Hypertrophy of the tonsils

Hypertrophy of the tonsils (hypertrophic tonsillitis), like hypertrophy of the pharyngeal tonsil, most often occurs in childhood as a manifestation of a common lymphatic constitution. In most cases, there are no inflammatory changes in hypertrophied tonsils.

ICD-10 code

Surgical diseases of the tonsils and adenoids.

• J31.1 Tonsil hypertrophy (enlarged tonsils).
• J35.3 Tonsil hypertrophy with adenoid hypertrophy.
• J35.8 Other chronic diseases of the tonsils and adenoids,
• J35.9 Chronic disease of the tonsils and adenoids, unspecified.

[1], [2], [3]

Epidemiology of hypertrophy of the tonsils

They observe mainly in early childhood against the background of age-related physiological immunodeficiency.

[4], [5], [6], [7], [8], [9], [10], [11]

Causes of hypertrophy of the tonsils

Hypertrophy of the tonsils is considered as an immunoreactin state, which is one of the manifestations of the mobilization of the compensatory capabilities of the lymphoid pharyngeal ring in the process of adaptation of the organism to constantly changing living conditions. This is facilitated by the constant cooling of the tonsils and the result of oral respiration in hypertrophy of the adenoids, especially in winter: an irritating effect on the tonsils is caused by infected mucus from the nasopharynx during the recurrent course of adenoiditis. Hyperplasia contributes to repeated inflammatory diseases of the nasopharynx and oropharynx, children's infectious diseases, malnutrition, poor living conditions and other factors that reduce the protective functions of the body. The lymphatic-hypoplastic anomaly of the constitution, endocrine disorders, especially the hypofunction of the adrenal cortex, hypovitaminosis, prolonged exposure to low doses of radiation are of known importance. The basis of hypertrophy of the lymphoid tissue of the tonsils is an increase in the number of lymphoid cells, in particular, an excessive proliferation of immature T-lymphocytes.

[12], [13], [14], [15]

Pathogenesis of hypertrophy of the tonsils

Note the variety of factors leading to hypertrophy of the tonsils.

• In children under 3 years of age, there is a T-helper deficiency that does not allow for adequate differentiation of B-lymphocytes into plasma cells and, accordingly, the production of high-grade antibodies. Disturbances in the immune system as a result of frequent infectious diseases against the background of physiological immunodeficiency in young children, constant antigenic bacterial and viral stimulation lead to a compensatory increase in lymphoid tissue. A critical period in the development of a child’s immunological reactivity is considered to be 4-6 years old. Corresponding to the largest number of prophylactic vaccinations.
• Hypertrophy of the tonsils is defined as a manifestation of a special immunopathological predisposition of a child’s body in the form of a lymphatic diathesis (lymphatism), which is based on the hereditary tendency to a failure of the lymphoid system.
• True hypertrophy of the lymphoid tissue of the tonsils is considered as the main symptom of lymphatic diathesis, causing an increase in the number of lymphatic cells, which are different in structure and function.
• The main importance in the formation of hypertrophy of the tonsils is given to allergic reactions occurring in the lymphoid tissue of the tonsils, which is confirmed by the discovery in remote fragments of hypertrophied tonsils of a large number of mast cells in various stages of degranulation, plasmaization of lymphoid tissue and large concentrations of eosinophils.

Hypertrophy of the tonsils is a reversible process; in adolescents, the age-related involution of the lymphoid tissue begins.

[16], [17], [18], [19]

Symptoms of hypertrophy of the tonsils

Hypertrophy of the tonsils is often combined with hypertrophy of the entire pharyngeal lymphoid ring, especially with hypertrophy of the pharyngeal tonsil.

Sharply enlarged tonsils look different. They can be on the leg, weakly adjacent to the palatal arches, with a smooth surface, free lacunae. More often enlarged palatine tonsils are dense-elastic consistency; in some cases they are flattened, of a soft consistency, with a developed lower pole, without signs of inflammation and cohesion with the palatine arches, have a pale yellowish or bright pink color, bordered by the palatine arches and a triangular fold from below, the lacunae of the usual structure are not extended.

