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The tonsils are collections of mucosa-associated lymphoid tissue (MALT) situated strategically at the entrance of the aerodigestive tract. They constitute the first line of immunological defense against inhaled and ingested pathogens.
The major tonsils include:
Palatine tonsils (paired)
Pharyngeal tonsil (adenoids)
Tubal tonsils (paired)
Lingual tonsil
The palatine tonsils are the ones commonly affected by tonsillitis and are the focus of ENT clinical practice.
Waldeyer's lymphatic ring is a circular arrangement of lymphoid tissue surrounding the nasopharynx and oropharynx.
It provides:
Local immune surveillance
Antigen recognition
Production of lymphocytes
Secretory IgA-mediated mucosal immunity
| Component | Location |
|---|---|
| Palatine tonsils (2) | Oropharynx |
| Pharyngeal tonsil (Adenoid) | Roof of nasopharynx |
| Tubal tonsils (2) | Around Eustachian tube opening |
| Lingual tonsil | Base of tongue |
| Lateral pharyngeal bands | Posterior pharyngeal wall |
Samples inhaled antigens
Samples ingested antigens
Produces B and T lymphocytes
Initiates adaptive immune response
Produces secretory IgA
Maintains mucosal immunity
Palatine tonsils lie in the tonsillar fossa on each side of the oropharynx.
They are situated between:
Anterior pillar (Palatoglossal arch)
Posterior pillar (Palatopharyngeal arch)
Normally only the medial surface projects into the oropharynx.
Almond-shaped
Oval
Pink in healthy children
Surface irregular due to crypt openings
Average adult dimensions:
Length: 2–3 cm
Width: 1.5–2 cm
Thickness: 1 cm
Faces oral cavity.
Covered by:
Non-keratinized stratified squamous epithelium
Contains:
Multiple crypt openings
Lymphoid follicles
Germinal centres
Clinical importance:
Site of recurrent infection
Collection of debris
Tonsillolith formation
Faces superior constrictor muscle.
Covered by:
Fibrous capsule
Separated from muscle by:
Loose areolar tissue
This plane is used during tonsillectomy.
Related to:
Soft palate
Supratonsillar fossa
Clinical importance:
Common site of:
Residual tonsil tissue
Recurrent infection
Related to:
Tongue
Lingual tonsil
The tonsil possesses an incomplete fibrous capsule on its lateral aspect.
Derived from:
Pharyngobasilar fascia
Functions:
Separates tonsil from constrictor muscle
Surgical dissection plane
Limits spread of infection initially
Crypts are deep epithelial invaginations extending into tonsillar substance.
Approximately:
10–20 crypts
Largest crypt:
Intratonsillar crypt
Crypta magna
Increase antigen contact surface
Trap microorganisms
Facilitate immune activation
Crypts may accumulate:
Food particles
Desquamated epithelium
Bacteria
Fungi
Leading to:
Chronic tonsillitis
Tonsilloliths
Halitosis
The tonsillar bed is formed by structures lying lateral to the capsule.
From medial to lateral:
Fibrous capsule
Loose areolar tissue
Superior constrictor muscle
Buccopharyngeal fascia
Important structures include:
Glossopharyngeal nerve
Facial artery branches
Paratonsillar vein
Internal carotid artery (approximately 2–2.5 cm posterolateral)
Clinical importance:
Deep dissection during tonsillectomy may injure these structures.
Tonsils have an extremely rich arterial supply.
| Artery | Parent Vessel |
|---|---|
| Tonsillar branch | Facial artery |
| Ascending palatine artery | Facial artery |
| Ascending pharyngeal artery | External carotid artery |
| Dorsal lingual branches | Lingual artery |
| Greater palatine artery | Maxillary artery |
Highly vascular organ
Significant intraoperative bleeding
Post-tonsillectomy hemorrhage commonly arises from facial artery branches
Drainage occurs via:
Peritonsillar venous plexus
Paratonsillar vein (external palatine vein)
Ultimately drains into:
Facial vein
Pharyngeal venous plexus
Paratonsillar vein is:
Major source of bleeding during tonsillectomy
Main drainage:
➡ Jugulodigastric lymph node
(Upper deep cervical node)
Also called:
Tonsillar node
Painful enlargement occurs in:
Acute tonsillitis
Infectious mononucleosis
Tonsillar carcinoma
Main sensory supply:
Glossopharyngeal nerve (CN IX)
Additional contribution:
Lesser palatine nerves
Explains:
Severe throat pain
Referred ear pain (otalgia)
Pain during swallowing
Important clinical correlations:
Shared glossopharyngeal nerve supply to:
Tonsil
Middle ear
Hence throat pain radiates to ear.
Loose areolar tissue provides natural surgical plane.
Occurs due to injury of:
Tonsillar artery
Facial artery branches
Paratonsillar vein
Normally lies:
2–2.5 cm posterolateral.
Rarely may be medially displaced.
Risk:
Catastrophic hemorrhage.
May produce:
Loss of taste posterior one-third tongue
Severe neuralgia
Dysphagia
Infection spreads through capsule into:
Peritonsillar space.
Occurs due to:
Debris retention in crypts
Calcification
Presents with:
Halitosis
Foreign body sensation
Tonsils are one of the most active immune organs during childhood.
Maximum immunological activity occurs between:
4–10 years
After puberty, involution gradually occurs.
Tonsils belong to the MALT system.
Characteristics:
Secondary lymphoid organ
No afferent lymphatics
Antigen sampling directly from surface
Rich in lymphoid follicles
Local immune defense
Antibody production
Memory cell generation
Cytokine secretion
Sequence:
Antigen enters crypt
Captured by dendritic cells
Processed by macrophages
Presented to T lymphocytes
Activation of B cells
Plasma cell formation
Antibody secretion
B lymphocytes constitute the majority of tonsillar lymphocytes.
Functions:
Differentiate into plasma cells
Produce immunoglobulins
Form memory B cells
Antibodies produced:
IgA
IgG
IgM
Types:
Helper T cells (CD4)
Cytotoxic T cells (CD8)
Regulatory T cells
Functions:
Cell-mediated immunity
Viral defense
Cytokine secretion
B-cell activation
Most important antibody of upper airway mucosa.
Functions:
Prevents bacterial adherence
Neutralizes viruses
Protects mucosal surfaces
Prevents invasion
During childhood tonsils:
Continuously exposed to new antigens
Undergo follicular hyperplasia
Produce abundant antibodies
This explains:
Physiological enlargement in children
After adolescence:
Immune function decreases
Tonsils regress
Normal organisms include:
Viridans streptococci
Neisseria species
Corynebacteria
Lactobacilli
Anaerobes
Normally these remain non-pathogenic.
Most common cause of acute tonsillitis.
Viruses include:
Rhinovirus
Adenovirus
Influenza virus
Parainfluenza virus
Coronavirus
RSV
EBV
CMV
Coxsackie virus
HSV
Most common bacterial pathogen:
Group A β-hemolytic Streptococcus (GAS)
Others include:
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Anaerobes
Most important bacterial pathogen.
Characteristics:
Gram-positive cocci
Group A β-hemolytic streptococcus
M protein virulence factor
Complications:
Rheumatic fever
Acute glomerulonephritis
Scarlet fever
Usually causes:
Recurrent tonsillitis
Chronic tonsillitis
Abscess formation
Common in:
Children
Mixed bacterial infections
Common in:
Children
Recurrent infections
Adenotonsillitis
Biofilm is an organized bacterial community enclosed within extracellular polysaccharide matrix.
Explains:
Recurrent tonsillitis
Antibiotic resistance
Chronic infection
Persistent inflammation
Common organisms:
GAS
S. aureus
H. influenzae
Acute tonsillitis is an acute inflammation of the palatine tonsils caused by viral or bacterial infection, characterized by sore throat, fever, odynophagia, enlarged congested tonsils, and cervical lymphadenopathy.
Rhinovirus
Adenovirus
Influenza
EBV
RSV
Coronavirus
Group A Streptococcus
S. aureus
Pneumococcus
H. influenzae
Anaerobes
School-going children
Crowding
Poor nutrition
Cold weather
Viral URTI
Immunodeficiency
Poor oral hygiene
Smoking
Allergy
Sequence:
Upper respiratory infection
↓
Colonization of crypts
↓
Inflammatory response
↓
Edema
↓
Follicular hyperplasia
↓
Pus formation
↓
Pain and dysphagia
Gross changes:
Enlarged tonsils
Hyperemia
Edema
Crypt exudates
Follicular abscesses
Microscopy:
Neutrophilic infiltration
Congested vessels
Lymphoid hyperplasia
Surface ulceration in severe disease
Superficial inflammation involving mucosa of tonsils.
Mild congestion
Edema
Sore throat
Mild fever
Viral etiology common
Suppuration confined to tonsillar crypts.
High fever
Severe sore throat
White-yellow dots over tonsils
Tender cervical nodes
Diffuse inflammation involving entire tonsillar substance.
Gross enlargement
Severe dysphagia
Muffled voice
Toxic appearance
High fever
Formation of membrane over tonsil.
Causes:
Diphtheria
Infectious mononucleosis
Vincent angina
Leukemia
Severe streptococcal infection
Characterized by:
Ulcer formation
Necrosis
Severe pain
Fetor oris
Common causes:
Vincent angina
Agranulocytosis
Leukemia
Sudden sore throat
Painful swallowing (odynophagia)
Dysphagia
Fever
Chills
Malaise
Headache
Earache (referred)
Bad breath
Voice change
Reduced oral intake
General:
Fever
Toxic appearance
Local:
Congested tonsils
Enlarged tonsils
White exudates
Pus in crypts
Congested pillars
Edematous uvula
Occurs because:
Glossopharyngeal nerve supplies both:
Tonsil
Middle ear
Pain radiates to ipsilateral ear.
Usually involves:
Jugulodigastric lymph node.
Features:
Enlarged
Tender
Mobile
Membranous tonsillitis refers to formation of a visible membrane covering the tonsil due to infectious or hematological disorders.
Diphtheria
Infectious mononucleosis
Vincent angina
Streptococcal infection
Leukemia
Agranulocytosis
Chemical burns
Trauma
Fungal infection
| Disease | Membrane Characteristics |
|---|---|
| Diphtheria | Thick, dirty grey, firmly adherent, bleeds on removal |
| Streptococcal | Thin, removable |
| Infectious mononucleosis | Whitish exudative membrane |
| Vincent angina | Dirty ulcer with necrotic slough |
| Leukemia | Ulcerative necrotic membrane with bleeding tendency |
Organism:
Corynebacterium diphtheriae
Gram-positive bacillus producing exotoxin.
Transmission:
Respiratory droplets
Close contact
General:
Fever
Malaise
Toxic appearance
Local:
Severe sore throat
Dysphagia
Grey membrane
Cervical lymphadenopathy
Characteristics:
Dirty grey
Tough
Firmly adherent
Bleeds on attempted removal
Rapid reformation
Due to:
Massive cervical lymphadenopathy
Soft tissue edema
Produces:
Characteristic swollen neck.
May occur:
1–2 weeks after onset.
Manifestations:
Arrhythmias
Heart failure
Sudden death
Toxin causes demyelination.
Features:
Palatal paralysis
Nasal regurgitation
Cranial neuropathies
Limb weakness
Respiratory paralysis
Clinical suspicion
Throat swab
Albert stain
Culture on Loeffler's medium
Elek test (toxigenicity)
Medical emergency.
Strict respiratory isolation.
Should be administered immediately after clinical suspicion.
Dose depends on severity.
Antitoxin neutralizes only circulating toxin.
Penicillin
Erythromycin
If obstruction develops:
Intubation
Tracheostomy
Hydration
ECG monitoring
Neurological monitoring
Vincent angina (Acute necrotizing ulcerative tonsillitis/pharyngitis) is an acute ulceronecrotic infection caused by fusospirochetal organisms.
Organisms:
Fusobacterium nucleatum
Borrelia vincentii (spirochete)
Predisposing factors:
Poor oral hygiene
Smoking
Malnutrition
Immunosuppression
Unilateral sore throat
Severe halitosis
Dysphagia
Low-grade fever
Dirty grey ulcer
Necrotic slough
Tender cervical nodes
Clinical.
Peripheral smear may show fusospirochetal organisms.
Differentiate from:
Diphtheria
Leukemia
Malignancy
Oral hygiene
Hydrogen peroxide mouthwash
Chlorhexidine gargles
Penicillin
Metronidazole
Analgesics
Adequate nutrition
Infectious mononucleosis is an acute lymphoproliferative disorder caused by Epstein-Barr virus (EBV) presenting with severe exudative tonsillitis, fever, generalized lymphadenopathy, and hepatosplenomegaly.
Virus:
Epstein-Barr virus (Human herpesvirus-4)
Transmission:
Saliva ("Kissing disease")
High fever
Severe sore throat
Bilateral enlarged exudative tonsils
Cervical lymphadenopathy (especially posterior cervical)
Malaise
Fatigue
Hepatomegaly
Splenomegaly
Palatal petechiae
CBC: Absolute lymphocytosis
Atypical lymphocytes (Downey cells)
Monospot test (heterophile antibody)
EBV serology
Liver function tests (may be mildly elevated)
Administration of:
Ampicillin
Amoxicillin
in infectious mononucleosis produces a diffuse maculopapular rash in the majority of patients.
Important Point: This is not a true penicillin allergy, but a characteristic drug-related reaction in the setting of acute EBV infection.
Bed rest
Adequate hydration
Soft diet
Analgesics and antipyretics
Reserved for:
Impending airway obstruction due to massive tonsillar enlargement
Severe thrombocytopenia
Hemolytic anemia
Neurological complications
Not indicated unless there is documented secondary bacterial infection.
Avoid ampicillin and amoxicillin because of the characteristic rash.
Patients should avoid contact sports and strenuous physical activity for at least 3–4 weeks or until splenomegaly has resolved, to reduce the risk of splenic rupture.
Scarlet fever is an acute toxin-mediated illness caused by Group A β-hemolytic Streptococcus (Streptococcus pyogenes) producing erythrogenic (pyrogenic) exotoxins. It is characterized by acute streptococcal tonsillitis/pharyngitis, fever, a generalized erythematous rash, and characteristic changes of the tongue.
It commonly affects children between 5–15 years of age.
