Adenoid Hypertrophy

Adenoid Hypertrophy

• Age Group:
• Affects individuals aged 7-15 years.
• Adenoids normally regress after 15 years.
• Tonsils persist with age.

Presentation:

• Nasal obstruction/Sinusitis.

• Mouth breathing.

• Adenoid facies:
• Pinched-in nose.
• Hitched up upper lip.
• Crowded upper teeth.
• High-arched palate.

• Middle ear disease:
• B/L Serous otitis media/glue ear (most common).
• Acute suppurative otitis media.
• Chronic suppurative otitis media.
• Hearing loss can be present.

• Obstructive sleep apnea (OSA):
• Breathing stops for ≥ 10 seconds during sleep.
• Caused by
• Obstruction from relaxed pharyngeal muscles &
• Tongue falling back.

Diagnosis:

• Postnasal examination

• Endoscopy (invasive)



Grading (by choanal space occupied):

X-ray (investigation of choice in children):

• Lateral view is used.
• Measures airway space between skull base and palate.

Treatment:

• Grade I or II:
• Conservative treatment.

• Grade III or IV with symptoms:
• Surgery (adenoidectomy).

Historical method:

• Cold instruments
• St. Clair Thompson adenoid curette

Current methods:

• Hot instruments
• Coblation, radiofrequency, microdebrider with endoscopy.

Indications for Adenoidectomy:

• Nasal obstruction.

• Sleep apnoea.

• Sinusitis.

• Middle ear disease.

Contraindications for Adenoidectomy:

• Velopharyngeal insufficiency (e.g., in cleft palate).

• Acute adenoiditis.

• Acute URTI

Complications of adenoidectomy

• Hemorrhage (most common)

• Unmasking of velopharyngeal insufficiency

• Hypernasality

Triads

• Gradenigo's Syndrome:
• Petrous apicitis
1. Persistence of ear discharge (after cortical mastoidectomy)
2. Deep seated retro-orbital pain → D/t CN 5
3. Diplegia - Lateral rectus palsy due to CSOM → D/t CN 6
• Mnemonic: Pettennu (Petrositis) Granede (Gradenigo) 5,6 thavana itt → Kannilum cheviyilum kond → Eye pain + ↓ movement - case eduth(CSOM)

• Sampter's triad
• (Mnemonic: AAP): SAM → MAS → AS, AS, NAS
• AS - Asthma
• AS - Aspirin intolerance (& other NSAIDS that block COX1)
• NAS - Nasal polyp (Ethmoidal)

• Trotter's Triad
• Diagnostic of Nasopharyngeal Carcinoma
• NPC
• Temporoparietal neuralgia.
• Palatal paralysis.
• CN 10
• Tensor and Levator Veli Palatini involvement
• Unilateral conductive hearing loss.

---

• CSOM → Lateral sinus thrombophlebitis signs



• Hectic picket fence type
• Intermittent septic emboli enter bloodstream
• Fever + rigors
• Fever does not touch baseline
• Tobey-Ayre's test:
• Compression of IJV on healthy side raises CSF pressure.
• Mnemonic: Tobey has lot of pressure in his head
• Crowe-Beck test:
• Pressure on IJV on healthy side causes engorgement of retinal veins.
• Mnemonic: Crow with red eyes
• Griesinger sign
• Mastoid emissary veins cannot drain
• Edema and bluish discoloration of the mastoid
• Similar to battle sign
• Mnemonic: Blue color grease

---

• Grisel syndrome:
• Seen in Downs
• Non-traumatic inflammatory atlanto-axial subluxation
• Neck stiffness
• Torticollis
• Severe neck pain
• Due to paraspinal spasm from inflammation

Tonsil

I. Embryology & Development

• Origin: 2nd pharyngeal pouch
• Crypta magna
• Largest
• remnant of 2nd pouch

• Present at birth

• Max size by 12 yrs

II. Bed of Tonsil

1. 9th nerve (Glossopharyngeal nerve)
• Injury (Tonsillectomy)
• Referred pain to middle ear
• Supplied by tympanic branch of IXth nerve

2. Peritonsillar space
• Infection (Quinsy) → Displaces tonsil medially

3. External palatine/paratonsillar vein →
• Main source of hemorrhage post tonsillectomy

4. Superior constrictor muscle
• muscular bed
• Forms bed of tonsil

5. Parapharyngeal space
• Divided by styloid process
• Contains styloglossus muscle

III. Arterial Supply (ECA branches)

• Lingual artery → dorsal lingual branches

• Facial artery
• Tonsillar branch (main supply)
• Ascending palatine artery

• Ascending pharyngeal artery → tonsillar branches

• Maxillary artery → descending palatine artery

Clinical Note:

• Ligation of lower pole arterial supply (facial artery branches)
• reduces tonsillectomy hemorrhage

IV. Lymphatic Drainage

• Drains to upper deep cervical lymph nodes

• Mainly to tonsillar (jugulodigastric) node

Tonsillitis

Etiology:

• M/C cause
• Group A Beta Hemolytic Streptococcus
• Possesses cross-reactive antigen
• Leads to immune-mediated complications
• Myocardium
• Myocarditis
• Rheumatic fever
• Glomerulus
• Glomerulonephritis
• Joints
• Polyarthritis

Types:

• Acute: < 4 weeks.

