Tonsillitis, Peritonsillar and Lateral

Pharyngeal Abscesses
Jonathan M. Tagliareni, DDS , Earl I. Clarkson, DDS
Oral Maxillofacial Surg Clin N Am 24 (2012) 197 –204

Irwan Arif M. Dian Andi P.

Adhitya Wicaksana P. Juny Kurnia N.
Ni Luh Yuni S. Ajrina Luthfita B.P.
Ismi Mulyanti P. Agatha Novell H.
Erlynita Mahadevi Fika Amalia

Pembimbing:
dr. Yanuar Iman Santosa, Sp. THT-KL
Peritonsillar Anatomy
 Waldeyer tonsillar ring
(a ring of lymphoid or adenoid tissue around the upper
end of the Pharynx)
consists of

Anterior: lingual tonsils

similar
histology
Lateral: palatine tonsils and
functions
Posterosuperior: pharyngeal tonsils /
adenoids
Palatine Tonsil

the largest accumulation of lymphoid tissue in the Waldeyer ring

It constitutes a compact body with a definite thin capsule on its deep surface.

Palatoglossus muscle anterior pillar

Palatopharyngeal
Tonsillar fossa muscle
posterior pillar

Superior constrictor larger part of the

muscle of the pharynx tonsillar bed
Palatine Tonsil

◦ The muscular wall of tonsillar fossa is thin.

◦ Immediately against it on the outer wall of the pharynx  the glossopharyngeal nerve.

• It can be injured if the tonsillar bed is violated.

• The nerve can temporarily affected by edema after tonsillectomy  transitory loss of taste over
the posterior third of the tongue and referred otalgia.
Palatine Tonsil

Arterial blood supply Venous blood drainage

Lingual &
• Anterior: tonsillar branch of Peritonsillar
pharyngeal
Internal
the dorsal lingual artery pexus jugular vein
veins

• Posterior: ascending Innervation

palatine artery
Tonsillar branches of the glossopharyngeal nerve
(descending branches of the lesser palatine
• tonsillar branch of the facial nerves), which travel through the pterygopalatine
artery (enters the lower
ganglion.
aspect of the tonsillar bed)
 Adenoids
(or Pharyngeal tonsils)
• Surrounding the oropharyngeal isthmus, the adenoid or pharyngeal tonsils
form the central part of the ring of lymphoid tissue.
• Apex  toward the nasal septum
• Base  toward the roof and posterior wall of the nasopharynx
• The adenoid is covered by a pseudostratified ciliated columnar epithelium
that is plicated to form numerous surface folds.
• Fusion of 2 lateral primordia  a midline structure.
• The 2 lateral primordia become visible during early fetal life  fully
developed by the 7th month of gestation  continues to grow until the 5th
year of life (often causing airway obstruction)

It gradually atrophies  the nasopharynx grows  the airway improves

 Adenoids

Arterial blood supply

• Ascending pharyngeal artery

• Ascending palatine artery

Venous blood drainage
• Pharyngeal branch of the maxillary
artery Communicates internal
Pharyngeal
w/ pterygoid jugular &
plexus
plexus facial veins

• Artery of the pterygoid canal

• Contributing branches from the

tonsillar branch of the facial artery
Adenoids

Innervation
Pharyngeal plexus

Efferent lymphatic drainage

Lymph nodes in the
retropharyngeal and
pharyngomaxillary space
Immunology
Of the adenoids and tonsils
 Immunology

• B cells account for 50% to 65% of all tonsillar lymphocytes,

• T cells account for 40% of adenoid and tonsillar lymphocytes,
with 3% mature plasma cells
Conversely, 70% of the lymphocytes in peripheral blood are T cells

• Immunoreactive lymphoid cells of the adenoids and tonsils are found in:
 the reticular cell epithelium,
 the extrafollicular area,
 the mantle zone of the lymphoid follicle, and
 the germinal center of the lymphoid follicle
 Immunology

Adenoids and Tonsils

• They are exposed to airborne antigens  mediate immunologic protection of the upper
aerodigestive tract
• Particularly designed (specifically the tonsils) for direct transport of foreign material from the
exterior to the lymphoid cells

Lymph Nodes
• They depend on antigenic delivery through afferent lymphatics

Tonsillar Crypts
• Stratified squamous epithelium.
• There are 10 - 30 of these crypts in the tonsils.
• Ideally suited for trapping foreign material and transporting it to the lymphoid follicles
Immunology

◦ Intratonsillar defense mechanisms eliminate weak antigenic signals.