Group A β-hemolytic Streptococcus (GAS)
Streptococcus pyogenes
M protein
Streptolysin O
Streptokinase
Hyaluronidase
DNase
Erythrogenic (pyrogenic) exotoxins A, B and C (responsible for rash)
Respiratory droplets
Close contact
School outbreaks
Household transmission
Usually 2–5 days
Streptococcal infection of tonsils
↓
Production of erythrogenic toxin
↓
Systemic dissemination of toxin
↓
Capillary dilatation
↓
Diffuse erythematous rash
↓
Characteristic tongue changes
Sudden onset fever
Severe sore throat
Dysphagia
Headache
Malaise
Vomiting (especially in children)
Congested enlarged tonsils
Follicular exudates
Tender cervical lymph nodes
Erythematous pharynx
One of the classical signs.
Early stage:
White coating over tongue
Enlarged red papillae project through coating
Produces appearance of:
White strawberry tongue
Later:
White coating sheds
Tongue becomes bright red
Prominent papillae remain
Known as:
Red strawberry tongue
Highly suggestive of:
Scarlet fever
Kawasaki disease
Toxic shock syndrome
Diffuse erythematous rash
Fine papular eruption
Rough texture
Feels like:
Sandpaper
Starts over:
Neck
Upper chest
Axilla
Then spreads to:
Trunk
Extremities
Usually spares:
Palms
Soles
Dark red linear accentuation in skin folds.
Seen in:
Axilla
Groin
Elbow flexures
Characteristic finding.
Features:
Pale area around mouth
Contrasts with flushed face
Helps clinical diagnosis
Occurs after:
1–3 weeks
Most marked over:
Fingers
Toes
Palms
Soles
Peritonsillar abscess
Cervical lymphadenitis
Otitis media
Sinusitis
Acute rheumatic fever
Acute glomerulonephritis
Reactive arthritis
Throat swab
Rapid streptococcal antigen test
Throat culture
CBC
Elevated ASO titre (retrospective evidence)
First-line:
Penicillin V (10 days)
Alternative:
Amoxicillin
Penicillin allergy:
Azithromycin
Clarithromycin
Cephalexin (if non-anaphylactic allergy)
Antipyretics
Adequate hydration
Soft diet
Warm saline gargles
Early antibiotic therapy:
Reduces infectivity
Prevents rheumatic fever
Shortens disease duration
Recurrent acute tonsillitis refers to repeated episodes of acute tonsillitis separated by symptom-free intervals, with complete or near-complete recovery between attacks.
The Paradise criteria are commonly used to define clinically significant recurrence for consideration of tonsillectomy.
Streptococcus pyogenes
Staphylococcus aureus
Persistent bacteria survive within biofilms causing repeated attacks.
Frequent viral URTIs predispose to bacterial superinfection.
School-going children
Crowding
Poor oral hygiene
Allergy
Chronic sinusitis
Adenoid hypertrophy
Immunodeficiency
Smoking (adults)
Tonsillectomy is recommended when episodes are well documented and associated with fever, cervical lymphadenopathy, exudate, or positive GAS culture.
Criteria include:
≥7 episodes in one year, or
≥5 episodes/year for two consecutive years, or
≥3 episodes/year for three consecutive years
During acute attack:
Fever
Severe sore throat
Odynophagia
Enlarged congested tonsils
Exudates
Cervical lymphadenopathy
Between attacks:
Usually asymptomatic
Mild throat discomfort may persist
Halitosis
Enlarged cryptic tonsils
Chronic tonsillitis
Peritonsillar abscess
Sleep-disordered breathing
Poor school attendance
Nutritional problems
Each episode should be treated appropriately.
Includes:
Antibiotics for proven streptococcal infection
Analgesics
Antipyretics
Hydration
Warm saline gargles
Oral hygiene
Treatment of chronic nasal infection
Control of allergy
Adequate nutrition
Avoid smoking exposure
Tonsillectomy is indicated when:
Paradise criteria are fulfilled
Recurrent peritonsillar abscess
Significant morbidity
Failure of medical therapy
Chronic tonsillitis is a persistent low-grade inflammatory disease of the palatine tonsils, characterized by repeated infection, fibrosis, crypt obstruction, retained debris, and chronic symptoms lasting for months or years.
Most common cause.
Incomplete eradication of organisms.
Persistent bacterial communities within crypts.
Retention of:
Food particles
Bacteria
Keratin
Desquamated epithelium
Chronic rhinosinusitis
Adenoid hypertrophy
Allergy
Mouth breathing
Poor oral hygiene
Smoking
Biofilm is an organized microbial community embedded within a protective extracellular matrix attached to the tonsillar crypt epithelium.
Explains:
Antibiotic resistance
Recurrent infection
Persistent inflammation
Failure of conservative therapy
Streptococcus pyogenes
Staphylococcus aureus
Haemophilus influenzae
Anaerobes
Repeated infection
↓
Crypt obstruction
↓
Retention of debris
↓
Persistent bacterial colonization
↓
Biofilm formation
↓
Chronic inflammation
↓
Fibrosis and lymphoid hyperplasia
↓
Chronic symptoms
Gross Features
Enlarged or fibrotic tonsils
Deep crypts
Caseous material
Tonsilloliths
Irregular surface
Fibrosis of capsule
Microscopic Features
Lymphoid hyperplasia
Fibrosis
Chronic inflammatory infiltrate
Dilated crypts
Keratin debris
Plasma cells
Lymphocytes
Biofilm colonies
The commonest variety characterized by chronic inflammation confined predominantly to the tonsillar crypts (follicles).
Dilated crypts
Caseous debris
Chronic inflammatory infiltrate
Bacterial colonization
Crypt obstruction
Recurrent sore throat
Halitosis
White cheesy plugs
Foreign body sensation
Mild dysphagia
Enlarged crypts
Expressible caseous material
Congested pillars
Characterized by diffuse chronic inflammation involving the entire tonsillar substance.
Most common in children.
Diffuse lymphoid hyperplasia
Enlarged tonsils
Edema
Increased vascularity
Bilateral enlarged tonsils
Snoring
Mouth breathing
Dysphagia
Sleep-disordered breathing
Recurrent infections
Bulky tonsils
Narrow oropharyngeal airway
Enlarged jugulodigastric nodes
Occurs mainly in adults due to repeated inflammation resulting in progressive fibrosis and scarring.
Fibrosis
Reduced lymphoid tissue
Shrunken tonsils
Dense capsule
Obliterated crypts
Persistent throat discomfort
Foreign body sensation
Mild dysphagia
Halitosis
Small fibrotic tonsils
Scarred pillars
Adherent capsule
Less congestion
| Feature | Chronic Follicular | Chronic Parenchymatous | Chronic Fibroid |
|---|---|---|---|
| Age | Children & young adults | Mainly children | Adults |
| Main pathology | Crypt disease | Entire tonsil enlarged | Fibrosis |
| Tonsil size | Mildly enlarged | Grossly enlarged | Small or shrunken |
| Crypt debris | Marked | Variable | Minimal |
| Halitosis | Common | Less common | Moderate |
| Airway obstruction | Rare | Common | Rare |
Patients commonly complain of:
Recurrent sore throat
Mild odynophagia
Foreign body sensation
Persistent throat irritation
Recurrent fever
Difficulty swallowing
Bad breath (halitosis)
Dry throat
Frequent throat clearing
Snoring (children)
Mouth breathing (children)
Poor appetite
Recurrent cervical lymph node enlargement
General
Usually afebrile between attacks
Healthy appearance unless acute exacerbation
Local Examination
Enlarged or fibrotic tonsils
Congested anterior pillars
Dilated crypts
White cheesy material within crypts
Scarred tonsils
Adherent capsule
Tender jugulodigastric lymph nodes
Accumulation of:
Keratin
Food particles
Dead epithelial cells
Bacteria
Leukocytes
within tonsillar crypts.
Produces:
Halitosis
Foreign body sensation
Chronic irritation
Recurrent infection
Often visible as:
White
Yellow
Hard calcified masses
within crypt openings.
Anaerobic bacteria degrade proteins producing:
Hydrogen sulfide
Methyl mercaptan
Volatile sulfur compounds
Result:
Persistent foul breath.
Local
Peritonsillar abscess
Tonsillolith
Cervical lymphadenitis
Sleep-disordered breathing
Systemic (Rare)
Rheumatic fever
Post-streptococcal glomerulonephritis
Septicemia
Tonsilloliths (tonsil stones) are calcified concretions formed within the tonsillar crypts due to retention and mineralization of organic debris.
Repeated infection
↓
Crypt dilatation
↓
Retention of keratin and debris
↓
Bacterial colonization
↓
Biofilm formation
↓
Calcium salt deposition
↓
Tonsillolith formation
Contains:
Calcium phosphate
Calcium carbonate
Magnesium salts
Keratin
Food particles
Dead epithelial cells
Bacteria
Many are asymptomatic.
Symptomatic patients complain of:
Halitosis
Foreign body sensation
Chronic sore throat
Dysphagia
Bad taste
Referred otalgia
Visible white stone
Large stones may produce:
Chronic cough
Difficulty swallowing
Rare airway symptoms
White or yellow calcified mass
Usually located within crypt
Hard on palpation
May be expressed with pressure
Usually clinical.
If giant tonsillolith suspected:
X-ray neck
CT scan
Differentiate from:
Foreign body
Calcified lymph node
Eagle syndrome
Phlebolith
Warm saline gargles
Oral hygiene
Manual removal
Water irrigation
Treat associated chronic tonsillitis.
Indications:
Large symptomatic tonsillolith
Recurrent stones
Chronic halitosis
Recurrent tonsillitis
Options:
Curettage
Cryptolysis (laser/coblation)
Tonsillectomy
Tonsillar cysts are benign cystic lesions arising within or on the surface of the palatine tonsil, usually due to obstruction of crypts or developmental inclusion of epithelial tissue.
They are uncommon and are often detected incidentally during oropharyngeal examination.
A retention cyst develops due to obstruction of the opening of a tonsillar crypt or mucous gland, leading to accumulation of secretions.
Chronic tonsillitis
Crypt obstruction
Fibrosis
Chronic inflammation
Lined by squamous or respiratory epithelium
Contains mucus or keratinous material
Usually small (<1 cm)
Often asymptomatic
Foreign body sensation
Mild dysphagia
Incidental finding
Rarely recurrent infection
Smooth
Round
Yellowish-white or translucent swelling
Soft and cystic
Observation if asymptomatic
Excision if symptomatic
Tonsillectomy when associated with chronic tonsillitis
An epidermoid cyst is a benign developmental cyst lined by keratinizing stratified squamous epithelium and filled with keratin debris.
Congenital epithelial inclusion
Rarely acquired following trauma or surgery
Keratin-filled cavity
Squamous epithelial lining
No skin appendages (distinguishes it from a dermoid cyst)
Slow-growing
Painless
Foreign body sensation
Dysphagia if large
Rarely causes airway symptoms
Well-defined
Smooth
Whitish or yellow lesion
Non-tender
Firm to cystic consistency
Clinical diagnosis
Ultrasound (selected cases)
CT/MRI for large or atypical lesions
Histopathological examination confirms the diagnosis after excision
Retention cyst
Lymphoepithelial cyst
Tonsillolith
Papilloma
Minor salivary gland cyst
Early tonsillar malignancy
Complete surgical excision
Tonsillectomy if the lesion is intratonsillar or associated with chronic tonsillar disease
Histopathological examination of all excised specimens
Usually benign and asymptomatic
May mimic chronic tonsillitis or tonsillar neoplasm
Can cause recurrent throat discomfort, dysphagia, or foreign body sensation
Large cysts may interfere with swallowing or speech
Histopathological examination is essential after excision to exclude occult malignancy, especially in adults with unilateral tonsillar enlargement
Tonsillar focal sepsis is a historical concept that describes a chronic focus of infection within the palatine tonsils capable of producing disease at distant sites in the body through hematogenous spread, lymphatic dissemination, immune-mediated mechanisms, or persistent bacterial toxin release.
Traditionally, chronic tonsillitis was believed to be responsible for numerous systemic diseases, leading to widespread tonsillectomy during the early twentieth century.
The Theory of Focal Sepsis was proposed in the late 19th and early 20th century.
Chronic infected tonsils serve as a persistent bacterial reservoir.
Organisms or their toxins enter systemic circulation.
This results in chronic inflammation or infection at distant organs.
Common organisms implicated:
Group A β-hemolytic Streptococcus (GAS)
Staphylococcus aureus
Anaerobic bacteria
Mixed polymicrobial flora
Rheumatic fever
Chronic arthritis
Nephritis
Endocarditis
Chronic skin diseases
Uveitis
Chronic urticaria
Psoriasis
Alopecia areata
Recurrent fever
Chronic fatigue
Because of these beliefs, tonsillectomy became one of the most frequently performed operations worldwide during the early 1900s.
Several mechanisms were proposed:
Bacteria escape into bloodstream
Produce transient bacteremia
Seed distant organs
Streptococcal exotoxins
Superantigens
Inflammatory cytokines
↓
Remote tissue inflammation
Most accepted mechanism.
Repeated streptococcal infections induce:
Molecular mimicry
Cross-reacting antibodies
Immune complex deposition
Examples:
Rheumatic fever
Acute glomerulonephritis
Modern studies show:
Tonsillar crypts harbor bacterial biofilms.
Biofilms resist antibiotics.
Persistent low-grade inflammation continues.
Modern evidence-based medicine has significantly modified the focal sepsis concept.
Strong evidence exists only for selected conditions.
These include:
Recurrent streptococcal tonsillitis
Peritonsillar abscess
Rheumatic fever
Post-streptococcal glomerulonephritis
PANDAS
PFAPA syndrome (selected patients)
No convincing evidence links chronic tonsillitis with:
Hypertension
Chronic arthritis
Psoriasis
Eczema
Chronic urticaria
Migraine
Chronic fatigue syndrome
Autoimmune disorders
Routine tonsillectomy is not recommended for these conditions.
Current ENT practice recognizes tonsillar focal sepsis only in selected clinical situations.
Recurrent streptococcal tonsillitis
Recurrent peritonsillar abscess
Rheumatic fever prophylaxis
PANDAS
PFAPA syndrome
Persistent chronic tonsillitis with halitosis or tonsilloliths
Psoriasis alone
Alopecia areata
Acne
Chronic urticaria
Non-specific arthritis
Chronic fatigue
Fibromyalgia
Focal sepsis theory is largely historical.
