Tonsillitis & Adenoid Hypertrophy
ENT · Throat & Larynx · lean revision notes
Tonsillitis & Adenoid Hypertrophy
A perennial ENT favourite for NEET PG, this topic bundles together acute and chronic tonsillar disease, adenoid hypertrophy with its classic facies, the surgical indications (Paradise criteria), and the must-know post-tonsillectomy haemorrhage spotters. Master the quinsy distinction and the primary-versus-secondary bleed timing and you have banked most of the easy marks here.
Waldeyer's ring — the anatomical frame
The lymphoid tissue guarding the entrance to the aerodigestive tract is arranged as Waldeyer's ring. Knowing its components prevents confusion between tonsil and adenoid disease.
| Component | Location | Epithelium | Crypts? |
|---|---|---|---|
| Palatine tonsils ("the tonsils") | Between anterior (palatoglossus) & posterior (palatopharyngeus) pillars | Stratified squamous | Deep branching crypts (12–15) |
| Adenoids (nasopharyngeal/Luschka's tonsil) | Roof & posterior wall of nasopharynx | Ciliated pseudostratified columnar | No true crypts; folds only |
| Lingual tonsil | Base of tongue | Stratified squamous | Shallow crypts |
| Tubal tonsils (Gerlach) | Around Eustachian tube opening | — | — |
High-yield: The palatine tonsil's arterial supply comes mainly from the tonsillar branch of the facial artery; other contributors are ascending pharyngeal, ascending palatine, dorsal lingual, and descending palatine arteries. The paratonsillar vein (external palatine vein) is the chief source of primary reactionary haemorrhage after tonsillectomy.
High-yield: The tonsil's lower pole is the commonest bleeding site; the gritty white spots on the surface are crypt debris, not pus.
The adenoid has no capsule and tends to atrophy after the age of ~10–12 years (maximal size 3–7 years), explaining why adenoid symptoms are a childhood problem and the tissue rarely needs surgery in adults. The palatine tonsil has a fibrous capsule on its deep (lateral) surface, which is the surgical plane of dissection.
Acute tonsillitis
Classification
Acute inflammation of the palatine tonsils is described morphologically:
- Acute catarrhal/superficial — part of a generalised pharyngitis, usually viral.
- Acute follicular — purulent material at the crypt mouths, giving yellow "follicles" (classic bacterial picture).
- Acute parenchymatous — uniform tonsillar enlargement, tonsil looks red and swollen.
- Acute membranous — coalescence of follicular exudate into a membrane over the tonsil.
Etiology
- Viral (most cases overall): adenovirus, rhinovirus, EBV (infectious mononucleosis), coxsackie (herpangina).
- Bacterial: Group A beta-haemolytic Streptococcus (GABHS, Streptococcus pyogenes) is the single most important pathogen — the one to treat to prevent sequelae. Also Staphylococcus, Haemophilus, pneumococcus.
High-yield: Group A Streptococcus is the organism that matters for NEET — it underlies follicular tonsillitis and its non-suppurative complications (rheumatic fever, post-streptococcal glomerulonephritis).
Clinical features
- Sore throat, odynophagia, referred otalgia (via glossopharyngeal nerve, CN IX — same nerve supplies tonsil and middle ear), fever, malaise.
- Examination: enlarged, congested tonsils with yellow follicles; tender, enlarged jugulodigastric (tonsillar) lymph node at the angle of the mandible.
- Foul breath, thick voice ("hot potato voice" if marked oedema).
High-yield: Referred otalgia in tonsillitis is via the tympanic branch of CN IX (Jacobson's nerve).
The Centor / McIsaac criteria
Used to estimate the probability of GABHS and the need for antibiotics. One point each:
| Centor criterion | Note |
|---|---|
| Tonsillar exudates | white/yellow |
| Tender anterior cervical Lymphadenopathy | |
| Fever (history >38°C) | |
| Absence of cough | viral clue if cough present |
| McIsaac modification: age 3–14 yrs (+1); 15–44 (0); ≥45 (−1) | adjusts for age |
Mnemonic for Centor: "FLAT" — Fever, Lymphadenopathy, tonsillar Absence-of-cough... think Can't breathe Easily. Score ≥3 → consider throat swab / empirical antibiotics.