Histologically determine the prevalence of hyperplasia of lymphoid tissue with an increase in the area of follicles and the number of mitoses in the absence of macrophages and plasma cells.

In severe hypertrophy of the tonsils are a significant obstacle to breathing and swallowing, which leads to severe dysphonia, dysphagia and noisy breathing. The formation of speech is difficult, it is expressed nasalness and illegibility of speech, the incorrect pronunciation of some consonants. The development of dysphonia is explained by a change in the shape of the resonating cavities (extension tube), as well as by limiting the mobility of the soft palate, especially with intramural hypertrophy of the tonsils, when a significant mass of them is hidden in the depths of the arches. Characterized by restless sleep due to hypoxia, snoring in sleep, bouts of obstructive sleep apnea due to the relaxation of the muscles of the pharynx, night cough. Due to tubular dysfunction, hearing is impaired, an exudative otitis media is formed.

Classification of hypertrophy of the tonsils

There are three degrees of hypertrophy of the tonsils. With grade I hypertrophy, the tonsils occupy the outer third of the distance from the palatine arch to the midline of the pharynx, with grade II take 2/3 of this distance and with grade III the tonsils touch each other and sometimes go behind each other

According to the etiopathogenetic trait, three forms of hypertrophy of the tonsils are distinguished: hypertrophic, inflammatory, and hypertrophic-allergic.

[20], [21]

Screening

Examination of the oral cavity during pharyngoscopy at any stage of medical care.

[22], [23], [24]

Diagnosis of hypertrophy of the tonsils

A history of persistent respiratory failure and swallowing in the absence of angina and repeated respiratory viral diseases.

[25], [26]

Physical examination

Ultrasound of the throat area.

[27], [28]

Laboratory research

Determination of the microflora species composition with the study of its sensitivity to the drugs used, clinical blood and urine tests, the study of the acid-base composition of the blood.

[29], [30], [31], [32], [33]

Instrumental studies

Pharyngoscopy, rigid endoscopy and fibrinoscopy.

[34], [35], [36], [37], [38]

Differential diagnosis of hypertrophy of the tonsils

Hypertrophy of the tonsils is possible with tuberculosis, infectious pharyngeal granulomas, tonsil tumors, leukemia and lymphogranulomatosis.

[39], [40], [41]

Indications for consulting other specialists

In preparation for the operation of the partial removal of the tonsils, an examination by a physician is necessary.

[42], [43], [44], [45]

Indications for hospitalization

No, because tonsillotomy surgery is usually performed in an outpatient clinic.

[46], [47], [48], [49], [50], [51]

Non-drug treatment of hypertrophy of the tonsils

KUV-tube on tonsils, ozone therapy. Sanatorium and resort treatment - climatotherapy (climatic and balneological and mud spas in the warm season), a combination of methods for local treatment of the tonsils with general treatment of natural physical factors of the resort: ultrasound therapy on the projection of the tonsils using the LOR-3 apparatus; vacuum hydrotherapy of the tonsils with mineral species, preparations of plant and animal origin with antiseptic properties; gargling; irrigation of the tonsils with sea or mineral water; inhalations with carbonated mineral waters, mud solution, phytoncides, sage broth, chamomile, vegetable oils; pelotherapy - mud applications on the submaxillary and collar area; electrophoresis of mud solution on the submandibular region; ultraphonophoresis with mud on the projection of the tonsils, laser endopharyngeal; pharynx oxygenation - oxygen cocktails, UHF and microwave on the submandibular lymph nodes.

[52], [53], [54], [55]

Drug treatment of hypertrophy of the tonsils

For mild forms of hypertrophy of the tonsils, astringents and cauterizers are used - rinsing with a solution of tannin (1: 1000). Antiseptics, lubrication 2-5% solution of silver nitrate. Inside prescribe lymphotropic drugs: umkalor, lymphoma myosothosis, tonsilgon, tonsilotren.

Surgical treatment of hypertrophy of the tonsils

In most cases, the hypertrophied parts of the tonsils are removed simultaneously with the adenoids. Tonsillotomy is performed with Mathieu tonsillotomy.