Only selected immune-mediated streptococcal diseases are now scientifically supported.
Evidence-based indications should guide tonsillectomy.
Complications of tonsillitis occur when infection extends beyond the tonsillar capsule or produces systemic immune-mediated sequelae.
These are divided into:
Local complications
Systemic complications
| Local Complications | Systemic Complications |
|---|---|
| Peritonsillitis | Rheumatic fever |
| Peritonsillar abscess (Quinsy) | Rheumatic heart disease |
| Parapharyngeal abscess | Acute glomerulonephritis |
| Retropharyngeal abscess | Septicemia |
| Cervical lymphadenitis | Infective endocarditis |
| Deep neck space infection | PANDAS |
| Airway obstruction (rare) | Streptococcal toxic shock syndrome |
Inflammation involving tissues surrounding the tonsil without frank pus formation.
Also called:
Cellulitis of peritonsillar space
Severe unilateral sore throat
Dysphagia
Fever
Muffled voice
Odynophagia
Tender cervical nodes
May progress to peritonsillar abscess.
Collection of pus between:
Tonsillar capsule
Superior constrictor muscle
Usually follows:
Acute tonsillitis
Peritonsillitis
Severe unilateral throat pain
Trismus
Drooling
Hot potato voice
Uvular deviation
Bulging soft palate
High fever
Airway obstruction
Deep neck infection
Septicemia
Infection extends laterally through superior constrictor muscle.
Neck swelling
Severe pain
Trismus
Dysphagia
High fever
Torticollis
Life-threatening.
Can involve:
Carotid artery
Internal jugular vein
Cranial nerves IX–XII
Posterior spread into retropharyngeal space.
Common in:
Children
Neck stiffness
Dysphagia
Drooling
Respiratory distress
Stridor
Mediastinitis
Airway obstruction
Spread to:
Jugulodigastric lymph nodes
Painful enlarged nodes
Fever
Neck tenderness
Suppuration may occur.
Immune-mediated disease occurring 2–3 weeks after GAS pharyngotonsillitis.
Organs affected:
Heart
Joints
CNS
Skin
Permanent valvular damage following rheumatic fever.
Most commonly affected:
Mitral valve
Less commonly:
Aortic valve
Occurs after nephritogenic streptococcal infection.
Mechanism:
Immune complex deposition in glomeruli.
Occurs due to bloodstream dissemination.
Common in:
Immunocompromised patients
May progress to:
Septic shock
Multi-organ failure
Transient bacteremia may infect abnormal heart valves.
High-risk patients:
Prosthetic valves
Congenital heart disease
Previous infective endocarditis
Peritonsillar abscess is the commonest deep neck complication.
Rheumatic fever is prevented by early treatment of GAS pharyngitis.
Acute glomerulonephritis is not prevented by antibiotic therapy once nephritogenic infection has occurred.
Post-streptococcal complications are immune-mediated or toxin-mediated diseases occurring after infection with Group A β-hemolytic Streptococcus (GAS).
They usually develop 1–4 weeks after acute pharyngotonsillitis.
Rheumatic fever
Rheumatic heart disease
Acute glomerulonephritis
PANDAS
Streptococcal toxic shock syndrome
An acute multisystem inflammatory disease caused by autoimmune response to GAS infection.
Molecular mimicry between:
Streptococcal M protein
Human tissues
Affected organs:
Heart
Joints
Brain
Skin
Based on Jones Criteria.
Major manifestations:
Carditis
Migratory polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor manifestations:
Fever
Arthralgia
Raised ESR/CRP
Prolonged PR interval
Evidence of recent GAS infection:
ASO titre
Anti-DNase B
Positive throat culture
Rapid antigen detection
Penicillin
NSAIDs
Corticosteroids (selected cases)
Long-term penicillin prophylaxis
Permanent valvular deformity following rheumatic fever.
Mitral
Aortic
Clinical manifestations:
Murmurs
Heart failure
Arrhythmias
Immune complex-mediated inflammation of glomeruli after nephritogenic streptococcal infection.
Cola-colored urine
Hematuria
Edema
Hypertension
Proteinuria
Urinalysis
Serum complement (C3 ↓)
ASO titre
Renal function tests
Supportive:
Salt restriction
Diuretics
Blood pressure control
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
Autoimmune neuropsychiatric disorder occurring after GAS infection.
Sudden onset OCD
Tics
Anxiety
Emotional lability
Behavioral regression
Clinical diagnosis supported by:
Recent GAS infection
Elevated ASO titre
Antibiotics
Behavioral therapy
Psychiatric management
Selected recurrent cases may benefit from:
Tonsillectomy (controversial)
Group A Streptococcus producing superantigen exotoxins.
High fever
Hypotension
Rash
Shock
Multiorgan failure
Emergency management:
ICU care
IV penicillin
Clindamycin
IV fluids
Vasopressors
Surgical source control if necessary
PFAPA stands for:
Periodic Fever
Aphthous stomatitis
Pharyngitis
Adenitis
It is the commonest periodic fever syndrome of childhood.
Unknown.
Likely due to dysregulation of innate immunity.
Not infectious.
Usually <5 years
Boys slightly more affected
Normal growth between episodes
Typical episodes recur every:
3–8 weeks
Features include:
High fever
Exudative pharyngitis
Aphthous ulcers
Tender cervical lymphadenopathy
Malaise
Headache
Child remains completely well between episodes.
Clinical diagnosis.
Marshall criteria include:
Regular fever episodes
Aphthous stomatitis/pharyngitis/cervical adenitis
Normal growth
Exclusion of cyclic neutropenia and infections
Recurrent tonsillitis
Cyclic neutropenia
Behçet disease
Familial Mediterranean fever
Single-dose oral prednisolone
NSAIDs
Observation
Colchicine (selected patients)
Multiple studies demonstrate:
Marked reduction in attacks
Complete resolution in many children
Hence:
Tonsillectomy ± adenoidectomy is considered in recurrent severe PFAPA.
Lemierre syndrome is a life-threatening complication of oropharyngeal infection characterized by:
Septic thrombophlebitis of internal jugular vein
Anaerobic septicemia
Septic emboli
Most commonly caused by:
Fusobacterium necrophorum
Other organisms:
Fusobacterium nucleatum
Streptococci
Bacteroides
Acute tonsillitis
↓
Peritonsillar infection
↓
Parapharyngeal spread
↓
Internal jugular vein thrombophlebitis
↓
Septic embolization
↓
Lungs and distant organs
Initial phase:
Severe sore throat
Fever
Neck pain
Later phase:
Neck swelling
Rigors
Septicemia
Metastatic disease:
Pleuritic chest pain
Dyspnea
Hemoptysis
Pulmonary abscesses
Most commonly affect:
Lungs
Joints
Liver
Brain
Leukocytosis
Blood cultures (anaerobic)
Ultrasound neck
Contrast CT neck
CT chest
MRI venography (selected cases)
Hospital admission.
Prolonged IV therapy:
Piperacillin-tazobactam
Carbapenems
Ceftriaxone + Metronidazole
Duration:
3–6 weeks
If abscess present:
Drainage
Rarely:
Internal jugular vein ligation
Controversial.
Used in selected patients with:
Extensive thrombosis
Persistent embolization
Mortality has reduced significantly with:
Early diagnosis
Prompt IV antibiotics
Peritonsillitis is acute cellulitis and inflammation of the peritonsillar tissues without a localized pus collection. It represents the stage preceding formation of a peritonsillar abscess (quinsy).
Usually follows:
Acute bacterial tonsillitis
Inadequately treated streptococcal infection
Common organisms:
Group A Streptococcus
Staphylococcus aureus
Fusobacterium species
Mixed anaerobic flora
Acute tonsillitis
↓
Spread through tonsillar capsule
↓
Inflammation of peritonsillar space
↓
Cellulitis (Peritonsillitis)
↓
If untreated → Peritonsillar abscess (Quinsy)
Severe unilateral sore throat
Increasing odynophagia
Dysphagia
Fever
Earache (referred otalgia)
Malaise
Congested anterior pillar
Edematous soft palate
Peritonsillar swelling
Mild trismus
Tender jugulodigastric lymph nodes
No obvious fluctuation or pus
Primarily clinical.
If abscess suspected:
Needle aspiration
Ultrasound
Contrast-enhanced CT neck (selected cases)
Acute tonsillitis
Peritonsillar abscess
Parapharyngeal abscess
Retropharyngeal abscess
Infectious mononucleosis
Adequate hydration
Analgesics
Antipyretics
Intravenous antibiotics in severe cases:
Ampicillin-sulbactam
Amoxicillin-clavulanate
Clindamycin (penicillin allergy)
Warm saline gargles
Observe for progression to abscess formation.
Reassess airway and swallowing.
Not required unless a peritonsillar abscess develops, in which case:
Needle aspiration
Incision and drainage
Quinsy tonsillectomy (selected cases)
Key Point: Peritonsillitis is the cellulitic stage of infection around the tonsil. Early recognition and appropriate antibiotic therapy can prevent progression to a peritonsillar abscess and other deep neck space infections.
Peritonsillar abscess (Quinsy) is a localized collection of pus in the peritonsillar space, situated between the capsule of the palatine tonsil and the superior constrictor muscle of the pharynx. It is the most common deep neck space infection in adults and usually develops as a complication of acute tonsillitis or peritonsillitis.
The peritonsillar space is a potential space surrounding the lateral aspect of the palatine tonsil.
| Boundary | Structure |
|---|---|
| Medial | Tonsillar capsule |
| Lateral | Superior constrictor muscle |
| Superior | Soft palate |
| Inferior | Tongue base |
| Anterior | Palatoglossal arch (anterior pillar) |
| Posterior | Palatopharyngeal arch (posterior pillar) |
Loose areolar tissue
Connective tissue
Small blood vessels
Lymphatics
Minor salivary glands (Weber glands)
Clinical Importance: Infection commonly originates in the Weber glands located superior to the tonsil, explaining why most abscesses develop at the superior pole.
Acute bacterial tonsillitis
Recurrent tonsillitis
Chronic tonsillitis
Peritonsillitis
Smoking
Poor oral hygiene
Diabetes mellitus
Immunocompromised state
Usually polymicrobial.
Aerobic bacteria
Group A β-hemolytic Streptococcus
Streptococcus pyogenes
Staphylococcus aureus
Anaerobic bacteria
Fusobacterium necrophorum
Prevotella species
Bacteroides species
Peptostreptococcus
Acute tonsillitis
↓
Spread through tonsillar capsule
↓
Peritonsillitis (cellulitis)
↓
Suppuration within peritonsillar space
↓
Peritonsillar abscess (Quinsy)
Without treatment, infection may extend to:
Parapharyngeal space
Retropharyngeal space
Mediastinum
Bloodstream
Severe unilateral sore throat
Progressive odynophagia
Dysphagia
Drooling of saliva
Fever with chills
Referred otalgia
Difficulty opening mouth
Muffled speech
Foul breath
Toxic appearance
High fever
Trismus
Bulging soft palate
Fluctuant swelling above superior pole
Congested anterior pillar
Medial displacement of tonsil
Uvula pushed towards opposite side
Tender cervical lymphadenopathy
Spasm of the muscles of mastication leading to restricted mouth opening.
Inflammation involving:
Medial pterygoid muscle
Pterygomandibular space
Difficulty examining throat
Difficulty swallowing
Suggests deep neck infection
A characteristic muffled, thick, indistinct speech resembling the voice of a person speaking with a hot potato in the mouth.
Soft palate edema
Pain
Reduced palatal mobility
Peritonsillar swelling
The enlarging abscess pushes:
Soft palate medially
Tonsil medially
Uvula towards the healthy side
This is one of the most characteristic signs of quinsy.
Usually based on:
Severe unilateral sore throat
Trismus
Hot potato voice
Uvular deviation
Bulging soft palate
CBC
CRP
ESR
Blood culture (if septic)
Not routinely required.
Indications:
Suspicion of parapharyngeal extension
Failure to improve
Airway compromise
Recurrent abscess
Preferred imaging:
Contrast-enhanced CT neck
Needle aspiration confirms diagnosis and provides therapeutic drainage.
The needle is inserted at the point of maximum fluctuance, usually:
Superior pole of tonsil
Approximately:
At the junction of the upper one-third and lower two-thirds of the anterior pillar
Just superior and medial to the upper pole
Needle penetration should not exceed 1 cm to avoid injury to the internal carotid artery, which lies approximately 2–2.5 cm posterolateral to the tonsil.
Confirmed abscess
Significant trismus
Failure of aspiration
Large abscess
Local or general anesthesia
Mouth gag insertion
Incision at the point of maximum bulge
Blunt dissection
Drainage of pus
Irrigation
Antibiotics continued
Immediate pain relief
Rapid improvement in swallowing
Reduced airway compromise
Immediate tonsillectomy performed during the acute phase of peritonsillar abscess.
Bilateral quinsy
Airway obstruction
Recurrent quinsy
Failure of drainage
Recurrent tonsillitis
Inability to drain abscess adequately
Patient unsuitable for repeated procedures
Complete drainage
Removes infection focus
Prevents recurrence
Single hospital admission
Increased bleeding
Technically difficult
Edematous tissues
Higher anesthetic risk
Elective tonsillectomy performed 6–8 weeks after complete resolution of quinsy.
Recurrent tonsillitis
Previous quinsy
Bilateral disease
Persistent chronic tonsillitis
Young adults with recurrent episodes
Airway obstruction
Aspiration
Parapharyngeal abscess
Retropharyngeal abscess
Mediastinitis
Septicemia
Lemierre syndrome
Internal carotid artery erosion (rare)
Parapharyngeal abscess is a deep neck space infection involving the parapharyngeal (lateral pharyngeal) space, most commonly secondary to tonsillar infections.
Peritonsillar abscess
Acute tonsillitis
Dental infections
Parotid infection
Trauma
Foreign body
Penetrating injuries
Streptococcus pyogenes
Staphylococcus aureus
Fusobacterium
Bacteroides
Mixed anaerobes
High fever
Toxic appearance
Severe throat pain
Dysphagia
Odynophagia
Tender swelling below angle of mandible
Neck stiffness
Torticollis
Trismus
Medial bulging of lateral pharyngeal wall
Tonsillar displacement
Respiratory distress
Cranial nerve palsies (IX–XII)
Septicemia
Contrast-enhanced CT neck is the investigation of choice.