• Chronic: >12 weeks

Acute Tonsillitis

• Acute superficial:
• Infection limited to superficial mucosa.
• Presents only with redness, no enlargement.

• Acute follicular:
• Crypts blocked with pus.
• Whitish yellow dots on tonsil surface.

• Acute membranous:
• Pearly white membrane on tonsils.
• Composed of dead tissues, debris, and bacteria.

• Acute parenchymal:
• Infection reaches parenchyma.
• Tonsils become red and enlarged, may meet in the midline.

Membranous Tonsillitis vs Diphtheria

Feature	Membranous Tonsillitis	Diphtheria
Membrane Type	• True membrane	• Pseudomembrane
Colour	• Pearly white.	• Dirty white/greyish.
Spread	• Limited to the tonsil.	• Spreads to adjacent sites.
Bleeding on Peeling	• Underlying surface will not bleed.	• Will bleed. • Toxic features • Bull neck
Investigation	ㅤ	Throat-swab microscopy • Club shaped gram positive rods.
Complication :	ㅤ	• Respiratory obstruction, ↳ d/t membrane dislodgment. • Myocarditis, arrhythmia • Peripheral neuritis → Palatal palsy

Chronic Tonsillitis

• Chronic follicular:
• Infection in crypts.
• Enlarged tonsils with yellow pus.

• Chronic parenchymatous:
• Infection in parenchyma.
• Tonsils are enlarged.

• Chronic fibroid:
• Fibrosis due to antigen-antibody reaction.
• Tonsil decreases in size, becomes firm.

Irwin Moore test:

• Differentiates chronic fibroid from normal tonsil.

• Pressure on crypts with a probe causes pus to ooze

• Mnemonic: Irukki more and more njekkumbo → more and more Pazhupppu varum

Symptoms

• Fever (can be very high-grade).

• Sore throat.

• Difficulty in swallowing (with drooling).

• Halitosis.

• Earache (referred otalgia via glossopharyngeal nerve).

Tonsillectomy Indications

Absolute indications:

• Malignancy of the tonsil.

• Obstructive sleep apnea (OSA):
• Large tonsils cause oropharyngeal obstruction.
• Can lead to
• Chronic hypoxia
• Pulmonary hypertension
• Right ventricular hypertrophy (RVH)
• Cor pulmonale
• Adenotonsillectomy is the gold standard for children with OSA.

Relative indications:

• Recurrent tonsillitis:
• 7+ episodes in 1 year.
• 5+ episodes in 2 years.
• 3+ episodes in 3 years.

• Chronic tonsillitis.

• Second attack of quinsy/peritonsillar abscess.

• Streptococcal infection (to prevent long-term complications).

• Tonsillitis causing febrile seizures, cardiac disease, and IGA nephropathy.

Non-tonsillar indications:

• Excision of the styloid process (trans oral).

• Glossopharyngeal neuralgia.

• Laser UPPP (uvulopalatopharyngoplasty).
• Done for snoring

Methods of Tonsillectomy

Cold method

• Dissection & snare (most common)

• Microdebrider

Hot method

• Coblation

• Laser

• Cautery

Types of Tonsillectomy

• Extracapsular:
• Tonsil & capsule removed
• Indication: Infectious

• Intracapsular:
• Part of tonsil removed
• Indication: Obstructive
• Preferred in cold (as less post operative pain)

Complications of Tonsillitis

• Streptococcal complications:
• Rheumatic fever.
• Acute glomerulonephritis.
• Subacute bacterial endocarditis.

• Abscesses:
• Peritonsillar abscess.
• Parapharyngeal abscess.
• Retropharyngeal abscess.

Complications of Tonsillectomy

• Primary hemorrhage:
• Occurs during surgery.
• Due to Paratonsillar/peritonsillar vein or tonsillar artery.

• Reactionary hemorrhage:
• Within 24 hours after surgery.
• Due to a slipped ligature.
• Requires immediate re-exploration.

• Secondary hemorrhage:
• Occurs 24 hours to 14 days after surgery.
• Can be secondary to infection.
• Treat with antibiotics first
• re-explore if bleeding persists.

Absolute Contraindications of Tonsillectomy

• Hemoglobin < 10 g%

• Age < 3 years

• Acute upper respiratory tract infection (Including acute tonsillitis)

• Polio epidemic

• Submucous cleft palate

• Bleeding disorders

• During menstruation

Juvenile Nasopharyngeal Angiofibroma and Nasopharyngeal Cancer

Important Information:

• Unilateral serous otitis media in an adult:
• Suspect nasopharyngeal cancer.

• Unilateral serous otitis media in a teenage boy:
• Suspect juvenile nasopharyngeal angiofibroma.

