Tonsils and Adenoids Disease

Diagnosis/Definition

The palatine tonsils are paired lymphatic structures located in the oropharynx and have a physiologic role in antigen processing and immune surveillance. The histologic structure of the tonsils is closely related to this immunologic function. There are no afferent lymphatics, however there are numerous crypts that provide an access port for inhaled and swallowed antigens. The adenoid pad is a midline structure similar to the tonsils in function and histology. Both are part of Waldeyer’s ring, which is completed by the lingual tonsils at the base of the tongue. Pathology of the tonsils and adenoid most commonly involves infection and/or hyperplasia. Patients can complain of recurrent sore throat, halitosis, or purulent rhinorrhea due to infection, or airway problems such as loud snoring, mouth breathing, and voice abnormalities due to increased size of these organs. The definition of recurrent adenotonsillitis is a patient with 3 or more infections per year despite adequate medical therapy. Chronic adenotonsillitis is defined as a patient with persistent symptoms for greater than 3 months despite adequate medical therapy.

Initial Diagnosis and Management

• History: The diagnosis of adenotonsillar disease is easily made on history and physical exam. Pertinent historical data include the presence of fever, severity of discomfort, history of otitis, previous infections, missed school or work, antecedent therapy, and culture results. For obstructive patients, documentation should include any mouth breathing, dysphagia, growth chart statistics, chronic rhinorrhea, sleep apnea symptoms, snoring, bedwetting, and malocclusion. Patients who complain of recent onset of odynophagia, neck pain, and voice change should be suspect for peritonsillar abscess.
• Physical Examination: The physical exam should include a description of the tonsils, including the size, presence of exudate or cryptic debris, and any asymmetry. The palate should be examined for symmetrical contraction with vocalization. The absence of this symmetry, along with trismus, drooling, and voice changes are possible signs of peritonsillar abscess and should be documented. Any rhinorrhea should be noted, as should any cervical lymphadenopathy.

Ancillary Tests:

• Throat culture
• Monospot as appropriate
• CBC
• X-ray of adenoid bed as appropriate (lateral soft tissue of the neck)

Initial Management:

The initial management of adenotonsillitis is the institution of appropriate medical therapy. This includes adequate hydration and pain relief as well as antibiotic coverage if indicated (Refer to the MAMC Intranet Pharmacy Guidelines or the Sanford Antimicrobial Handbook). If a peritonsillar abscess (See Physical Examination Section for physical signs ) is suspected, referral to ENT by contacting the ENT Clinic during duty hours or the ENT resident on call after duty hours. Nasal steroids may help reduce adenoidal hypotrophy.

Ongoing Management and Objectives

Relief of symptoms.

Indications for Specialty Care Referral

Recurrent infection: three or more infections of tonsils and/or adenoids per year despite adequate therapy.

Hypertrophy causing upper airway obstruction, severe dysphagia or sleep disorders.

Hypertrophy causing dental malocclusion or adversely affecting oro-facial growth documented by orthodontist.

Suspected peritonsillar abscess.

Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy.

Chronic adenotonsillitis not responding to beta-lactamase resistant antibiotics.- Unilateral tonsillar hypertrophy.

Unilateral tonsillar hypertrophy.

Any other symptom or clinical findings that are of concern by the referring provider.

Criteria for Return to Primary Care

Resolution of the problem by medical or surgical therapy.