Typical findings:
Hypodense fluid collection
Peripheral rim enhancement
Gas locules (anaerobic infection)
Displacement of carotid sheath
Extension into adjacent neck spaces
Internal jugular vein thrombosis
Airway narrowing
Hospital admission
Airway monitoring
IV fluids
Broad-spectrum IV antibiotics
Examples:
Ampicillin-sulbactam
Piperacillin-tazobactam
Ceftriaxone + Metronidazole
Clindamycin (penicillin allergy)
Indications:
Established abscess
Airway compromise
Failure of antibiotics
Large collection
Procedures:
External drainage
Intraoral drainage (selected cases)
Drain placement
Airway obstruction
Carotid artery erosion
Internal jugular vein thrombosis
Lemierre syndrome
Mediastinitis
Septicemia
Investigations help to:
Confirm infection
Identify causative organism
Detect streptococcal infection
Assess complications
Exclude alternative diagnoses
Bacterial infection
Leukocytosis
Neutrophilia
Viral infection
Lymphocytosis
Infectious mononucleosis
Atypical lymphocytes
Recurrent infection
Treatment failure
Outbreak investigation
Suspected diphtheria
Swab taken from:
Tonsillar surface
Tonsillar crypts
Posterior pharyngeal wall
Avoid touching:
Tongue
Buccal mucosa
For bacterial identification.
Common isolates:
Group A Streptococcus
Staphylococcus aureus
Mixed flora
Advantages:
Confirms diagnosis
Guides antibiotic therapy
Not useful in acute diagnosis.
Useful in:
Rheumatic fever
Acute glomerulonephritis
Previous streptococcal infection
Raised after:
1–3 weeks
Peak:
3–5 weeks
Raised in:
Acute bacterial infection
Peritonsillar abscess
Deep neck infection
Useful for:
Monitoring response to treatment
Not routinely required.
May demonstrate:
Retropharyngeal abscess
Airway narrowing
Useful for:
Cervical lymphadenitis
Guided aspiration
Indications:
Deep neck infection
Parapharyngeal abscess
Retropharyngeal abscess
Airway compromise
Reserved for:
Skull base extension
Intracranial complications
Vascular involvement
Eradicate infection
Relieve symptoms
Prevent complications
Reduce transmission
Prevent rheumatic fever
Adults:
500 mg orally twice daily or 250 mg four times daily for 10 days
Children:
250 mg orally twice or three times daily for 10 days (dose adjusted by age/weight)
Advantages:
Narrow spectrum
Highly effective
Prevents rheumatic fever
Adults:
500 mg orally every 8 hours or 875 mg twice daily for 10 days
Children:
40–50 mg/kg/day in divided doses (maximum according to standard pediatric dosing)
Avoid in infectious mononucleosis because of the risk of maculopapular rash.
Indications:
Poor compliance
Rheumatic fever prophylaxis
Unable to take oral drugs
Dose:
≥27 kg: 1.2 million units IM (single dose)
<27 kg: 600,000 units IM (single dose)
Indications:
Non-immediate penicillin allergy
Adults:
500 mg orally twice daily for 10 days
Children:
20–40 mg/kg/day in divided doses
Indications:
Immediate penicillin allergy
Adults:
500 mg once daily for 3–5 days
Children:
12 mg/kg once daily for 5 days
Indications:
Recurrent tonsillitis
Anaerobic infection
Chronic carrier state
Penicillin allergy
Adults:
300 mg orally every 8 hours for 10 days
Children:
20–30 mg/kg/day in divided doses
Adequate hydration
Bed rest
Warm saline gargles
Soft diet
Analgesics (Paracetamol, Ibuprofen)
Antipyretics
Adequate nutrition
Avoid unnecessary corticosteroids except in selected severe cases (e.g., significant edema or airway compromise).
Tonsillar hypertrophy refers to enlargement of the palatine tonsils beyond the normal size, with or without active infection.
Normal lymphoid hyperplasia in childhood (3–10 years)
Recurrent tonsillitis
Chronic tonsillitis
Infectious mononucleosis
Allergic airway disease
PFAPA syndrome
Lymphoma
Leukemia
HIV infection
Rare neoplasms
Snoring
Mouth breathing
Dysphagia
Hyponasal speech
Recurrent sore throat
Sleep disturbance
Obstructive sleep apnea
Failure to thrive (children)
| Grade | Tonsillar Size |
|---|---|
| Grade 0 | Tonsils absent (post-tonsillectomy) |
| Grade 1 | Occupy <25% of oropharyngeal width |
| Grade 2 | Occupy 25–50% |
| Grade 3 | Occupy 50–75% |
| Grade 4 | Occupy >75% ("Kissing tonsils") |
Large tonsils reduce the caliber of the oropharyngeal airway, especially during sleep, leading to intermittent upper airway obstruction.
The risk of OSA increases with:
Brodsky grade 3–4 tonsils
Adenotonsillar hypertrophy
Obesity
Craniofacial anomalies
Observation
Treat associated infections/allergy
Weight reduction (if obese)
Tonsillectomy is indicated when hypertrophy causes:
OSA
Dysphagia
Failure to thrive
Speech impairment
Recurrent infections meeting criteria
Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, resulting in intermittent hypoxia, hypercapnia, and sleep fragmentation.
In children, adenotonsillar hypertrophy is the most common cause of OSA.
Enlarged tonsils and adenoids narrow the upper airway.
During sleep:
Reduced pharyngeal muscle tone
Collapse of narrowed airway
Apnea or hypopnea
Oxygen desaturation
Arousal from sleep
Recurrent obstruction
Loud habitual snoring
Witnessed apneas
Gasping/choking during sleep
Restless sleep
Mouth breathing
Night sweats
Enuresis
Daytime sleepiness (more common in adults)
Hyperactivity (common in children)
Poor concentration
Behavioral problems
Morning headache
Poor school performance
Failure to thrive
Grade 3–4 tonsils
Adenoid facies
Hyponasal speech
Mouth breathing
Obesity (some patients)
Sleep history
ENT examination
Brodsky tonsil grading
Gold standard: Overnight polysomnography (sleep study)
Additional tests (selected cases):
Pulse oximetry
Drug-induced sleep endoscopy
Lateral nasopharyngeal X-ray
Nasal endoscopy
Weight reduction (if obese)
Management of allergic rhinitis
Intranasal corticosteroids (mild disease)
CPAP when surgery is contraindicated or residual OSA persists
Adenotonsillectomy is the treatment of choice in children with OSA due to adenotonsillar hypertrophy.
Additional procedures may be required for persistent OSA.
Tonsillectomy is the surgical removal of the palatine tonsils together with their capsule from the tonsillar fossa.
Described by Celsus (1st century AD) using finger dissection.
Guillotine tonsillectomy became popular in the 19th century.
Modern techniques include cold steel dissection, electrocautery, coblation, harmonic scalpel, laser, radiofrequency, and microdebrider-assisted techniques.
Tonsillectomy is recommended when documented episodes are:
≥7 episodes in the preceding year, or
≥5 episodes/year for 2 consecutive years, or
≥3 episodes/year for 3 consecutive years
Each qualifying episode should include one or more of:
Fever >38.3°C
Tender cervical lymphadenopathy
Tonsillar exudate
Positive Group A Streptococcus test/culture
Moderate to severe pediatric OSA due to adenotonsillar hypertrophy
Significant sleep-disordered breathing affecting quality of life
Marked tonsillar enlargement causing difficulty in swallowing
Poor weight gain or growth secondary to severe adenotonsillar hypertrophy and sleep-disordered breathing
Recurrent peritonsillar abscess
Bilateral quinsy
Persistent recurrent peritonsillar infection
Unilateral tonsillar enlargement
Tonsillar ulcer
Persistent asymmetry
Cervical metastatic lymphadenopathy with suspected tonsillar primary
Children with severe, recurrent PFAPA refractory to medical management
Symptomatic recurrent tonsilloliths associated with halitosis, recurrent inflammation, or significant patient distress when conservative measures fail
Acute tonsillitis or acute upper respiratory tract infection (postpone elective surgery until infection resolves)
Uncorrected bleeding disorders
Cleft palate or submucous cleft palate (risk of velopharyngeal insufficiency)
Uncontrolled systemic diseases (e.g., poorly controlled diabetes, severe cardiopulmonary disease)
Severe anemia until corrected
Poor anesthetic fitness
Frequency and severity of tonsillitis
Previous peritonsillar abscess
Snoring or OSA symptoms
Drug history
Allergy history
Assess for:
Easy bruising
Epistaxis
Prolonged bleeding after dental extraction
Family history of bleeding disorders
Use of anticoagulants or antiplatelet drugs
Tonsil size (Brodsky grading)
Oral cavity
Airway assessment
Cervical lymph nodes
General systemic examination
Hemoglobin
Total and differential leukocyte count
Platelet count
Routine coagulation testing is not indicated in all patients. It should be performed when there is a positive bleeding history or clinical suspicion of a coagulation disorder.
Tests may include:
PT/INR
aPTT
Additional coagulation studies as indicated
Pre-anesthetic assessment includes:
Airway evaluation
ASA grading
Assessment of comorbidities
Fitness for general anesthesia
Fasting instructions
Counseling regarding perioperative risks and postoperative care
The Paradise criteria are standardized clinical criteria used to identify children with sufficiently frequent and severe recurrent throat infections who may benefit from tonsillectomy.
The criteria consider:
Frequency of throat-infection episodes
Clinical severity of each episode
Adequacy of treatment
Contemporary medical documentation
Tonsillectomy may be considered when the required frequency is fulfilled and every counting episode is properly documented. (AAO-HNS)
A child qualifies on the basis of frequency when there have been:
Seven or more episodes during the preceding year, or
Five or more episodes per year during each of the preceding two years, or
Three or more episodes per year during each of the preceding three years
In addition to sore throat, each counting episode should include at least one of the following:
Temperature greater than 38.3°C
Tender cervical lymphadenopathy or cervical lymph node larger than approximately 2 cm
Tonsillar or pharyngeal exudate
Positive test or culture for Group A β-haemolytic Streptococcus
Episodes should have received appropriate treatment when bacterial infection was proven or strongly suspected.
Tonsillectomy may be considered when the patient has experienced:
At least seven adequately documented episodes of acute tonsillitis or qualifying throat infection
All occurring during the immediately preceding 12 months
Each episode must satisfy the clinical-feature and documentation requirements.
A history of seven nonspecific sore throats without fever, cervical lymphadenopathy, exudate or streptococcal confirmation does not strictly fulfil the original Paradise criteria.
The criterion is fulfilled when:
At least five qualifying episodes occurred in the first year, and
At least five qualifying episodes occurred in the second consecutive year
Thus, the patient should have at least ten qualifying episodes distributed across two consecutive years.
The pattern should demonstrate persistent recurrent disease rather than a single unusually severe year.
The criterion is fulfilled when:
At least three qualifying episodes occurred during each of three consecutive years
This represents a lower annual frequency but a prolonged disease burden.
At least nine qualifying episodes should therefore have occurred over the three-year period, with the required minimum present in each year.
Each episode should preferably be recorded at the time of illness in a medical record.
Documentation should include:
Date of the episode
Presence of sore throat
Recorded temperature
Tonsillar or pharyngeal exudate
Cervical lymph-node findings
Streptococcal test or throat-culture result, when performed
Antibiotic prescribed
Duration and severity of symptoms
School or work absence, where relevant
When previous episodes were not adequately documented:
A reliable history may suggest recurrent tonsillitis.
The clinician should generally observe and document subsequent episodes.
Tonsillectomy may be reconsidered once the same pattern is confirmed under medical observation.
Tonsillectomy may still be considered even when the exact numerical criteria are not met if important modifying factors are present, such as:
Multiple antibiotic allergy or intolerance
PFAPA syndrome
More than one peritonsillar abscess
Severe episodes requiring repeated hospitalization
Significant impact on education, work or quality of life
The Paradise criteria guide decision-making but should not replace individualized clinical assessment.
The palatine tonsil lies in the tonsillar fossa on the lateral wall of the oropharynx.
Anteriorly: Palatoglossal arch and palatoglossus muscle
Posteriorly: Palatopharyngeal arch and palatopharyngeus muscle
Superiorly: Soft palate
Inferiorly: Dorsum and base of tongue
Laterally: Superior constrictor muscle and pharyngobasilar fascia
Medially: Free mucosal surface of the tonsil facing the oropharynx
From medial to lateral, the principal layers are:
Tonsillar substance
Fibrous tonsillar capsule
Loose areolar tissue of the peritonsillar space
Pharyngobasilar fascia
Superior constrictor muscle
Buccopharyngeal fascia
Parapharyngeal space
The loose areolar tissue between the tonsillar capsule and superior constrictor forms the natural plane used during extracapsular tonsillectomy.
The lateral surface of the tonsil is covered by a fibrous capsule.
It is formed by condensation of the pharyngobasilar fascia.
The capsule is most distinct over the lateral surface.
Fibrous septa extend from the capsule into the tonsillar substance.
The capsule separates the tonsil from the superior constrictor muscle.
During conventional tonsillectomy, the tonsil and capsule are removed together.
The palatine tonsil has a rich vascular supply derived principally from:
Tonsillar branch of facial artery
Ascending palatine branch of facial artery
Ascending pharyngeal artery
Dorsal lingual branches of lingual artery
Lesser palatine branches of maxillary artery
The tonsillar branch of the facial artery is usually the most important arterial supply.
Bleeding points are commonly encountered:
At the lower pole
In the middle of the tonsillar bed
Near the upper pole
The paratonsillar vein, also called the external palatine vein, descends over or near the lateral surface of the tonsil.
It is a frequent source of venous bleeding during tonsillectomy.
It is particularly vulnerable during dissection near the upper pole.
Bleeding may obscure the surgical plane.
Careful capsular dissection and early control are required.
The venous plexus around the tonsil drains into the:
Pharyngeal venous plexus
Facial vein
Lingual vein
The internal carotid artery is an important posterolateral relation of the tonsillar region.
It lies approximately 2–2.5 cm posterolateral to the palatine tonsil in adults.
The distance may be less in children.
The artery is separated from the tonsil by:
Tonsillar capsule
Superior constrictor muscle
Buccopharyngeal fascia
Parapharyngeal fat and associated tissues
The artery may be abnormally close because of:
Tortuosity
Medial displacement
Congenital vascular variation
Advanced age
Previous deep neck infection or surgery
Excessively deep lateral dissection must be avoided.
