Classification of tonsillitis :

1) Acute tonsillitis :

• Acute catarrhal or superficial tonsillitis.
• Acute follicular tonsillitis.
• Acute parenchymatous tonsillitis.
• Acute membranous tonsillitis.

Chronic tonsillitis :

• Chronic follicular tonsillitis.
• Chronic parenchymatous tonsillitis.
• Chronic fibroid tonsillitis.

Aetiology of tonsillitis :

Bacterial causes :

• Streptococcus beta haemolyticus
• Staphylococcus
• Haemophilus influenzae
• Pneumococcus.

Viral causes : 

• Influenza virus
• Para influenza virus
• Adeno virus
• Rhino virus.

Acute tonsillitis:

Definition of acute tonsillitis : It is an acute inflammation of palatine tonsil.

Incidence:

• Acute tonsillitis often affects school-going children, but also affects adults.
• It is rare in infants and in persons who are above 50 years of age.

Symptoms of acute tonsillitis :

1. Sore throat-uneasiness or foreign body sensation during swallowing
2. Difficulty on swallowing
3. Fever
4. Earache
5. Constitutional symptoms:

• Headache
• General body aches.
• Malaise
• Constipation.
• There may be abdominal pain.

Signs of acute tonsillitis :

1. Often the breath is foetid and tongue is coasted.
2. Hypersemia of pillars, soft palate and uvula
3. Tonsils are red and swollen with yellowish spots of purulent material presenting at the opening of crypts (acute follicular tonsillitis) or there may be a whitish membrane on the medial surface of tonsil which can be easily wiped away with a swab (acute membranous tonsillitis).
4. The tonsils may be enlarged and congested so much so that they almost meet in the midline along with some oedema of the uvula and soft palate (acute parenchymatous tonsillitis).
5. Temperature-102°F to 104°F.
6. Enlarged, tender, jugulo-digastric lymph node or tonsillar lymph node.

Investigations of acute tonsillitis :

1. Throat swab for culture & sensitivity.
2. Blood for TC & DC of WBC, ESR.

Treatment acute tonsillitis :

General treatment :

• Bed rest
• Soft diet.
• More fluid intake.
• Warm saline gurgling
• Vitamin C is sometimes helpful.
• Tepid sponging.

Specific treatment :

Systemic antibiotics-Penicillin is the drug of choice.

• Oral Penicillin-V 250 mg every 6 hourly for 5-7 days.
• Amoxicillin 50 mg/kg body weight every 8 hourly for 5-7 days.

Analgesics to relieve pain & antipyretics.

Complications of acute tonsillitis :

1. Chronic tonsillitis with recurrent acute attacks.
2. Peritonsillar abscess.
3. Parapharyngeal & retropharyngeal abscess.
4. Cervical abscess.
5. Acute otitis media.
6. Rheumatic fever.
7. Acute glomerulonephritis.
8. Subacute bacterial endocarditis.

Differential diagnosis of white patch on the tonsillitis:

1. Membranous tonsillitis.
2. Diphtheria.
3. Vincent’s angina.
4. Infectious mononucleosis.
5. Agranulocytosis.
6. Leukaemia.
7. Aphthous ulcers.
8. Malignancy tonsil.
9. Traumatic ulcer.
10. Candidal infection of tonsil.

Chronic Tonsillitis : 

Definition of chronic tonsillitis : It is the chronic inflammation of palatine tonsils where inflammation & repair goes side by side.

Incidence : 

• Chronic parenchymatous tonsillitis: Seen in children & adolescents.
• Chronic follicular & fibrotic tonsillitis: Adults are usually affected.

3 important causes of unilateral tonsillar enlargement:

1. Tonsillitis
2. Peritonsillar abscess
3. Tonsillar neoplasm

Symptoms of Chronic tonsillitis : 

1. Recurrent attacks of sore throat or acute tonsillitis.
2. Chronic irritation in throat with cough.
3. Bad taste in mouth and foul breath (halitosis) due to pus in crypts.
4. Thick speech
5. Difficulty in swallowing.
6. Choking spells at night.

Signs of chronic tonsillitis :

• Tonsils may show varying degree of enlargement.
• There may be yellowish beads of pus on the medial surface of tonsil.
• Tonsils are small but pressure on the anterior pillar expresses frank pus (inspissated pus) or cheesy material.
• Flushing of anterior pillars.
• Non-tender bilateral palpable enlarged jugulo-digastric lymph node.

Investigations of chronic tonsillitis :

• Throat swab for culture & sensitivity.
• Blood for TC & DC of WBC.

Treatment of chronic tonsillitis :

• Conservative treatment : Attention to general health, diet, treatment of coexistent infection of teeth, nose and sinuses.
• Surgical treatment : Tonsillectomy under G/A.