◦ Additional higher antigenic concentrations are presented  dose
proliferation of antigen-sensitive B cells occurs in the germinal centers
◦ Low antigen doses affect the differentiation of lymphocytes to plasma
cells.
◦ High antigen doses produce B-cell proliferation.
◦ One of the most essential tonsillar functions : The generation of B cells in
the germinal centers of the tonsils. (Siegel)
 Immunology

The Tonsils
• Immunologically most active between ages 4 and 10 years.
• Involution begins after puberty a decrease of the B-cell population and a relative increase in the
ratio of T to B cells
• Although the overall immunoglobulin-producing function is affected, considerable B-cell activity is still
seen in clinically healthy tonsils even at age 80 years

in disease-associated changes, such as recurrent tonsillitis and adenoid hyperplasia

Immunologically active cells are shredded  replaced subsequently by

stratified squamous epithelium  decreased antigen transport function 
reduced activation of the local B-cell system, decreased antibody production,
and an overall reduction in density of the B-cell and germinal centers in
extrafollicular areas.
Infections
Of the Waldeyer Ring
 Infections

◦ Caused by many organisms including aerobic and anaerobic bacteria,

viruses, yeasts, and parasites

◦ Normal oral pharyngeal flora >>> and external pathogens

◦ These organisms work synergistically  mixed aerobic and anaerobic

infections: antibiotic-degrading enzyme  to protect an organism susceptible
to that agent.

◦ Polymicrobial >>>  difficulties:

◦ to interpret data derived from clinical samples obtained from mucosal
surfaces
◦ to differentiate between organisms that are colonized and those that are
invaders
Viruses

◦ Most frequent cause of tonsillar infection

◦ Viral pharyngitis :
◦ Causes: rhinovirus, influenza virus, parainfluenza virus,
adenovirus, Coxsackie virus, echovirus, reovirus, and respiratory
syncytial virus.
◦ Mild in manifestations
◦ sore throat and dysphagia
◦ fever, erythema of the pharyngeal mucosa, enlarged tonsils (frequently no
exudate)
Viruses

Herpangina (cause: Coxsackie

virus):
◦ small vesicles with erythematous bases that
become ulcers
◦ spread over the anterior tonsillar pillar, palate,
and posterior pharynx
Management algorithms for pediatric pharyngitis
and adenotonsillar disease

Algorithm for evaluation of a patient referred for recurrent sore throat

Algorithm for management of
posttonsillectomy
hemorrhage
Algorithm for evaluation of a
patient referred for
adenotonsillar hypertrophy
 EBV
◦ Mononucleosis syndrome:
◦ general malaise
◦ high fever A differential blood count:
50% lymphocytosis with 10% atypical lymphocytes
◦ large, swollen, gray tonsils
Serologic studies:

• Include monospot and other serum heterophil antibody titer

• Detected by the Paul-Bunnell-Davidsohn or ox-cell hemolysis
• The results may be negative initially  repeat in 1-2 weeks
• Positive result:
60% within the first 2 weeks after onset
90% within 1 month after onset
• As confirmation of acute or convalescent EBV infection
 EBV
Management

Symptomatic

◦ Upper airway obstruction from severely enlarged tonsils: life

threatening  should be managed immediately with:
◦ insertion of a nasopharyngeal airway
◦ short-term high-dose steroid therapy
◦ Severe obstruction: tonsillectomy or tracheotomy may be
indicated
 Streptococcal Acute pharyngitis
Tonsillitis - Pharyngitis  common cause : Group A streptococcus

Acute streptococcal tonsillitis

 peak incidence: 5 – 6 yrs
Manifests as:
Dry throat

Malaise
Examination reveals:
Fever
Erythematous
Dry tongue tonsils
Fullness of the throat
Yellowish white
Enlarged tonsils
Odynophagia spots on the tonsils

Dysphagia

Otalgia
 Streptococcal
Tonsillitis - Pharyngitis
Diagnostic tools

• The clinical manifestations of streptococcal and nonstreptococcal

pharyngitis overlap frequently  microbiologic tests (throat
culture) by swabbing the posterior pharynx and tonsillar areas

• Rapid detection test  diagnose acute GAHBS

• Standard throat culture  if rapid strep test (-) and strong

suspicion
 Streptococcal
Tonsillitis - Pharyngitis
Antibiotics

• Penicillin is the antibiotic of choice  if failed  b-lactamase

inhibitor

• Alternative:
 Clindamycin
 Combination of erythromycin and metronidazole

• Antibiotics given in full 10-day course.