Needles or instruments introduced into the peritonsillar region should not be advanced deeply in a posterolateral direction.
Lies deep to the superior constrictor muscle.
Passes close to the lower pole of the tonsil.
Injury can cause:
Taste disturbance over posterior one-third of tongue
Reduced pharyngeal sensation
Dysphagia
Neuralgic pain
These muscles are situated posterolaterally and may be encountered if dissection extends beyond the superior constrictor.
The facial artery may form a loop close to the lower pole, making lower-pole dissection and ligation particularly important.
The correct surgical plane in extracapsular tonsillectomy lies:
Immediately outside the tonsillar capsule
Within the loose areolar tissue of the peritonsillar space
Medial to the superior constrictor muscle
A correct plane is characterized by:
Relatively avascular loose areolar tissue
Smooth appearance of the tonsillar capsule
Minimal muscle injury
Controlled separation of the tonsil from its bed
Dissection that is too medial:
Enters tonsillar tissue
Leaves residual tonsil
Causes troublesome bleeding from tonsillar parenchyma
Dissection that is too lateral:
Injures the superior constrictor muscle
Produces more pain
Increases bleeding
Risks damage to deeper neurovascular structures
Tonsillectomy techniques may be classified according to:
Extracapsular tonsillectomy
Intracapsular tonsillectomy
Cold-steel techniques
Electrosurgical techniques
Radiofrequency or plasma-mediated techniques
Ultrasonic techniques
Laser techniques
Thermal welding techniques
No single technique is ideal for every patient. Selection depends on:
Indication
Patient age
Tonsil size
Surgeon experience
Available equipment
Expected pain and bleeding risk
Need for complete removal
The tonsil is dissected from its capsule within the peritonsillar plane, and the lower-pole pedicle is divided using a tonsillar snare.
General anaesthesia with oral endotracheal intubation
Patient positioned with neck extended
Boyle-Davis mouth gag inserted and suspended
Tonsil grasped with holding forceps
Mucosal incision made near the anterior pillar
Tonsillar capsule identified
Tonsil dissected from upper pole downward in the extracapsular plane
Lower-pole attachment engaged in a tonsillar snare
Pedicle crushed and divided
Haemostasis secured by pressure, ligature, bipolar cautery or another method
Clear anatomical dissection
Complete removal of tonsil and capsule
Limited thermal injury
Reliable specimen for histopathology
Requires technical skill
Operative bleeding may be greater than with some hot techniques
Operative time may be longer
Postoperative pain remains significant
The tonsil is engaged through the ring of a guillotine instrument and amputated rapidly.
Historically performed without complete capsular dissection
Commonly used in children in the past
Could be performed rapidly
Often removed the tonsil incompletely
Poor control of bleeding
Risk of incomplete removal
Risk of injury to pillars
Risk of aspiration of the tonsil
Unsuitable for fibrotic or scarred tonsils
Limited visualization of the tonsillar bed
The method has largely been abandoned in modern practice.
Electrical energy generates heat for tissue dissection and haemostasis.
Monopolar electrocautery
Needle-tip cautery
Electrosurgical dissection
Rapid dissection
Effective haemostasis
Reduced intraoperative blood loss
Widely available
Greater thermal injury
Increased postoperative pain
Deeper tissue damage if excessive power is used
Eschar formation
Possible increased risk of delayed haemorrhage in some settings
Current passes between the two tips of the bipolar forceps and is confined mainly to the tissue grasped between them.
Dissection
Coagulation
Control of individual bleeding vessels
More localized thermal effect than monopolar cautery
Effective haemostasis
Reduced intraoperative bleeding
Precise vessel control
Thermal damage remains possible
Excessive use increases tissue necrosis and postoperative pain
May contribute to secondary haemorrhage through slough separation
Bipolar scissors may combine cutting and coagulation.
Coblation is a controlled plasma-mediated technique that uses radiofrequency energy in a saline medium to produce a plasma field capable of molecular tissue dissociation at relatively low temperatures.
Extracapsular tonsillectomy
Intracapsular tonsil reduction
Tonsillotomy
Lower operating temperature than conventional electrocautery
Effective tissue removal
Good intraoperative haemostasis
Potentially less early postoperative pain
Useful for intracapsular surgery
Expensive disposable equipment
Learning curve
Possibility of postoperative haemorrhage
Tissue regrowth after intracapsular reduction
Complete histological specimen may not be obtained with partial ablation
The harmonic scalpel uses high-frequency ultrasonic vibration to cut and coagulate tissue.
Mechanical vibration disrupts tissue.
Protein denaturation seals small vessels.
Tissue temperatures are generally lower than those produced by conventional electrocautery.
Simultaneous cutting and coagulation
Reduced lateral thermal spread
Good haemostasis
Relatively precise dissection
Expensive
Bulky instrument in a confined oral cavity
Risk of thermal injury still exists
No consistent superiority over established techniques
Carbon dioxide laser
Potassium-titanyl-phosphate laser
Diode laser
Nd:YAG laser
Complete tonsillectomy
Tonsillotomy
Cryptolysis for selected tonsilloliths or cryptic tonsillitis
Precise cutting
Good haemostasis
Reduced intraoperative blood loss
Useful for selected partial procedures
High cost
Laser safety precautions required
Risk of airway fire
Thermal injury
Postoperative pain
Smoke-plume hazard
Specialized training and equipment required
Radiofrequency energy produces controlled tissue heating, coagulation and volume reduction.
Radiofrequency tonsil reduction
Partial tonsil ablation
Treatment of obstructive tonsillar hypertrophy
Reduced tissue volume without complete excision
Limited bleeding
May be performed with less postoperative pain than extracapsular surgery
Delayed reduction in size
Possibility of inadequate airway improvement
Residual tonsillar tissue
Recurrence or regrowth
Unsuitable where complete histology is necessary
Thermal-welding devices use controlled heat and pressure to seal blood vessels and divide tissue.
Simultaneous dissection and haemostasis
Reduced intraoperative blood loss
Controlled vessel sealing
Relatively rapid procedure
Thermal tissue injury
Equipment cost
Postoperative pain
Risk of secondary haemorrhage
Limited availability in some centres
A plasma field generated in an electrically conductive medium breaks molecular bonds within tissue.
Coblation is the best-known clinical example of plasma-mediated ablation.
Intracapsular tonsillectomy
Extracapsular tonsillectomy
Tonsillar volume reduction
Operates at a lower temperature than traditional electrocautery
Causes less charring
Allows suction and ablation through the same instrument in some systems
Cost
Equipment dependence
Learning curve
Residual tissue when used intracapsularly
Intracapsular tonsillectomy removes most tonsillar tissue while preserving:
Tonsillar capsule
A thin rim of lymphoid tissue over the capsule
The pharyngeal musculature beneath the capsule
It is also called:
Subtotal tonsillectomy
Partial tonsillectomy
Tonsillotomy, though terminology varies
Microdebrider
Coblation
Radiofrequency
Laser
Less exposure of the pharyngeal muscle
Less postoperative pain
Earlier return to normal diet
Lower risk of postoperative haemorrhage in many studies
Useful for obstructive tonsillar hypertrophy
Residual tonsillar tissue
Possibility of regrowth
Recurrent tonsillitis may persist or recur
Repeat surgery may occasionally be required
Less suitable for suspected malignancy
Less suitable when chronic infection is the primary indication
Extracapsular tonsillectomy removes:
Entire tonsillar tissue
Tonsillar capsule
The tonsil is separated from the superior constrictor muscle through the peritonsillar surgical plane.
Complete removal
Lower risk of clinically significant tonsillar regrowth
Preferred for recurrent or chronic tonsillitis
Provides an intact specimen for histopathological examination
Appropriate when malignancy is suspected
Exposes the pharyngeal muscle
Greater postoperative pain
Longer recovery
Greater risk of postoperative haemorrhage compared with intracapsular surgery in many series
Intracapsular surgery generally offers faster recovery and less bleeding, whereas extracapsular surgery provides complete tissue removal and remains preferable when recurrent infection or malignancy is the principal concern. (ScienceDirect)
Tonsillotomy is the partial removal or reduction of the palatine tonsil in which a thin layer of tonsillar tissue and the tonsillar capsule are deliberately preserved.
The objective is to enlarge the oropharyngeal airway while avoiding exposure of the superior constrictor muscle.
The principal indication is:
Obstructive tonsillar hypertrophy causing sleep-disordered breathing or obstructive sleep apnoea
Other selected indications include:
Dysphagia caused by markedly enlarged tonsils
Feeding difficulty due to mechanical obstruction
Speech or resonance disturbance caused by massive tonsillar enlargement
Tonsillar hypertrophy in children where reduced postoperative morbidity is desirable
Tonsillotomy is generally less suitable when the main problem is:
Recurrent bacterial tonsillitis
Chronic crypt infection
Tonsillolith formation
Peritonsillar abscess
Suspicion of malignancy
Tonsillotomy may be performed using:
Microdebrider
Coblation
Radiofrequency
Laser
Electrocautery
Cold instruments
The surgeon removes the medially projecting tonsillar tissue while preserving the capsule.
Less postoperative pain
Reduced requirement for analgesics
Earlier oral intake
Reduced risk of dehydration
Earlier return to normal activity
Lower postoperative haemorrhage rate in many studies
Preservation of the tonsillar capsule
Reduced trauma to the superior constrictor muscle
Residual lymphoid tissue remains
Possibility of tonsillar regrowth
Recurrent infection may occur
Persistent obstructive symptoms may occur if reduction is inadequate
Repeat surgery may occasionally be required
Histopathological assessment is limited
Not appropriate for suspected tonsillar malignancy
Recurrence may occur due to:
Hypertrophy of residual lymphoid tissue
Young age at surgery
Allergic inflammation
Recurrent upper respiratory infection
Incomplete initial reduction
Ongoing lymphoid stimulation
Return of snoring
Recurrent mouth breathing
Witnessed apnoea
Recurrent dysphagia
Visible tonsillar enlargement
Recurrent throat infection
Observation in mild cases
Treatment of nasal allergy or associated adenoid hypertrophy
Sleep assessment when obstructive symptoms recur
Revision tonsillotomy or complete extracapsular tonsillectomy in significant recurrence
Adenotonsillectomy is the surgical removal of the palatine tonsils together with removal of the nasopharyngeal adenoid tissue during the same anaesthetic procedure.
It is one of the commonest operations performed for paediatric upper-airway obstruction.
Obstructive sleep apnoea due to adenotonsillar hypertrophy
Significant sleep-disordered breathing
Chronic upper-airway obstruction
Persistent mouth breathing with adenotonsillar enlargement
Failure to thrive related to obstructive sleep disturbance
Dysphagia caused by massive tonsillar hypertrophy
Cardiopulmonary complications of chronic obstruction
Recurrent adenotonsillitis
Recurrent tonsillitis associated with chronic or recurrent adenoiditis
Recurrent infection accompanied by persistent nasal obstruction
Recurrent infection with chronic middle-ear or sinonasal disease where adenoid disease contributes
Craniofacial growth disturbance associated with prolonged obstruction
Hyponasal speech caused by obstructive adenoid hypertrophy
Selected cases of recurrent otitis media with coexisting tonsillar indication
Selected patients requiring removal of both lymphoid tissues for separate established indications
In children:
Adenotonsillar enlargement narrows the retropalatal and oropharyngeal airway.
Pharyngeal muscle tone decreases during sleep.
The narrowed airway undergoes recurrent partial or complete collapse.
This causes snoring, hypopnoea, apnoea, oxygen desaturation and sleep fragmentation.
Adenotonsillectomy is usually the first-line surgical treatment when:
The tonsils and adenoids are enlarged, and
Obstructive sleep apnoea or clinically important sleep-disordered breathing is present
Reduced snoring
Reduced apnoeic events
Improved sleep quality
Improved daytime behaviour
Improved attention and school performance
Improved growth in affected children
Reduction of cardiopulmonary stress
Persistent OSA is more likely in patients with:
Obesity
Craniofacial anomaly
Down syndrome
Neuromuscular disease
Severe preoperative OSA
Lingual tonsillar hypertrophy
Nasal obstruction
Such patients may require postoperative reassessment and additional treatment.
Adenotonsillectomy may be considered when:
Tonsillar infections meet accepted frequency and severity criteria, and
There is simultaneous recurrent or chronic adenoid infection
Associated features may include:
Recurrent fever and sore throat
Purulent postnasal discharge
Nasal obstruction
Chronic mouth breathing
Halitosis
Recurrent otitis media
Persistent cervical lymphadenopathy
The decision should distinguish true recurrent bacterial adenotonsillitis from frequent self-limiting viral upper respiratory infections.
Complications may occur:
During surgery
In the immediate postoperative period
During the first 24 hours
Several days after surgery
Rarely, as delayed functional complications
Primary haemorrhage occurs:
During the operation, or
Before the patient leaves the operating theatre
Inadequate surgical haemostasis
Injury to tonsillar vessels
Trauma to the tonsillar bed
Difficult dissection
Fibrosis from recurrent infection or previous quinsy
Unrecognized bleeding disorder
Slippage of ligature
Tonsillar branch of facial artery
Paratonsillar vein
Lower-pole vessels
Dorsal lingual branches
Ascending palatine vessels
Pressure with a tonsillar swab
Bipolar coagulation
Vessel ligation
Suturing of the tonsillar pillars or bed where necessary
Correction of coagulopathy
Reactionary haemorrhage usually occurs within the first few hours after surgery, conventionally within the first 24 hours.
Slipped ligature
Dislodgement of clot
Recovery of blood pressure after anaesthesia
Coughing, vomiting or straining
Inadequately controlled vessel
Vasodilatation after resolution of anaesthetic vasoconstriction
Coagulation abnormality
Fresh bleeding from mouth
Frequent swallowing
Haematemesis
Tachycardia
Pallor
Hypotension in severe cases
Children may swallow blood rather than spit it out.
Secondary haemorrhage occurs more than 24 hours after surgery, commonly between the fifth and tenth postoperative days, when the fibrinous slough separates.
Bleeding can nevertheless occur at any time during the first two postoperative weeks. (PMC)
Infection of the tonsillar bed
Premature separation of slough
Trauma from hard food
Dehydration
Excessive thermal tissue injury
Exposure of a vessel during healing
Even apparently minor bleeding may precede severe haemorrhage and requires urgent medical assessment.