MALIGNANT TUMOURS OF THE TONSIL / CARCINOMA TONSIL

Two malignancies of the palatine tonsil;

• Squamous cell carcinoma.
• Adenocarcinoma.
• Lymphoma.
• Sarcoma.

Malignant tumours of the tonsil:

Introduction of the malignant tumours : Squamous cell carcinoma is the most common & presents as an ulcerated lesion with necrotic base. Adenocarcinoma, lymphoma, sarcoma etc. may also occur. Lymphomas may present a unilateral tonsillar enlargement with or without ulceration & may simulate indolent peritonsillar abscess.

Clinical features of malignant tumour :

1. Average age: 50-60 years.
2. Sore throat.
3. Difficulty in swallowing
4. Pain in the ear.
5. Lump in the neck
6. Speech is altered as the growth involves pillars & tongue.
7. Later, bleeding from the mouth, felor oris & trismus may occur.
8. On examination :

• In early stage there is localized ulcerative lesion on the tonsil with induration.
• The tonsil is mobile in early stage, but gets fixed as the growth spreads to the pillars, tonsillo-lingual sulcus & the tongue.
• Metastasis in the upper deep cervical or jugulodigastric node is common.

Investigations : 

• In early suspected ulcer on the tonsil & in unilateral tonsillar enlargement, whole tonsalis removed (tonsillectomy biopsy) & sent for histopathological examination.
• In advanced stage punch biopsy & histopathology is performed.

Treatment of tumours of the tonsil :

Radiotherapy : Early & radiosensitive tumours are treated by radiotherapy along with irridation of cervical nodes.

Surgery :

• Excision of the tonsil can be done for early superficial lesion.
• Larger lesion & those which invade bone require wide surgical excision with hemimandibulectomy & neck dissection (Commando operation).

Combination therapy :

• Surgery may be combined with pre or post-operative radiation.
• Chemotherapy may be given as an adjunct to surgery or radiation.

Anatomy of the Tonsil

The palatine tonsils : Tonsils are bilateral ovoid mass of lymphoid tissue on the lateral wall of the pharynx occupying the interval between the anterior & posterior pillar of fauces.

Anatomy of the tonsil :

It has

Two surfaces :

1. Medial surface : Lined by the nonkeratinizing stratified squamous epithelium. Openings of 12- 15 crypts can be seen on the medial surface of the tonsil Largest one is called Crypta Magna or intratonsillar cleft.
2. Lateral surface : Lateral surface of the tonsil presents a well-defined fibrous capsule.

Two poles :

1. Upper pole : Related to the soft palate.
2. Lower pole : Related to the base of the tongue. The tonsil is separated from the tongue by a sulcus called tonsillolingual sulcus which may be the seat of carcinoma.

Two borders :

1. Anterior border : Related to the palatoglossal arch with its muscle.
2. Posterior border : Related to the palatopharyngeal arch with its muscle.

Two folds :

1. Plica semilunaris : A triangular vestigial fold of mucous membrane covering the anteroinferion part of the tonsil.
2. Plica triangularis : A similar semilunar fold that may cross the upper part of the tonsil.

Blood supply of the tonsil :

Artery supply :

1). Main source : Tonsillar branch of facial artery

2) Additional sources :

• Ascending palatine branch of facial artery.
• Dorsal lingual branches of the lingual artery.
• Ascending pharyngeal branch of the external carotid artery.
• The greater palatine branch of the maxillary artery.

Venous drainage : Veins from the tonsils drain into paratonsillar vein which joins the common facial vein & pharyngeal venous plexus.

Lymphatic drainage :

• Send efferent vessels to the upper deep cervical group.
• Most of them end in the jugulodigastric lymph node.

Nerve supply : By-

• Lesser palatine branches of sphenopalatine ganglion (CNV).
• Glossopharyngeal nerve.

Formation of tonsillar bed :

• The bed of tonsil is formed from within outwards by
• Pharyngobasilar fascia.
• Superior constrictor & palatopharyngeus muscles.
• Buccopharyngeal fascia
• Lower part of the styloglossus.
• Glossopharyngeal nerve.

Boundaries of tonsillar sings or fossa/peritonsillar space :

In front : Palatoglossal arch containing the corresponding muscle

Behind : Palatopharyngeal arch containing the muscle of the same name.

Apex : By the soft palate where both arches meet.

Base : By the dorsal surface of the posterior one-third of the tongue.

Functions of tonsil : 

They act as sentinels to guard against foreign intruders like viruses, bacteria and other antigens coming into contact through inhalation and ingestion. There are two mechanisms.

• Providing local immunity.
• Providing a surveillance mechanism so that entire body is prepared for defence.