhage | Recommendation that the surgeon document primary and secondary hemorrhage after tonsillectomy at least annually | NA | NA |
| Adjunctive therapy | NA | NA | Recommendation against Echinacea purpurea for treatment of sore throat |
| Recommendation for acupuncture in patients at risk of postoperative nausea and vomiting who cannot take antiemetic drugs | |||
* Statement made prior to most recent Cochrane review.
AAO-HNS, American Academy of Otolaryngology–Head and Neck Surgery; NA, not applicable.
Adapted with permission from Baugh RF, Archer SM, Mitchell RB, et al: American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 144(1 Suppl):S23, 2011, Table 9.
Adenoidectomy
Adenoidectomy alone may be indicated for the treatment of chronic nasal infection (chronic adenoiditis), chronic sinus infections that have failed medical management, and recurrent bouts of acute otitis media, including those in children with tympanostomy tubes who suffer from recurrent otorrhea. Adenoidectomy may be helpful in children with chronic or recurrent otitis media with effusion. Adenoidectomy alone may be curative in the management of patients with nasal obstruction, chronic mouth breathing, and loud snoring suggesting sleep-disordered breathing. Adenoidectomy may also be indicated for children in whom upper airway obstruction is suspected of causing craniofacial or occlusive developmental abnormalities.
Tonsillectomy and Adenoidectomy
The criteria for both tonsillectomy and adenoidectomy for recurrent infection are the same as those for tonsillectomy alone. The other major indication for performing both procedures together is upper airway obstruction secondary to adenotonsillar hypertrophy that results in sleep-disordered breathing, failure to thrive, craniofacial or occlusive developmental abnormalities, speech abnormalities, or, rarely, cor pulmonale. A high proportion of children with failure to thrive in the context of adenotonsillar hypertrophy resulting in sleep disorder experience significant growth acceleration after adenotonsillectomy.
Complications
Poststreptococcal Glomerulonephritis and Acute Rheumatic Fever
The two major complications of untreated GABHS infection are poststreptococcal glomerulonephritis and acute rheumatic fever (see Chapters 537.4 and 210 ).
Peritonsillar Infection
Peritonsillar infection can occur as either cellulitis or a frank abscess in the region superior and lateral to the tonsillar capsule (see Chapter 409 ). These infections usually occur in children with a history of recurrent tonsillar infection and are polymicrobial, including both aerobes and anaerobes. Unilateral throat pain, referred otalgia, drooling, and trismus are presenting symptoms. The affected tonsil is displaced down and medial by swelling of the anterior tonsillar pillar and palate. The diagnosis of an abscess can be confirmed by CT or by needle aspiration, the contents of which should be sent for culture.
Retropharyngeal Space Infection
Infections in the retropharyngeal space develop in the lymph nodes that drain the oropharynx, nose, and nasopharynx (see Chapter 410 ).
Parapharyngeal Space Infection
Tonsillar infection can extend into the parapharyngeal space, causing symptoms of fever, neck pain and stiffness, and signs of swelling of the lateral pharyngeal wall and neck on the affected side. The diagnosis is confirmed by contrast medium-enhanced CT, and treatment includes intravenous antibiotics and external incision and drainage if an abscess is demonstrated on CT (see Chapter 410 ). Septic thrombophlebitis of the jugular vein, Lemierre syndrome, manifests with fever, toxicity, neck pain and stiffness, and respiratory distress as a result of multiple septic pulmonary emboli and is a complication of a parapharyngeal space or odontogenic infection from Fusobacterium necrophorum. Concurrent Epstein-Barr virus mononucleosis (see Chapter 281 ) can be a predisposing event before the sudden onset of fever, chills, and respiratory distress in an adolescent patient. Treatment includes high-dose intravenous antibiotics (ampicillin-sulbactam, clindamycin, penicillin, or ciprofloxacin) and heparinization.
Recurrent or Chronic Pharyngotonsillitis
See Chapter 409 .
Chronic Airway Obstruction
Although rare, children with chronic airway obstruction from enlarged tonsils and adenoids can present with cor pulmonale.
The effects of chronic airway obstruction and mouth breathing on facial growth remain a subject of controversy. Studies of chronic mouth breathing, both in humans and animals, have shown changes in facial development, including prolongation of the total anterior facial height and a tendency toward a retrognathic mandible, the so-called adenoid facies. Adenotonsillectomy can reverse some of these abnormalities. Other studies have disputed these findings.
Tonsillectomy and Adenoidectomy
The risks and potential benefits of surgery must be considered (Table 411.3 ). Bleeding can occur in the immediate postoperative period or be delayed (consider von Willebrand disease) after separation of the eschar. The Clinical Guidelines for Tonsillectomy include a recommendation for a single intravenous dose of intraoperative dexamethasone (0.5 mg/kg), which decreases postoperative nausea and vomiting and reduces swelling. There is no evidence that use of dexamethasone in postoperative tonsillectomy patients results in an increased risk of postoperative bleeding. Routine use of antibiotics in the postoperative period is ineffective and thus the AAO Clinical Practice Guidelines advise against its use, although this recommendation is not consistent among the major professional organizations who have issued guidelines (see Table 411.2 ). Codeine is associated with excessive sedation and fatalities and is not recommended.
Table 411.3
Risks and Potential Benefits of Tonsillectomy or Adenoidectomy or Both
| RISKS |
|
• Cost* • Risk of anesthetic accidents • Aspiration with resulting bronchopulmonary obstruction or infection • Risk of miscellaneous surgical or postoperative complications • Airway obstruction from edema of tongue, palate, or nasopharynx, or retropharyngeal hematoma • Prolonged muscular paralysis |
| POTENTIAL BENEFITS |
* Cost for tonsillectomy alone and adenoidectomy alone are somewhat lower.
Modified from Bluestone CD, editor: Pediatric otolaryngology , ed 4, Philadelphia, 2003, WB Saunders, p. 1213.
Swelling of the tongue and soft palate can lead to acute airway obstruction in the first few hours after surgery. Children with underlying hypotonia or craniofacial anomalies are at greater risk for suffering this complication. Dehydration from odynophagia is not uncommon in the first postoperative week. Rare complications include velopharyngeal insufficiency, nasopharyngeal or oropharyngeal stenosis, and psychologic problems.