True infection is less common than the normal inflammatory healing response.
Persistent or increasing fever
Worsening pain after initial improvement
Cervical lymphadenitis
Increasing foul odour with systemic illness
Purulent discharge beyond the expected fibrinous coating
Raised inflammatory markers in selected cases
The normal white or yellow tonsillar-bed slough should not be mistaken for pus.
Laryngospasm
Oedema of tongue, uvula or soft palate
Blood clot in the pharynx
Aspiration of blood
Residual anaesthetic effect
Opioid-induced respiratory depression
Negative-pressure pulmonary oedema
Severe pre-existing OSA
Very young children
Severe OSA
Craniofacial anomalies
Neuromuscular disorders
Obesity
Significant cardiopulmonary disease
Velopharyngeal insufficiency is failure of adequate closure between the soft palate and posterior pharyngeal wall during speech and swallowing.
Overt cleft palate
Submucous cleft palate
Short palate
Neuromuscular palatal dysfunction
Previous palatal surgery
Removal of a large adenoid pad that was assisting closure
Hypernasal speech
Nasal air escape
Nasal regurgitation of liquids
Reduced speech intelligibility
It is more closely related to adenoidectomy but may follow adenotonsillectomy.
Glossopharyngeal nerve injury
Lingual nerve pressure
Tongue compression by the mouth gag
Zinc disturbance
Local inflammation
Reduced taste
Altered taste
Metallic taste
Taste loss over posterior tongue
Most cases are temporary, but persistent disturbance may rarely occur.
Grisel syndrome is non-traumatic atlantoaxial subluxation associated with inflammation or surgery in the upper aerodigestive tract.
Inflammation may produce:
Ligamentous laxity
Spasm of cervical muscles
Instability of the atlantoaxial joint
Painful torticollis
Neck stiffness
Restricted neck movement
Abnormal head posture
Cervical immobilization
Anti-inflammatory treatment
Antibiotics when infection is present
Orthopaedic or neurosurgical consultation
Reduction or fixation in severe cases
May include:
Chipped tooth
Fractured tooth
Loosening of tooth
Injury to dental crown or prosthesis
Gingival trauma
It usually results from:
Mouth-gag insertion
Excessive pressure on incisors
Difficult airway instrumentation
A preoperative dental assessment is especially important when teeth are loose or restored.
Excessive mouth opening
Forceful insertion of the mouth gag
Prolonged mouth-gag suspension
Pre-existing temporomandibular joint instability
Inability to close mouth
Preauricular pain
Abnormal mandibular position
Prompt reduction is required.
Material aspirated may include:
Blood
Blood clot
Tooth or dental prosthesis
Tonsillar tissue
Surgical swab or foreign material
Gastric contents
Aspiration may cause:
Airway obstruction
Chemical pneumonitis
Atelectasis
Aspiration pneumonia
Throat packs, suction and careful counting of swabs are important preventive measures.
The glossopharyngeal nerve lies close to the lower tonsillar pole, deep to the superior constrictor.
Loss or alteration of taste over posterior one-third of tongue
Reduced pharyngeal sensation
Dysphagia
Impaired gag reflex
Glossopharyngeal neuralgia
Referred otalgia
Deep lateral dissection and excessive lower-pole cautery increase the risk.
Nasopharyngeal stenosis is cicatricial narrowing between the soft palate and posterior or lateral pharyngeal walls.
Excessive tissue removal
Simultaneous injury to opposing mucosal surfaces
Extensive cautery
Postoperative infection
Repeated nasopharyngeal surgery
Aggressive adenotonsillar surgery
Nasal obstruction
Hyponasal speech
Mouth breathing
Difficulty clearing nasal secretions
Sleep-disordered breathing
May require:
Scar release
Mucosal flaps
Skin or mucosal grafting
Stenting
Repeated dilatation
Post-tonsillectomy haemorrhage is an airway and circulatory emergency.
Every patient with:
Fresh oral bleeding
Blood-stained saliva
Haematemesis
Repeated swallowing
A visible clot in the tonsillar fossa
must be assessed urgently in a facility capable of airway management and surgical haemostasis.
Place the conscious patient sitting upright.
Lean the patient forward.
Encourage spitting of blood rather than swallowing.
Provide suction to clear blood and clot.
A deteriorating or unconscious patient should be managed in an appropriate airway position.
An upright, forward-leaning position helps reduce aspiration of blood. (Perth Children's Hospital)
Assess simultaneously:
Airway
Breathing
Circulation
Mental status
Estimated blood loss
Time since tonsillectomy
Active bleeding or clot
Previous bleeding episodes
Drug and bleeding history
Obtain early intravenous access.
Use one or two large-bore cannulae where feasible.
Intraosseous access may be required in a shocked child when intravenous access cannot be obtained rapidly.
Send:
Complete blood count
Haemoglobin and haematocrit
Platelet count
Blood group and cross-match
PT/INR
aPTT
Fibrinogen where significant bleeding or coagulopathy is suspected
Renal and electrolyte profile when clinically indicated
An initially normal haemoglobin does not exclude major acute blood loss.
Begin isotonic crystalloid for circulatory compromise.
Administer packed red cells according to haemodynamic status and estimated blood loss.
Correct coagulopathy.
Consider platelets, plasma or fibrinogen replacement when indicated.
Keep the patient nil by mouth.
Depending on institutional protocol and clinical circumstances:
Intravenous tranexamic acid may be considered.
Nebulized or topical antifibrinolytic therapy may be used in selected settings.
Antibiotics may be given when secondary haemorrhage with infection is suspected.
Medication must not delay definitive airway control or operative haemostasis.
The airway may be compromised by:
Active bleeding
Large clot
Aspiration
Hypovolaemia
Oedema
Difficult visualization
Full stomach containing swallowed blood
Call the ENT surgeon and anaesthesia team immediately.
Prepare suction with multiple suction catheters.
Administer supplemental oxygen.
Avoid unnecessary repeated throat examination.
Prepare for difficult intubation.
Use rapid-sequence induction when general anaesthesia is required.
Ensure availability of rescue airway equipment.
Intubation should be performed by an experienced anaesthetist because visualization may be obscured by blood.
When the patient is stable:
Use adequate lighting and suction.
Inspect both fossae.
Look for:
Active arterial bleeding
Generalized oozing
Adherent clot
Slough disruption
Signs of infection
A clot should not be casually removed outside a controlled setting because it may be tamponading an underlying vessel.
Active bleeding
Recurrent bleeding
Haemodynamic instability
Visible pulsatile vessel
Large clot with concerning history
Failure of conservative measures
Significant previous blood loss
Inability to examine safely
Under general anaesthesia:
Remove clot with suction.
Identify the bleeding point.
Apply bipolar coagulation.
Ligate the vessel.
Place a transfixion suture where necessary.
Apply sustained pressure.
Inspect both tonsillar beds.
Correct any coagulopathy.
Rarely, uncontrolled major-vessel bleeding may require:
External carotid artery branch ligation
Endovascular intervention
Vascular surgical assistance
Return to theatre is generally required for:
Continuing active haemorrhage
Recurrent bleeding after initial cessation
Haemodynamic instability
Airway compromise
Large or expanding clot
Suspected arterial bleeding
Significant secondary haemorrhage
Bleeding in a patient unable to cooperate with examination
Even when active bleeding has stopped:
Admit for observation.
Maintain intravenous access.
Continue fasting initially.
Monitor pulse, blood pressure and oxygen saturation.
Reassess for repeated swallowing or renewed bleeding.
Repeat haemoglobin when clinically indicated.
Post-tonsillectomy bleeding can recur, and apparently minor bleeding should not be dismissed.
Following tonsillectomy, observe:
Airway patency
Respiratory rate
Oxygen saturation
Pulse and blood pressure
Level of consciousness
Oral bleeding
Repeated swallowing
Nausea and vomiting
Ability to tolerate oral fluids
Children with severe OSA or important comorbidities may require prolonged or overnight monitored observation.
Pain is usually greatest during the first several days and may worsen again when the tonsillar slough begins separating.
Give analgesics regularly rather than waiting for severe pain.
Use weight-appropriate dosing in children.
Maintain hydration.
Encourage early oral intake.
Treat nausea and vomiting.
Paracetamol
Ibuprofen, where not contraindicated
Additional rescue analgesia according to age, pain severity and institutional protocol
Opioids require caution because of:
Sedation
Respiratory depression
Increased risk in OSA
Nausea and vomiting
Codeine should not be used routinely in children after tonsillectomy because of unpredictable metabolism and risk of respiratory depression.
Post-tonsillectomy ear pain is usually referred pain through the glossopharyngeal nerve.
Commonly bilateral
Usually begins or increases several days after surgery
Otoscopic examination is generally normal
Does not necessarily indicate otitis media
Reassurance
Regular analgesia
Hydration
Chewing and swallowing as tolerated
Persistent unilateral otalgia with fever or abnormal otoscopy should be evaluated separately.
Begin oral fluids once the patient is fully awake and swallowing safely.
Progress to an age-appropriate normal diet as tolerated.
Encourage chewing and swallowing.
Avoid foods that directly traumatize the operative bed.
Suitable options include:
Cool fluids
Soft food during the painful early period
Non-spicy meals
Regular food as tolerance improves
Avoid:
Very hot food or drinks
Sharp foods that cause trauma
Highly spicy or acidic foods if painful
Alcohol in adults during recovery
Prolonged restriction to liquids alone is unnecessary and may worsen nutritional intake.
Adequate hydration is essential because dehydration:
Intensifies pain
Reduces swallowing
Causes lethargy
May increase the risk of readmission
Can contribute to secondary haemorrhage
Reduced urine output
Dry mouth
Absence of tears
Lethargy
Tachycardia
Dizziness
Inability to tolerate fluids
Intravenous fluids may be necessary if oral intake is inadequate.
After tonsillectomy, the fossae are covered by:
White
Cream
Yellowish-grey
fibrinous material.
This represents normal healing and is not pus.
Associated normal findings may include:
Mild halitosis
Throat pain
Referred ear pain
Low-grade temperature during the early postoperative period
Uvular oedema
Mild voice alteration
Persistent high fever
Progressive systemic illness
Increasing cervical swelling
Worsening pain after a period of improvement
Inability to drink
Persistent vomiting
Fresh bleeding
Respiratory difficulty
Marked asymmetrical swelling
Routine antibiotics are not required solely because fibrinous slough is visible.
Rest during the early recovery period.
Avoid strenuous physical activity.
Avoid heavy lifting.
Avoid distant travel where emergency care is unavailable during the main bleeding-risk period.
Return to school or work when oral intake, pain and general activity have substantially recovered.
Recovery commonly extends for approximately 10–14 days. (Cleveland Clinic)
Follow-up should assess:
Healing of both tonsillar fossae
Pain control
Oral intake
Weight and hydration
Bleeding history
Infection
Voice or swallowing difficulty
Resolution of the original indication
For obstructive sleep apnoea, reassess:
Snoring
Witnessed apnoea
Daytime symptoms
Growth
Residual obstruction
Repeat polysomnography may be required in high-risk patients or when symptoms persist.
Tonsillar enlargement may be:
Acute or chronic
Unilateral or bilateral
Painful or painless
Infective, inflammatory, reactive, haematological or malignant
Evaluation should consider:
Duration
Fever and pain
Recurrent infections
Constitutional symptoms
Tonsillar surface
Consistency
Ulceration
Cervical lymphadenopathy
Hepatosplenomegaly
Blood-count abnormalities
Viral tonsillitis
Group A streptococcal tonsillitis
Other bacterial tonsillitis
Diphtheria
Acute infectious mononucleosis
Acute sore throat
Fever
Odynophagia
Erythematous swollen tonsils
Exudate or membrane
Tender cervical lymphadenopathy
Short duration
Acute enlargement is commonly bilateral but may appear asymmetrical.
Recurrent sore throat
Chronic throat discomfort
Halitosis
Tonsilloliths
Crypt debris
Recurrent cervical lymphadenopathy
Enlarged or fibrotic tonsils
Congested anterior pillars
The tonsils may be:
Hypertrophied
Small and fibrosed
Cryptic
Asymmetrical because of scarring
The palatine tonsil is an important extranodal site for lymphoma, especially non-Hodgkin lymphoma.
Rapidly enlarging tonsil
Usually painless
Unilateral or markedly asymmetrical enlargement
Smooth or lobulated surface
Cervical lymphadenopathy
Dysphagia
Muffled voice
Obstructive symptoms
Unexplained fever
Night sweats
Weight loss
Generalized lymphadenopathy
Complete blood count
Peripheral smear
Imaging
Tonsil biopsy or diagnostic tonsillectomy
Histopathology and immunophenotyping
Tonsillar infiltration may occur in haematological malignancy.
Bilateral or asymmetrical tonsillar enlargement
Pallor
Fever
Recurrent infections
Gingival enlargement
Petechiae or bleeding
Generalized lymphadenopathy
Hepatosplenomegaly
Complete blood count
Peripheral smear
Bone-marrow examination when indicated
Haematology consultation
Squamous cell carcinoma
It may be associated with:
Tobacco and alcohol exposure
Human papillomavirus-related oropharyngeal carcinoma
Unilateral tonsillar enlargement
Ulceration
Induration
Irregular or friable surface
Bleeding on touch
Persistent sore throat
Dysphagia or odynophagia
Referred otalgia
Cervical metastatic lymph node
Weight loss
Complete head-and-neck examination
Flexible endoscopy
Imaging
Biopsy
Assessment of cervical lymph nodes
Most commonly caused by Epstein–Barr virus.
Fever
Severe sore throat
Markedly enlarged exudative tonsils
Posterior cervical lymphadenopathy
Palatal petechiae
Fatigue
Hepatosplenomegaly
Generalized lymphadenopathy
Complete blood count showing lymphocytosis
Atypical lymphocytes
Heterophile antibody testing
EBV-specific serology where required
Tonsillar enlargement may cause airway obstruction.
Amoxicillin or ampicillin may produce a prominent maculopapular rash.
Contact sports should be avoided when splenomegaly is present.
Unilateral tonsillar enlargement refers to true or apparent enlargement of one palatine tonsil relative to the other.
It may represent:
Normal anatomical asymmetry
Unequal tonsillar-fossa depth
Infection or inflammation
Benign lymphoid hyperplasia
Benign tumour
Malignancy
The clinical significance depends more on associated suspicious findings than on asymmetry alone.