To remove these tonsils at different times, they developed various methods of mechanical and physical impact. The mechanical method of removing a hypertrophied palatine tonsil is tonsillotomy, for which Mathieu tonsillotum is used, which is a special device consisting of a ring-shaped knife, a double “harpoon” for fixing the palatine tonsil, one fixed handle for the first finger and two movable for II and III fingers the tension of which drives the knife of the tonsillotome, cutting off the tonsil.

Tonsillotomy with Mathieu Tonsillotomy is performed as follows. After application of anesthesia, any of the clamps with the crest is threaded into the ring-shaped knife and the free part of the tonsil is tightly clamped to them; the knife ring is strung on the amygdala as deep as possible and a “harpoon” is inserted into her body, then the amygdala is cut off with a quick movement. If the amygdala is soldered to the arms, then preseparate them from the body of the amygdala, so that they are not damaged during tonsillotomy, and then proceed as described above. The bleeding during this intervention is insignificant and quickly stops with the usual pressing of a cotton ball to the wound surface.

French authors have come up with a method of lumping or squeezing the tonsils, used instead of tonsillotomy, when the latter cannot be produced due to the small size of the tonsils, and it is undesirable to do tonsillectomy, for example, in young children. The operation consists in the fact that the amygdala is bitten in round pieces with a round conchome, with particular attention being paid to the removal of the upper pole, since it is in it, according to many clinicians, that most of the pathological elements that form the basis of a chronic focus of infection are concentrated.

In addition to the tonsillotomy methods described above, at different times other methods of destructive treatment of chronic tonsillitis and removal of the "extra" tonsil tissue were also developed. So, at the beginning of the XX century. The French otorhinolaryngologist E.Escat (1908) developed an electrotomy procedure for the palatine tonsils using an incandescent loop connected to a source of electrical current. The loop was put on the body of the amygdala, when the electric current was turned on, it heated up to a red color and burned it by gradual squeezing. Later this method was used in the United States with the only difference being that the principle of diathermocoagulation was used as a destructive factor, based on the ability of high-frequency current to heat tissue to a temperature at which irreversible coagulation of proteins occurs. Gradual compression of the loop led to the burning of the tonsil tissue and its separation from the main mass.

The principle of diathermocoagulation was used to develop deep coagulation of the tonsils over its entire surface. Despite the apparent advantages of this method (bloodlessness, ability to regenerate the remaining lymphoid tissue) over the above, it is not deprived of a number of significant drawbacks: the exact depth of coagulation is never known, it is difficult to dose it, the risk of coagulation of large arteries followed by arterial bleeding is high, radically impossible remove the entire amygdala. Under the cover of coagulated tissue, there are always “active” lacunae containing microorganisms and the products of their activity. From the resulting closed lacunar spaces, cysts are formed, etc. The cryosurgery of the palatine tonsils is based on the same principle and received at the end of the 20th century. Fairly widespread.

[56], [57], [58], [59]

Further management

Toilet of the oral cavity, gargling with antiseptic agents, timely sanitation of teeth.

[60], [61],

Prevention of palatine tonsil hypertrophy

Timely removal of the adenoids, after which the irritating effect on the tonsils of the infected mucus from the nasopharynx stops with the often recurring course of adenoiditis, free nasal breathing and the protective mechanisms of the nasal cavity are restored, the child stops breathing through the mouth, the tonsils are not constantly cooled and infected, the sensitization decreases.

[62], [63], [64], [65], [66], [67]

Forecast

After tonsillotomy, normal breathing, swallowing and formation of legible speech in young children are restored. With moderately severe hypertrophy of the tonsils, usually over time, after 10 years of age, these “physiological hypertrophied tonsils undergo a reverse development. Sometimes this involution lingers, then in adults one can observe relatively large tonsils without inflammatory phenomena. If the tonsil hypertrophy develops as a result of repeated inflammatory processes, the further development and contraction of the connective tissue leads to a decrease and atrophy of the tonsils.

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