Diagnosis & investigation of choice
- Throat swab culture is the gold standard for confirming GABHS.
- Rapid Antigen Detection Test (RADT) — quick, high specificity; a negative in children should be backed by culture.
- ASO titre is not for acute diagnosis; it documents recent strep infection (relevant to rheumatic fever workup).
- Peripheral smear / Monospot (heterophile antibody) if infectious mononucleosis is suspected — atypical lymphocytes, hepatosplenomegaly, marked cervical nodes.
High-yield: Never give ampicillin/amoxicillin empirically when mononucleosis is possible — it precipitates a florid maculopapular rash in ~90% of EBV cases.
Management / drug of choice
- Penicillin V (oral) or a single IM benzathine penicillin is the drug of choice for GABHS — a full 10-day course is needed to eradicate the organism and prevent rheumatic fever.
- Penicillin-allergic: erythromycin / azithromycin (macrolide).
- Supportive: paracetamol for fever/pain, warm saline gargles, hydration, rest.
Flow of acute tonsillitis decision-making: Sore throat → assess Centor/McIsaac → score low → symptomatic care; score high → throat swab / RADT → GABHS positive → penicillin × 10 days → resolution → if recurrent attacks meet Paradise criteria → tonsillectomy.
Chronic tonsillitis
Repeated acute attacks lead to fibrosis and crypt obstruction. Types: chronic follicular (crypts full of debris/cheesy material), chronic parenchymatous (lymphoid hyperplasia, large tonsils causing dysphagia/snoring), and chronic fibroid (small fibrosed tonsils).
Signs include persistent tonsillar enlargement, expression of pus/debris on pressing the anterior pillar, congestion of anterior pillars (Irwin Moore sign), and persistent jugulodigastric nodes.
High-yield: A tonsillolith (tonsil stone) is concretion of inspissated crypt debris in chronic follicular tonsillitis — a classic cause of halitosis and foreign-body sensation.
Adenoid hypertrophy
Pathophysiology
Physiological enlargement of nasopharyngeal lymphoid tissue, exaggerated by recurrent upper-respiratory infections and allergy. The enlarged adenoid obstructs the posterior choanae and the Eustachian tube orifice, producing the two great consequences: nasal obstruction → mouth breathing and Eustachian dysfunction → otitis media with effusion (glue ear) → conductive hearing loss.
Adenoid facies
Chronic mouth breathing in a growing child remodels the face:
- Open mouth, pinched nose / hypoplastic nasal alae
- High-arched palate, crowded teeth, prominent (protruding) upper incisors
- Dull, expressionless face; shortened upper lip
- Hitched-up nostrils
High-yield: Adenoid facies = elongated face + open mouth + high-arched palate + prominent incisors, from long-standing mouth breathing.
Consequences of mouth breathing / adenoid disease
- Nasal: chronic rhinosinusitis, nasal twang/rhinolalia clausa (hyponasal speech), nasal discharge.
- Aural: recurrent acute otitis media and otitis media with effusion (glue ear) → conductive deafness, delayed speech.
- Respiratory/sleep: snoring, obstructive sleep apnoea (OSA); severe long-standing cases → pulmonary hypertension and cor pulmonale.
- General: aprosexia (poor concentration), failure to thrive.
Investigation of choice
- Soft-tissue lateral neck/nasopharynx X-ray classically demonstrates the adenoid shadow and post-nasal airway narrowing.
- Flexible nasopharyngoscopy / posterior rhinoscopy gives direct visualisation (the modern preferred method).
- Tympanometry/audiometry to document associated glue ear.
High-yield: Lateral soft-tissue X-ray nasopharynx is the traditional "investigation of choice" for adenoid size, but endoscopy is the current gold standard for direct assessment.
Surgery: indications and the Paradise criteria
Tonsillectomy — indications
Absolute:
- Recurrent throat infections meeting Paradise frequency criteria
- Suspected malignancy / unilateral enlargement (asymmetry → exclude lymphoma)
- Obstructive sleep apnoea / sleep-disordered breathing due to tonsillar hypertrophy
- Recurrent / chronic quinsy (peritonsillar abscess)
- Tonsillitis causing febrile convulsions
Relative: diphtheria carrier, chronic tonsillitis unresponsive to treatment, halitosis from tonsilloliths.