Difference in depth of tonsillar fossae
Rotation of one tonsil
Asymmetrical anterior pillars
Scarring from previous infection
Displacement by a parapharyngeal mass
Acute unilateral tonsillitis
Chronic tonsillitis
Peritonsillitis
Peritonsillar abscess
Tuberculosis
Syphilis
Fungal infection
Infectious mononucleosis with asymmetric enlargement
Reactive lymphoid hyperplasia
Tonsillar retention cyst
Epidermoid or lymphoepithelial cyst
Squamous papilloma
Fibroma
Lipoma
Vascular lesion
Squamous cell carcinoma
Lymphoma
Leukemic infiltration
Minor salivary-gland malignancy
Metastatic tumour, rarely
A mass outside the tonsil may push it medially:
Parapharyngeal-space tumour
Deep-lobe parotid tumour
Neurogenic tumour
Vascular tumour
Parapharyngeal abscess
Suspicion of malignancy increases when unilateral enlargement is accompanied by:
Progressive increase in size
Mucosal ulceration
Induration
Irregular or friable surface
Spontaneous bleeding
Ipsilateral cervical lymphadenopathy
Unexplained weight loss
Persistent unilateral throat pain
Referred otalgia
Dysphagia or odynophagia
Trismus
Voice change
Cranial nerve abnormality
Constitutional symptoms
Significant tobacco or alcohol exposure
Immunosuppression
Previous head-and-neck malignancy
Persistent tonsillar ulceration may indicate:
Squamous cell carcinoma
Tuberculosis
Syphilis
Traumatic ulcer
Deep fungal infection
Lymphoma with surface breakdown
Irregular margins
Everted edges
Friable base
Contact bleeding
Failure to heal
Associated induration
A persistent tonsillar ulcer requires biopsy.
Induration is abnormal firmness or hardening of the tonsil or surrounding tissue.
It may indicate:
Infiltrating carcinoma
Fibrosis following chronic inflammation
Deep infection
Induration extending into the:
Tongue base
Anterior pillar
Posterior pillar
Soft palate
is particularly concerning for invasive malignancy.
Examine all cervical lymph-node levels for:
Size
Number
Consistency
Tenderness
Mobility
Fixity
Skin involvement
Hard consistency
Progressive enlargement
Fixity
Central necrosis
Painless persistence
Cystic lateral neck mass in an adult
An adult with a persistent cervical node and tonsillar asymmetry should be evaluated for an occult oropharyngeal primary.
Unexplained weight loss may result from:
Malignancy
Chronic infection
Painful swallowing
Systemic lymphoma
Tuberculosis
Weight loss occurring with tonsillar asymmetry, neck nodes or referred otalgia is a significant warning feature.
The tonsil is supplied by the glossopharyngeal nerve, which also carries sensory fibres associated with referred pain to the ear.
Persistent unilateral otalgia with a normal ear examination may indicate:
Tonsillar carcinoma
Base-of-tongue carcinoma
Oropharyngeal malignancy
Deep tonsillar infection
The oropharynx and hypopharynx must therefore be examined when unexplained unilateral otalgia is present.
Ask about:
Duration and progression
Sore throat
Fever
Recurrent tonsillitis
Dysphagia
Odynophagia
Referred otalgia
Bleeding
Voice change
Trismus
Weight loss
Night sweats
Tobacco and alcohol use
Immunosuppression
Previous malignancy
Assess:
True size of each tonsil
Tonsillar surface
Crypts and debris
Ulceration
Induration
Mobility
Extension to pillars or tongue base
Soft-palate displacement
Cervical lymph nodes
Cranial nerves
Oral cavity and contralateral tonsil
Flexible nasopharyngolaryngoscopy should examine:
Nasopharynx
Tongue base
Vallecula
Oropharynx
Hypopharynx
Larynx
Depending on clinical suspicion:
Complete blood count
Peripheral smear
CRP or ESR
EBV testing
HIV testing with appropriate consent
Tests for tuberculosis
Other infection-specific investigations
Useful for:
Tonsillar mass
Deep extension
Parapharyngeal lesion
Cervical lymphadenopathy
Abscess
Bone involvement
Useful for:
Soft-tissue extent
Tongue-base involvement
Parapharyngeal disease
Perineural spread
Skull-base involvement
Useful for:
Characterizing cervical lymph nodes
Guiding fine-needle aspiration or core biopsy
May be used in confirmed malignancy for:
Staging
Occult primary assessment
Distant disease evaluation
Indications for biopsy or diagnostic tonsillectomy include:
Progressive asymmetry
Suspicious ulceration
Induration
Abnormal surface
Ipsilateral neck node
Constitutional symptoms
Strong clinical concern for malignancy
Diagnostic options include:
Incisional biopsy
Unilateral tonsillectomy
Bilateral tonsillectomy in selected occult-primary evaluation
Fine-needle aspiration or core biopsy of a cervical node
Histopathological examination should include appropriate immunohistochemistry when lymphoma is suspected.
Observation may be appropriate when:
The asymmetry is mild.
The mucosa is normal.
There is no induration.
No cervical lymphadenopathy is present.
No constitutional or other red-flag symptoms exist.
The apparent difference is attributable to tonsillar-fossa anatomy.
The patient should be reviewed to confirm stability.
When infection is present:
Give appropriate antimicrobial and supportive treatment.
Reassess after the acute inflammation resolves.
Persistent asymmetry after resolution requires renewed evaluation.
A peritonsillar abscess requires drainage and appropriate antibiotics.
Tonsillectomy is indicated when malignancy cannot be excluded clinically.
The specimen should be:
Correctly oriented where required
Sent separately when both tonsils are removed
Submitted for complete histopathological examination
Management depends on histology and stage.
May require:
Transoral surgical resection
Neck dissection
Radiotherapy
Concurrent chemoradiotherapy
Multidisciplinary oncological treatment
Usually requires:
Haematology-oncology referral
Immunophenotyping
Systemic staging
Chemotherapy with or without radiotherapy
Surgery is principally diagnostic rather than therapeutic for lymphoma.
Although chronic tonsillitis is a common benign condition, the palatine tonsil can also be the site of primary malignant tumors. Any persistent unilateral tonsillar enlargement, ulceration, or cervical lymphadenopathy should raise suspicion of malignancy.
The common malignant lesions involving the tonsil are:
Squamous cell carcinoma (SCC)
HPV-related oropharyngeal carcinoma
Lymphoma
Rare salivary gland tumors and metastatic lesions
HPV-related tonsillar carcinoma is a subtype of oropharyngeal squamous cell carcinoma caused predominantly by persistent infection with high-risk Human Papillomavirus (HPV), especially HPV-16.
It usually arises from the crypt epithelium of the palatine tonsil.
Increasing incidence worldwide
Common in younger adults (40–60 years)
More common in males
Frequently occurs in non-smokers or light smokers
Better prognosis than HPV-negative SCC
HPV-16 (most common)
HPV-18 (less common)
Multiple sexual partners
Oral sexual practices
Persistent HPV infection
Smoking (synergistic effect)
Immunosuppression
Persistent HPV infection leads to:
Viral DNA integration
Expression of E6 protein
Degrades p53 tumor suppressor
Expression of E7 protein
Inactivates Rb protein
Uncontrolled cellular proliferation
Development of carcinoma
Many patients present with cervical lymph node metastasis before throat symptoms.
Symptoms include:
Persistent sore throat
Foreign body sensation
Odynophagia
Dysphagia
Referred otalgia
Blood-stained saliva
Neck swelling
Voice alteration (late)
Unilateral tonsillar enlargement
Ulcerative lesion
Exophytic mass
Crypt irregularity
Ipsilateral cervical lymphadenopathy
Flexible nasopharyngolaryngoscopy
Contrast-enhanced CT
MRI
PET-CT for staging
Punch biopsy
Tonsillectomy biopsy if occult lesion suspected
p16 immunohistochemistry (surrogate marker)
HPV DNA testing
Depends on stage.
Surgery
Transoral robotic surgery (TORS)
Transoral laser microsurgery
Concurrent chemoradiotherapy
Cisplatin-based chemotherapy
Neck dissection when indicated
HPV-positive tumors have:
Better treatment response
Higher survival rates
Lower recurrence
Improved overall prognosis
Squamous cell carcinoma is the commonest malignant tumor of the palatine tonsil arising from the stratified squamous epithelium.
Tobacco smoking
Alcohol consumption
HPV infection
Poor oral hygiene
Nutritional deficiency
Immunosuppression
Usually arises from:
Tonsillar crypt epithelium
Lateral tonsillar surface
Types:
Ulcerative
Exophytic
Infiltrative
Persistent unilateral sore throat
Dysphagia
Odynophagia
Foreign body sensation
Referred otalgia
Blood-stained saliva
Halitosis
Enlarged cervical lymph node
Fixed neck mass
Bilateral nodes in advanced disease
Trismus
Weight loss
Speech difficulty
Airway obstruction
Cranial nerve involvement
Findings include:
Irregular ulcer
Friable growth
Bleeding on touch
Hard indurated tonsil
Extension to:
Soft palate
Tongue base
Tonsillar pillars
Pharyngeal wall
Complete ENT examination
Flexible endoscopy
Contrast CT
MRI
PET-CT
Biopsy
FNAC of neck node
Uses AJCC TNM staging for oropharyngeal carcinoma.
Separate staging exists for:
HPV-positive SCC
HPV-negative SCC
Surgery
Radiotherapy
Concurrent chemoradiotherapy
Surgery in selected cases
Neck dissection
Salvage surgery
Re-irradiation
Immunotherapy (selected patients)
Depends on:
Tumor stage
HPV status
Nodal metastasis
Surgical margins
Overall patient health
Primary tonsillar lymphoma is a malignant lymphoid neoplasm arising from tonsillar lymphoid tissue.
It is the second most common malignant tumor of the tonsil after SCC.
Examples:
Diffuse large B-cell lymphoma (DLBCL)
Follicular lymphoma
Mantle cell lymphoma
Rare involvement.
Rapid unilateral tonsillar enlargement
Dysphagia
Foreign body sensation
Cervical lymphadenopathy
Fever
Night sweats
Weight loss (B symptoms)
Large smooth tonsil
Non-ulcerated mass
Minimal pain
Multiple enlarged lymph nodes
Biopsy
Immunohistochemistry
PET-CT
Bone marrow biopsy
CBC
LDH
Depends on lymphoma subtype.
May include:
Chemotherapy
Immunotherapy (e.g., Rituximab for CD20-positive B-cell lymphomas)
Radiotherapy
Combined modality treatment
Depends upon:
Histological subtype
Stage
International Prognostic Index (IPI)
Response to therapy
Any patient with the following features requires urgent ENT evaluation and biopsy.
Persistent unilateral tonsillar enlargement
Unilateral tonsillar ulcer
Tonsillar induration
Non-healing ulcer
Recurrent bleeding from tonsil
Persistent sore throat >3 weeks
Progressive dysphagia
Progressive odynophagia
Referred otalgia with normal ear examination
Persistent cervical lymph node
Weight loss
Voice change
Trismus
Blood-stained saliva
Difficulty opening the mouth
Airway compromise
Constitutional symptoms
Any unilateral tonsillar enlargement associated with ipsilateral cervical lymphadenopathy should be considered malignant until proven otherwise.
Certain uncommon inflammatory and infective disorders involve the palatine or lingual tonsils and are clinically important because they may mimic malignancy or chronic tonsillitis.
Lingual tonsillitis is inflammation of the lymphoid tissue located at the base of the tongue (lingual tonsil).
Viral infection
Streptococcal infection
Chronic irritation
Following tonsillectomy (compensatory hypertrophy with secondary infection)
Trauma
Immunocompromised states
Severe sore throat
Odynophagia
Dysphagia
Pain at tongue base
Referred otalgia
Muffled voice
Fever
Tender cervical lymph nodes
Routine oral examination is often normal.
Diagnosis requires:
Indirect laryngoscopy
Flexible fibre-optic laryngoscopy
Findings:
Congested lingual tonsils
Edema
Purulent exudate
Epiglottitis
Tongue base abscess
Vallecular cyst
Malignancy
Glossitis
Antibiotics
NSAIDs
Hydration
Warm saline gargles
Airway monitoring if severe
Enlargement of the lingual tonsils beyond normal size.
Compensatory hypertrophy after palatine tonsillectomy
Chronic infection
GERD/LPR
Allergy
Smoking
Obesity
Chronic irritation
Globus sensation
Chronic cough
Dysphagia
Snoring
Obstructive sleep apnea
Voice change
Difficult intubation
Airway obstruction (rare)
Flexible laryngoscopy
CT or MRI if malignancy suspected
Sleep study if OSA present
Treat reflux
Treat allergy
Antibiotics if infected
Weight reduction
Smoking cessation
Reserved for severe symptoms.
Options include:
Coblation reduction
Laser excision
Radiofrequency ablation
Lingual tonsillectomy
Tuberculosis involving the palatine tonsil due to Mycobacterium tuberculosis.
Usually secondary to pulmonary tuberculosis.
Spread from:
Pulmonary TB
Infected sputum
Occurs without pulmonary disease.
Poor oral hygiene
Immunodeficiency
HIV infection
Malnutrition
Persistent sore throat
Painful swallowing
Tonsillar ulcer
Irregular enlarged tonsil
Cervical lymphadenopathy
Weight loss
Fever
Night sweats
May show:
Ulcer with undermined edges
Granulation tissue
Pale unhealthy tonsil
Enlarged cervical nodes
Chest X-ray
Sputum examination
Mantoux test
IGRA
Biopsy
Ziehl–Neelsen staining
GeneXpert/CBNAAT
Histopathology showing caseating granulomas
Tonsillar carcinoma
Syphilis
Fungal infection
Chronic tonsillitis
Standard anti-tubercular therapy (ATT)
Nutritional support
Management of pulmonary disease
Surgery rarely required
Tonsillar involvement by Treponema pallidum infection.
Tonsillar chancre
Painless ulcer
Firm base
Regional lymphadenopathy
Mucous patches
Bilateral tonsillitis
Generalized lymphadenopathy
Skin rash
Gumma formation
Tissue destruction
Fibrosis
VDRL
RPR
TPHA
FTA-ABS
Dark-field microscopy (selected lesions)
Biopsy if diagnosis uncertain
Benzathine penicillin G (drug of choice)
Doxycycline for penicillin-allergic patients (where appropriate)
Follow-up serology
Various tonsillar disorders occurring in individuals infected with Human Immunodeficiency Virus (HIV).