 Streptococcal
Tonsillitis - Pharyngitis
Fig. 3. Pharyngotonsillitis. This common syndrome has several causative pathogens and a
wide spectrum of severity.

(A) The diffuse tonsillar and (B) This intense erythema, (C) This picture of exudative
pharyngeal erythema seen seen in association with tonsillitis is most commonly
here is a nonspecific finding acute tonsillar enlargement seen with either group A
that can be produced by a and palatal petechiae, is streptococcal or EBV
variety of pathogens. highly suggestive of groupA infection.
b-streptococcal infection,
although other pathogens
can produce these
findings.
(From Yellon RF, McBride TP, Davis HW. Otolaryngology. In: Zitelli BJ, Davis HW, editors. Atlas of pediatric physical diagnosis. 4th edition. Philadelphia: Mosby; 2002. p. 852; with permission.)
 Peritonsillar &
Parapharyngeal
Abscess
Tonsillitis
complications

Suppurative Non Suppurative

Peritonsillar and • Scarlet fever

parapharyngeal abscess • Acute rheumatic
development. fever
• Post streptococcal
glomerulonephritis
Peritonsillar
Infections

◦ >>> patient with recurrent tonsilitis or chronic tonsillitis, inadequately

treated

◦ The spread of infection is from the superior pole of the tonsil, with pus formation
between the tonsil bed and the tonsillar capsule

◦ usually unilateral, and the pain is severe

◦ Drooling  caused by odynophagia and dysphagia

◦ Trismus  pterygoid musculature is irritated by pus and inflammation

Peritonsillar
Infections

◦ Gross unilateral swelling of the palate and anterior pillar, with

displacement of the tonsil downward and medially

◦ Cultures of peritonsillar abscess  polymicrobial infection

(aerobic and anaerobic microbes)

◦ Computed tomography (CT) with contrast  indicated to

determine the anatomic borders of the infection

◦ Needle aspiration  used to obtain a test aspirate and identify

the site of the abscess.
 Peritonsillar
Infections
Management of Peritonsillar Abscess

Traditional management:
Incision and drainage with tonsillectomy 4 to 12 weeks later

◦ Consider tonsillectomy when:

◦ incision and drainage or needle aspiration fail to drain an abscess
adequately
◦ patients with a previous history of recurrent peritonsillar abscess or recurrent
severe tonsillitis
◦ Children patients
 Peritonsillar
Infections

Left peritonsillar abscess in an 18 - month-old

child
MRI of the peritonsillar
abscess, showing extension
of the abscess into the
retropharyngeal space
Parapharyngeal
Space Abscess

Infection or pus drains from either the tonsils or from a

peritonsillar abscess through the superior constrictor
muscle

• Located between superior constrictor muscle

and deep cervical fascia  displacement of
tonsil toward the midline
Parapharyngeal Space
• Involvement of the adjacent pterygoid and
Abscess parasponal muscle  trismus & stiff neck
• Thick overlying sternocleidomastoideus 
Fluctuance is difficult to be detected
 Parapharyngeal
Space Abscess
Parapharyngeal Space Infection

• Fever, leukocytosis and pain

• The abscess may spread down the carotid sheath into

mediastinum

• Usually polymicrobial and reflect oropharyngeal flora.

• IO :
 Swelling of the lateral pharyngeal wall  behind posterior
tonsillar pillar
 Anteromedial tonsil displacement
 Parapharyngeal
Space Abscess
Parapharyngeal Space Infection
 Parapharyngeal
Space Abscess
Lateral Parapharyngeal Space Infection – Management

• Aggressive antibiotic therapy

• Fluid replacement

• Close observation

• Surgical Intervention
 IO approaches  confined to management of peritonsillar abscess
 EO approaches
 Parapharyngeal
Space Abscess
Parapharyngeal Abscess – External Approach

• Transverse submandibular excision approximately 2 cm inferior to the

mandibular margin, which extends from the anterior limits of the
submandibular gland just past the angle of the mandible.

• The submandibular gland is freed inferiorly and posteriorly by sharp, blunt

dissection, and access to the space is achieved by dissection between
the tail of the submandibular gland and the anterior aspect of the
sternocleidomastoid muscle.
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