• Most common lymph node in NPC:
• HO's triangle.
• Medial end of clavicle
• Lateral end of clavicle
• Junction of neck with shoulder

Nasopharyngeal Cancer

Etiology:

• Chinese population (genetic susceptibility).
• Guandong cancer

• Common in northeast India.

• Epstein Barr virus.

• Environment: Smoking, nitrosamines.

Serological Markers:

• EBV IgA Viral capsid Antigen (screening).

• EBV IgA early antigen (IgEA) (specific).

Most Common Presentation:

• Orgin from Fossa of Rossenmuller

• M/c Presentation:
• Painless Cervical lymph node enlargement.
• First node affected: retropharyngeal node.

Spread of NPC:

Cranial Nerve Involvement:

• Can involve CN 2, 3, 4, 5, 6, 9, 10, 11.

• Horner's syndrome can occur.

• Jugular foramen syndrome can occur.

Diagnosis:

• Biopsy is primary.

• Often well-differentiated squamous cell carcinoma.

• Poor prognostic variants: verrucous, papillary.

Triads

• Gradenigo's Syndrome:
• Petrous apicitis
1. Persistence of ear discharge (after cortical mastoidectomy)
2. Deep seated retro-orbital pain → D/t CN 5
3. Diplegia - Lateral rectus palsy due to CSOM → D/t CN 6
• Mnemonic: Pettennu (Petrositis) Granede (Gradenigo) 5,6 thavana itt → Kannilum cheviyilum kond → Eye pain + ↓ movement - case eduth(CSOM)

• Sampter's triad
• (Mnemonic: AAP): SAM → MAS → AS, AS, NAS
• AS - Asthma
• AS - Aspirin intolerance (& other NSAIDS that block COX1)
• NAS - Nasal polyp (Ethmoidal)

• Trotter's Triad
• Diagnostic of Nasopharyngeal Carcinoma
• NPC
• Temporoparietal neuralgia.
• Palatal paralysis.
• CN 10
• Tensor and Levator Veli Palatini involvement
• Unilateral conductive hearing loss.

---

• CSOM → Lateral sinus thrombophlebitis signs



• Hectic picket fence type
• Intermittent septic emboli enter bloodstream
• Fever + rigors
• Fever does not touch baseline
• Tobey-Ayre's test:
• Compression of IJV on healthy side raises CSF pressure.
• Mnemonic: Tobey has lot of pressure in his head
• Crowe-Beck test:
• Pressure on IJV on healthy side causes engorgement of retinal veins.
• Mnemonic: Crow with red eyes
• Griesinger sign
• Mastoid emissary veins cannot drain
• Edema and bluish discoloration of the mastoid
• Similar to battle sign
• Mnemonic: Blue color grease

---

• Grisel syndrome:
• Seen in Downs
• Non-traumatic inflammatory atlanto-axial subluxation
• Neck stiffness
• Torticollis
• Severe neck pain
• Due to paraspinal spasm from inflammation

Juvenile Nasopharyngeal Angiofibroma (JNA)

• Nature: Common benign tumor, locally aggressive.

• Vascularity: Extremely vascular

• Origin: Sphenopalatine foramen

• Affects pubertal males; testosterone-dependent.

Symptoms:

• Recurrent unprovoked profuse epistaxis.

• Nasal obstruction.

• Conductive hearing loss with unilateral serous otitis media.

Frog face deformity.

• Widening of nasal bridge

• Swelling of cheek

• Proptosis of eye

• Involvement of CN 2, 3, 4, 5, 6.

Endoscopy:

• Red fleshy mass

Imaging:

Contraindicated Procedures:

• Biopsy, FNAC, probe test, digital palpation.

• D/t to absence of tunica media

Treatment:

• Pre-operative embolization (Internal maxillary artery) → surgery

• If surgery not possible → Anti Androgens → Flutamide

• Radiotherapy: Unresectable (3b) tumour.

Identify the Images

Ranula:

• Cystic swelling, floor of the mouth.

• From sublingual salivary gland.

• Extravasation cyst

• Transillumination test positive.

• Treatment: Excision with sublingual gland.

Retropharyngeal Abscess:

• On X-Ray:
• Pre-vertebral soft tissue shadow is 2x vertebra size.
• Straightening of cervical spine.
• Air bubbles present.
• At C2 > 7mm.

• At C7 > 22mm.

• CT and MRI for confirmation.

Ludwig's Angina:

• Cellulitis of submandibular space.
• Source: Dental/submandibular/sublingual infection.

• Polymicrobial infection.

Criteria

• Cellulitis of the floor of the mouth.
• Serosanguineous fluid.

• Bilateral submandibular swelling.

• Spread via tissue spaces
• not lymphatics

• Sparing of submandibular salivary glands.

Palpation:

• woody hard feeling.

Treatment

• Intubation for impending obstruction

• tracheostomy if tongue has fallen back.

• Incision & drainage : Incision b/w both angles of mandible.

Vincent's angina

• caused by Borrelia Vincenti.

Mylohyoid muscle

• Divides submandibular space into
• sublingual
• submylohyoid.