Recurrent bacterial tonsillitis
Oral candidiasis
Viral infections
Tuberculosis
Persistent lymphoid hyperplasia
Marked tonsillar enlargement
Non-Hodgkin lymphoma
Kaposi sarcoma (rare in tonsil)
HPV-related carcinoma
Recurrent throat infections
Persistent tonsillar enlargement
Oral candidiasis
Fever
Weight loss
Cervical lymphadenopathy
Opportunistic infections
HIV testing (if status unknown and clinically indicated)
CD4 count
HIV viral load
Throat culture
Biopsy of suspicious lesions
Imaging when malignancy is suspected
Appropriate antimicrobial therapy
Antiretroviral therapy (ART)
Treatment of opportunistic infections
Biopsy of persistent unilateral enlargement
Oncological management for associated malignancies
Persistent unilateral tonsillar enlargement, ulceration, unexplained cervical lymphadenopathy, or failure to respond to appropriate medical therapy should always prompt histopathological evaluation to exclude malignancy.
These are the IMPORTANT TABLES (60 GROUPS) to be added in the Pharyngitis and Tonsillitis chapter exactly as per the blueprint.
| Basis | Types |
|---|---|
| Duration | Acute, Chronic |
| Etiology | Infective, Non-infective |
| Infective | Viral, Bacterial, Fungal, Tuberculous, Syphilitic, HIV-associated |
| Non-infective | Allergic, Reflux-related (GERD/LPR), Smoking, Occupational, Irritant-induced |
| Morphology | Catarrhal, Granular, Hypertrophic, Lateral, Atrophic |
| Part | Extent | Important Structures |
|---|---|---|
| Nasopharynx | Base of skull to soft palate | Adenoids, Eustachian tube opening |
| Oropharynx | Soft palate to upper border of epiglottis | Tonsils, Tongue base |
| Hypopharynx | Epiglottis to lower border of cricoid | Pyriform sinus, Postcricoid region |
| Component | Location |
|---|---|
| Pharyngeal tonsil | Roof of nasopharynx |
| Tubal tonsils | Around Eustachian tube |
| Palatine tonsils | Tonsillar fossa |
| Lingual tonsil | Base of tongue |
| Lateral pharyngeal bands | Posterior pharyngeal wall |
| Feature | Viral | Bacterial |
|---|---|---|
| Fever | Mild | High |
| Cough | Common | Usually absent |
| Coryza | Common | Rare |
| Exudate | Minimal | Common |
| Cervical nodes | Mild | Tender anterior nodes |
| Antibiotics | Not required | Required if GAS confirmed/suspected |
| Feature | Streptococcal | Viral |
|---|---|---|
| Fever | High | Mild |
| Cough | Absent | Present |
| Tonsillar exudate | Present | Variable |
| Tender anterior cervical nodes | Present | Mild |
| Rhinorrhea | Rare | Common |
| Conjunctivitis | Rare | Common |
| Parameter | Centor | McIsaac |
|---|---|---|
| Tonsillar exudate | ✓ | ✓ |
| Tender anterior cervical nodes | ✓ | ✓ |
| Fever | ✓ | ✓ |
| Absence of cough | ✓ | ✓ |
| Age adjustment | No | Yes |
| Type | Etiology |
|---|---|
| Viral | Rhinovirus, Adenovirus |
| Streptococcal | Group A Streptococcus |
| Diphtheritic | Corynebacterium diphtheriae |
| Vincent angina | Fusobacterium + Spirochetes |
| Infectious mononucleosis | EBV |
| Fungal | Candida |
| Feature | Diphtheria | Vincent Angina |
|---|---|---|
| Membrane | Thick, adherent | Dirty ulcer |
| Bleeding on removal | Yes | Mild |
| Organism | C. diphtheriae | Fusobacterium + Borrelia |
| Toxicity | Severe | Mild |
| Treatment | DAT + Antibiotics | Penicillin/Metronidazole |
| Feature | IMN | Streptococcal |
|---|---|---|
| Cause | EBV | GAS |
| Hepatosplenomegaly | Common | Rare |
| Generalized nodes | Common | Rare |
| Monospot | Positive | Negative |
| Amoxicillin rash | Characteristic | No |
| Disease | Pharyngeal Manifestation |
|---|---|
| Measles | Koplik spots |
| Scarlet fever | Strawberry tongue |
| HIV | Persistent ulcers |
| Leukemia | Ulcers, bleeding |
| Agranulocytosis | Necrotic pharyngitis |
| Investigation | Purpose |
|---|---|
| Throat swab | Culture |
| RADT | GAS detection |
| CBC | Infection assessment |
| ASO titre | Previous GAS infection |
| Monospot | EBV |
| CRP | Severity |
| Drug | Duration |
|---|---|
| Penicillin V | 10 days |
| Amoxicillin | 10 days |
| Benzathine penicillin | Single IM dose |
| Azithromycin | 5 days |
| Cephalexin | 10 days |
| Clindamycin | 10 days |
| Feature | Carrier | Active Infection |
|---|---|---|
| Symptoms | Absent | Present |
| Culture | Positive | Positive |
| ASO | Normal | Elevated |
| Infectivity | Low | High |
| Antibiotics | Usually not needed | Required |
| Suppurative | Non-suppurative |
|---|---|
| Peritonsillar abscess | Rheumatic fever |
| Otitis media | Acute glomerulonephritis |
| Sinusitis | Reactive arthritis |
| Cervical adenitis | PANDAS |
| Feature | Acute | Chronic |
|---|---|---|
| Onset | Sudden | Gradual |
| Duration | <3 weeks | >3 months |
| Fever | Common | Rare |
| Cause | Infection | Irritation |
| Treatment | Medical | Cause correction |
| Type | Characteristic |
|---|---|
| Catarrhal | Congestion |
| Granular | Lymphoid follicles |
| Hypertrophic | Thick mucosa |
| Lateral | Lateral bands |
| Atrophic | Thin dry mucosa |
| Feature | Catarrhal | Granular | Atrophic |
|---|---|---|---|
| Mucosa | Congested | Granules | Thin |
| Secretion | Increased | Increased | Dry |
| Follicles | No | Prominent | Absent |
| Feature | Granular | Lateral |
|---|---|---|
| Site | Posterior wall | Lateral bands |
| Follicles | Numerous | Lateral ridges |
| Symptoms | FB sensation | Ear pain |
| Feature | Finding |
|---|---|
| Morning symptoms | Common |
| Heartburn | May be absent |
| Hoarseness | Common |
| Laryngoscopy | Posterior laryngitis |
| Treatment | PPIs + lifestyle |
| Organic | Functional |
|---|---|
| GERD | Anxiety |
| Cricopharyngeal spasm | Stress |
| Thyroid disease | Somatization |
| Tumor | Muscle tension |
| Organism | Predisposing Factors | Treatment |
|---|---|---|
| Candida | Diabetes, steroids, HIV | Fluconazole/Nystatin |
| Feature | Finding |
|---|---|
| Ulcer | Undermined |
| Nodes | Cervical |
| Diagnosis | Biopsy, GeneXpert |
| Treatment | ATT |
| Stage | Lesion |
|---|---|
| Primary | Chancre |
| Secondary | Mucous patches |
| Tertiary | Gumma |
| Manifestation | Cause |
|---|---|
| Recurrent pharyngitis | Bacterial |
| Oral candidiasis | Candida |
| Ulcers | Viral |
| Lymphoma | HIV-associated |
| Mechanism | Manifestation |
|---|---|
| Mucosal irritation | Chronic sore throat |
| Dryness | Foreign body sensation |
| Hyperplasia | Chronic cough |
| Occupation | Exposure |
|---|---|
| Teacher | Voice strain |
| Factory worker | Dust |
| Miner | Coal dust |
| Chemical worker | Irritant gases |
| Symptom | Differential Diagnosis |
|---|---|
| Globus | GERD, anxiety |
| Chronic sore throat | Chronic pharyngitis |
| Dysphagia | Malignancy |
| Hoarseness | Laryngitis |
| Local | Systemic |
|---|---|
| Peritonsillitis | Rheumatic fever |
| Abscess | Glomerulonephritis |
| Otitis media | Sepsis |
| Red Flag |
|---|
| Persistent unilateral sore throat |
| Dysphagia |
| Weight loss |
| Neck node |
| Hemoptysis |
| Trismus |
| Referred otalgia |
| Condition | Management |
|---|---|
| Viral | Supportive |
| GAS | Antibiotics |
| Diphtheria | DAT + Antibiotics |
| IMN | Supportive |
| Chronic | Treat underlying cause |
| Feature | Description |
|---|---|
| Location | Tonsillar fossa |
| Capsule | Fibrous |
| Medial surface | Crypts |
| Lateral surface | Capsule over superior constrictor |
| Artery | Origin |
|---|---|
| Tonsillar branch | Facial artery |
| Ascending palatine | Facial artery |
| Ascending pharyngeal | External carotid |
| Dorsal lingual | Lingual artery |
| Greater palatine | Maxillary artery |
| Type | Etiology |
|---|---|
| Viral | Respiratory viruses |
| Bacterial | GAS |
| Membranous | Diphtheria |
| Ulcerative | Vincent |
| Feature | Acute | Chronic |
|---|---|---|
| Fever | High | Usually absent |
| Pain | Severe | Mild |
| Exudate | Common | Crypt debris |
| Duration | Days | Months |
| Type | Feature |
|---|---|
| Follicular | Crypt debris |
| Parenchymatous | Enlarged tonsils |
| Fibroid | Small fibrotic tonsils |
| Cause | Organism |
|---|---|
| Diphtheria | C. diphtheriae |
| IMN | EBV |
| Vincent | Fusobacterium |
| Candida | Candida |
| Feature | Diphtheria | IMN | Vincent |
|---|---|---|---|
| Membrane | Thick | Exudate | Ulcer |
| Fever | High | Moderate | Mild |
| Organism | C. diphtheriae | EBV | Fusobacterium |
| Feature | Description |
|---|---|
| Cause | Retained crypt debris |
| Symptoms | Halitosis |
| Diagnosis | Examination/CT |
| Treatment | Removal |
| Type | Characteristics |
|---|---|
| Retention | Mucous |
| Epidermoid | Keratin-filled |
| Focus | Possible Association* |
|---|---|
| Tonsils | Rheumatic fever |
| Tonsils | Glomerulonephritis |
| Tonsils | Peritonsillar abscess |
*Many historical associations remain controversial.
| Feature | Peritonsillitis | Quinsy |
|---|---|---|
| Pus | No | Present |
| Trismus | Mild | Marked |
| Uvula | Mild deviation | Severe deviation |
| Feature | Peritonsillar | Parapharyngeal |
|---|---|---|
| Site | Around tonsil | Lateral pharynx |
| Trismus | Severe | Severe |
| Neck swelling | Rare | Common |
| Suppurative | Non-suppurative |
|---|---|
| Quinsy | Rheumatic fever |
| Otitis media | APSGN |
| Component | Description |
|---|---|
| P | Periodic fever |
| F | Aphthous ulcers |
| A | Pharyngitis |
| A | Adenitis |
| Feature | Description |
|---|---|
| Organism | Fusobacterium necrophorum |
| Vein | Internal jugular vein thrombosis |
| Complication | Septic emboli |
| Treatment | IV antibiotics ± drainage |
| Grade | Tonsillar Size |
|---|---|
| 0 | Removed |
| 1+ | <25% |
| 2+ | 25–50% |
| 3+ | 50–75% |
| 4+ | >75% ("Kissing tonsils") |
| Cause | Examples |
|---|---|
| Physiological | Childhood |
| Infection | Chronic tonsillitis |
| Allergy | Chronic stimulation |
| Malignancy | Lymphoma, SCC |
| Finding | Significance |
|---|---|
| Snoring | Airway obstruction |
| Apnea | Sleep-disordered breathing |
| Enlarged tonsils | Major pediatric cause |
| Indication | Requirement |
|---|---|
| 1 year | ≥7 episodes |
| 2 years | ≥5/year |
| 3 years | ≥3/year |
| Absolute | Relative |
|---|---|
| OSA | Recurrent tonsillitis |
| Suspected malignancy | Halitosis |
| Peritonsillar abscess (selected cases) | PFAPA |
| Absolute | Relative |
|---|---|
| Uncorrected bleeding disorder | Acute infection |
| Unfit for anesthesia | Poor medical control |
| Assessment | Purpose |
|---|---|
| History | Indications |
| CBC | Baseline |
| Coagulation profile | Bleeding risk (when indicated) |
| Anesthesia evaluation | Fitness |
| Technique | Principle |
|---|---|
| Cold steel | Dissection |
| Electrocautery | Heat |
| Coblation | Plasma |
| Harmonic scalpel | Ultrasonic |
| Laser | Laser energy |
| Feature | Intracapsular | Extracapsular |
|---|---|---|
| Capsule | Preserved | Removed |
| Pain | Less | More |
| Bleeding | Less | More |
| Recurrence | Possible | Rare |
| Feature | Tonsillotomy | Tonsillectomy |
|---|---|---|
| Tissue removal | Partial | Complete |
| Pain | Less | More |
| Recurrence | Higher | Lower |
| Indication | Benefit |
|---|---|
| OSA | Airway improvement |
| Recurrent adenotonsillitis | Infection control |
| Type | Timing |
|---|---|
| Primary | Within 24 hours |
| Secondary | After 24 hours (commonly 5–10 days) |
| Intraoperative | Postoperative |
|---|---|
| Bleeding | Hemorrhage |
| Dental injury | Infection |
| Airway injury | Pain |
| Soft palate trauma | Velopharyngeal insufficiency |
| Benign Causes | Malignant Causes |
|---|---|
| Chronic tonsillitis | SCC |
| Tonsillar cyst | Lymphoma |
| Peritonsillar abscess | HPV-related carcinoma |
| Red Flag |
|---|
| Persistent unilateral tonsillar enlargement |
| Ulcerative tonsillar lesion |
| Induration |
| Referred otalgia |
| Persistent cervical lymphadenopathy |
| Dysphagia/odynophagia |
| Trismus |
| Weight loss |
| Blood-stained saliva |
|
Failure to respond to appropriate medical treatment
|
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