Paradise criteria (frequency threshold for tonsillectomy)
Sore throats severe enough to count, each documented with ≥1 of: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GABHS culture.
| Time frame | Number of qualifying episodes |
|---|---|
| In 1 year | ≥7 episodes |
| In each of 2 years | ≥5 episodes per year |
| In each of 3 years | ≥3 episodes per year |
High-yield: Remember Paradise as "7-5-3" → 7 in one year, 5/year for two years, 3/year for three years.
Contraindications to tonsillectomy
- Active local infection / acute tonsillitis (operate after the acute episode settles — wait ~3 weeks)
- Bleeding diatheses / haematological disorders (haemophilia, leukaemia, purpura)
- Uncontrolled systemic disease, during epidemics of polio
- Cleft palate / submucous cleft — adenoidectomy especially risks velopharyngeal incompetence
Adenoidectomy — indications
- Adenoid hypertrophy causing nasal obstruction, OSA, or adenoid facies
- Recurrent otitis media with effusion (often combined with grommet insertion)
- Recurrent rhinosinusitis refractory to medical therapy
- Often performed with tonsillectomy ("adenotonsillectomy") in children.
High-yield: Adenoidectomy is contraindicated in cleft palate / submucous cleft because removing the adenoidal pad unmasks velopharyngeal insufficiency (hypernasal speech, nasal regurgitation).
Methods
- Tonsillectomy: dissection & snare method (Eve's/guillotine is historical), coblation, bipolar diathermy, laser, harmonic scalpel.
- Adenoidectomy: St Clair Thomson adenoid curette (with a guard), or endoscopic microdebrider/coblation under direct vision.
Complications of tonsillectomy — the haemorrhage spotters
This is the single most examined sub-topic. Distinguish primary, reactionary, and secondary bleeds by timing and cause.
| Type | Timing | Cause | Management |
|---|---|---|---|
| Primary | During surgery (intra-operative) | Slipped ligature / inadequate haemostasis | Ligate/cauterise vessel intra-op |
| Reactionary (primary reactionary) | Within first 24 hours (usually 4–8 h) | Rise in BP after recovery, slipped clot, paratonsillar vein | Often return to theatre; remove clot, ligate, may need to re-explore the fossa |
| Secondary | 5th–10th day (most common ~day 6–7) | Infection / sloughing of the healing fossa | Antibiotics, sedation, observation; rarely surgery — usually self-limiting |
High-yield: Reactionary haemorrhage occurs within 24 h; secondary haemorrhage occurs on the 5th–10th day and is due to infection. This timing pairing is asked almost every year.
High-yield: The commonest immediate complication of tonsillectomy is haemorrhage; the commonest source of reactionary bleed is the paratonsillar (external palatine) vein.
Other complications:
- Injury to glossopharyngeal nerve → altered/loss of taste posterior tongue, transient.
- Damage to internal carotid artery (lies ~2.5 cm posterolateral to tonsil; risk in medially placed/aberrant ICA).
- Pain and referred otalgia, dehydration, post-tonsillectomy infection.
- Atlantoaxial subluxation (Grisel syndrome) and eustachian tube/temporomandibular issues are rare.
Adenoidectomy complications: haemorrhage, injury to Eustachian tube opening, velopharyngeal insufficiency (esp. occult cleft), nasopharyngeal stenosis, recurrence (regrowth of adenoid tissue).
Quinsy (peritonsillar abscess) — the must-distinguish entity
A collection of pus in the peritonsillar space, between the tonsillar capsule and the superior constrictor muscle, superolateral to the upper pole of the tonsil. It is a complication of acute tonsillitis (often after inadequately treated infection).
Features distinguishing quinsy from tonsillitis
| Feature | Acute tonsillitis | Quinsy (peritonsillar abscess) |
|---|---|---|
| Laterality | Bilateral | Unilateral |
| Trismus | Absent/mild | Marked trismus (pterygoid spasm) |
| Uvula | Central | Pushed to opposite side |
| Soft palate | Symmetrical | Bulging, displaced medially, fullness above tonsil |
| Voice | Thick | "Hot potato"/muffled voice |
| Drooling | Minimal | Drooling of saliva |
| Tonsil | Both enlarged | Pushed down & medial |
High-yield: Trismus + unilateral bulge above the tonsil + uvular deviation + hot-potato voice = quinsy. Trismus is due to spasm/irritation of the medial pterygoid muscle.
Management of quinsy
Flow: Diagnose clinically → needle aspiration / incision & drainage at the point of maximal bulge (junction of upper and middle thirds — Kelly's point) → start IV antibiotics (penicillin + metronidazole) for anaerobic cover → analgesia/hydration → interval tonsillectomy ("quinsy/à chaud tonsillectomy" or interval) after 4–6 weeks because recurrence risk is high.
High-yield: Drainage point of quinsy = just lateral to the point where a horizontal line through the base of the uvula meets a vertical line through the anterior pillar (commonly described as upper-pole / Kelly's point). Beware the internal carotid posterolaterally — incise no deeper than ~1 cm.
Key differentials
- Diphtheria — grey, adherent pseudomembrane that bleeds on removal, extends beyond tonsil, bull-neck, systemic toxaemia; Corynebacterium diphtheriae.
- Infectious mononucleosis — membranous tonsillitis, generalised lymphadenopathy, hepatosplenomegaly, atypical lymphocytes; avoid ampicillin.
- Vincent's angina — fusospirochaetal, unilateral ulcer/membrane, foul odour, gingivitis.
- Agranulocytosis / leukaemic infiltration — necrotic ulcerative tonsillitis with low/abnormal counts.
- Candidiasis — white plaques, immunocompromised/post-antibiotic.
- Tonsillar malignancy (SCC, lymphoma) — unilateral enlargement/ulcer in an adult; biopsy mandatory.
- Retropharyngeal / parapharyngeal abscess — for the deep-neck-space differential of quinsy.
High-yield: Unilateral tonsillar enlargement in an adult is malignancy until proven otherwise — send for histopathology.
Recently asked / exam angle
- Timing of secondary haemorrhage after tonsillectomy (answer: 5th–10th day, due to infection) — repeatedly tested image/one-liner.
- Source of reactionary haemorrhage → paratonsillar vein.
- Paradise criteria numbers (7-5-3) for recurrent tonsillitis tonsillectomy.
- Drug to avoid in suspected mononucleosis → ampicillin/amoxicillin (rash).
- Adenoidectomy contraindicated in cleft palate → velopharyngeal insufficiency.
- Quinsy vs tonsillitis — trismus and uvular deviation as the discriminators; drainage site; interval tonsillectomy.
- Referred otalgia nerve in tonsil pathology → glossopharyngeal (CN IX), Jacobson's branch.
- Investigation of choice for adenoids → lateral soft-tissue X-ray nasopharynx / endoscopy.
- Main arterial supply of palatine tonsil → tonsillar branch of facial artery.
- Centor/McIsaac scoring for antibiotic decision in pharyngitis.
Rapid revision
- Waldeyer's ring = palatine + adenoid (Luschka) + lingual + tubal tonsils; adenoids have no capsule and no true crypts.
- GABHS (S. pyogenes) is the key pathogen; treat 10 days of penicillin to prevent rheumatic fever.
- Centor ≥3 → swab/treat; McIsaac adds age weighting.
- Tonsil arterial supply mainly tonsillar branch of facial artery; lower pole bleeds most.
- Referred ear pain in tonsillitis is via CN IX.
- Paradise criteria = 7 (1 yr) / 5 each × 2 yr / 3 each × 3 yr for tonsillectomy.
- Adenoid facies = open mouth, pinched nose, high-arched palate, prominent incisors; adenoids regress after ~10 yrs.
- Adenoid hypertrophy → glue ear, conductive deafness, OSA, cor pulmonale.
- Adenoidectomy contraindicated in cleft/submucous cleft palate (velopharyngeal insufficiency).
- Reactionary haemorrhage <24 h (slipped clot/vein); secondary haemorrhage day 5–10 (infection → antibiotics).
- Quinsy = unilateral, trismus, uvula deviated, hot-potato voice; drain + penicillin + metronidazole + interval tonsillectomy.
- Avoid ampicillin in mononucleosis; unilateral adult tonsil mass = biopsy for malignancy.