Hypertrophy of the palatine tonsils

Hypertrophy of the palatine tonsils (hypertrophic tonsillitis), like hypertrophy of the pharyngeal tonsil, most often occurs in childhood as a manifestation of the general lymphatic constitution. In most cases, hypertrophied tonsils do not show inflammatory changes.

ICD-10 code

Surgical diseases of tonsils and adenoids.

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

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Epidemiology of hypertrophy of the palatine tonsils

It is observed mainly in early childhood against the background of age-related physiological immunodeficiency.

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Causes of hypertrophy of the palatine tonsils

Hypertrophy of the palatine tonsils is considered an immunoreactin condition, which is one of the manifestations of the mobilization of compensatory capabilities of the lymphoid pharyngeal ring in the process of adaptation of the body to constantly changing living conditions. This is facilitated by constant cooling of the tonsils and the result of mouth breathing in hypertrophy of the adenoids, especially in winter: infected mucus from the nasopharynx has an irritating effect on the palatine tonsils in the case of recurrent adenoiditis. Hyperplasia is facilitated by repeated inflammatory diseases of the nasopharynx and oropharynx, childhood infectious diseases, malnutrition, poor living conditions and other factors that reduce the protective functions of the body. Of known importance are lymphatico-hypoplastic constitutional anomaly, endocrine disorders, especially hypofunction of the adrenal cortex, hypovitaminosis, long-term exposure to low doses of radiation. The basis of hypertrophy of the lymphoid tissue of the tonsils is an increase in the number of lymphoid cells, in particular excessive proliferation of immature T-lymphocytes.

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Pathogenesis of hypertrophy of the palatine tonsils

There are many factors that lead to hypertrophy of the palatine tonsils.

• Children under 3 years of age have T-helper deficiency, which does not allow for adequate differentiation of B-lymphocytes into plasma cells and, accordingly, the production of full-fledged 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. The critical period for the development of a child's immunological reactivity is considered to be the age of 4-6 years, corresponding to the greatest number of preventive vaccinations.
• Hypertrophy of the palatine tonsils is defined as a manifestation of a special immunopathological predisposition of the child's body in the form of lymphatic diathesis (lymphatism), which is based on a hereditary tendency to insufficiency of the lymphoid system.
• True hypertrophy of the lymphoid tissue of the tonsils is considered the main sign of lymphatic diathesis, which causes an increase in the number of lymphatic cells, which differ in their structure and function.
• The main significance in the formation of hypertrophy of the palatine tonsils is given to allergic reactions occurring in the lymphoid tissue of the tonsils, which is confirmed by the detection in the removed fragments of hypertrophied tonsils of a large number of mast cells in various stages of degranulation, plasmatization of lymphoid tissue and large accumulations of eosinophils.

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

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Symptoms of hypertrophy of the palatine tonsils

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

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

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

With severe hypertrophy, the palatine tonsils serve as a significant obstacle to breathing and swallowing, which leads to severe dysphonia, dysphagia and noisy breathing. Speech formation is difficult, nasal and slurred speech, and incorrect pronunciation of some consonants may be pronounced. The development of dysphonia is explained by a change in the shape of the resonating cavities (supplementary tube), as well as limited mobility of the soft palate, especially with intramural hypertrophy of the palatine tonsils, when a significant mass of them is hidden deep in the arches. Characteristic are restless sleep due to hypoxia, snoring during sleep, attacks of obstructive apnea due to relaxation of the pharyngeal muscles, and nocturnal cough. Due to tubal dysfunction, hearing is impaired, and exudative otitis media develops.

Classification of hypertrophy of the palatine tonsils

There are three degrees of hypertrophy of the palatine tonsils. In the first degree of hypertrophy, the palatine tonsils occupy the outer third of the distance from the palatine arch to the midline of the pharynx, in the second degree they occupy 2/3 of this distance, and in the third degree the tonsils touch each other, and sometimes overlap each other.

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

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Screening

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

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Diagnosis of hypertrophy of the palatine tonsils

The anamnesis shows persistent breathing and swallowing problems in the absence of tonsillitis and recurrent respiratory viral infections.

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Physical examination

Ultrasound of the pharynx area.

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Laboratory research

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

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Instrumental research

Pharyngoscopy, rigid endoscopy and fibrosindoscopy.

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Differential diagnostics of hypertrophy of the palatine tonsils

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

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Indications for consultation with other specialists

When preparing for partial tonsillectomy, an examination by a therapist is necessary.

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Indications for hospitalization

No, because tonsillotomy surgery is usually performed on an outpatient basis.

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Non-drug treatment of hypertrophy of the palatine tonsils

UF-tube on tonsils, ozone therapy. Sanatorium and spa treatment - climatotherapy (climatic and balneological mud resorts in the warm season), a combination of local treatment methods for the palatine tonsils with general treatment using natural physical factors of the resort: ultrasound therapy on the projection of the palatine tonsils using the ENT-3 device; vacuum hydrotherapy of the palatine tonsils with mineral species, herbal and animal preparations with antiseptic properties; gargling; irrigation of the tonsils with sea or mineral water; inhalation of carbonated mineral waters, mud solution, phytoncides, sage and chamomile decoctions, vegetable oils; peloidotherapy - mud applications on the submandibular and collar area; electrophoresis of mud solution on the submandibular area; Ultraphonophoresis with mud on the projection of the palatine tonsils, endopharyngeal laser; oxygenation of the pharynx - oxygen cocktails, UHF and microwave on the submandibular lymph nodes.

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Drug treatment of hypertrophy of the palatine tonsils

In mild forms of hypertrophy of the palatine tonsils, astringent and cauterizing agents are used - rinsing with a tannin solution (1:1000). antiseptics, lubrication with a 2-5% solution of silver nitrate. Lymphatic drugs are prescribed internally: umckalor, lymphomyosot, tonsilgon, tonsilotren.

Surgical treatment of hypertrophy of the palatine tonsils

In most cases, the hypertrophied parts of the palatine tonsils are removed simultaneously with the adenoids. Tonsillotomy is performed using a Mathieu tonsillotome.

To remove such tonsils, different methods of mechanical and physical action were developed at different times. The mechanical method of removing a hypertrophied palatine tonsil is tonsillotomy, for which the Mathieu tonsillotome 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 ones for the second and third fingers, the tension of which sets the tonsillotome knife in motion, cutting off the palatine tonsil.

Tonsillotomy with the help of the Mathieu tonsillotome is performed in the following manner. After application anesthesia, one of the clamps with a rack is threaded through a ring-shaped knife and the free part of the tonsil is tightly clamped with it; the ring of the knife is threaded onto the tonsil as deeply as possible and a “harpoon” is stuck into its body, then the tonsil is cut off with a quick movement. If the tonsil is fused with the arches, then they are first separated from the body of the tonsil so that they are not damaged during tonsillotomy, and then proceed as described above. Bleeding during this intervention is insignificant and quickly stops by simply pressing a cotton ball to the wound surface.

French authors came up with a method of biting or cutting out the palatine tonsil, used instead of tonsillotomy when the latter cannot be performed due to the small size of the tonsils, and tonsillectomy is undesirable, for example, in small children. The operation consists of biting out the tonsil in parts with a round conchotome, with special attention paid to removing the upper pole, since it is there, according to many clinicians, that most of the pathological elements are concentrated, forming the basis of a chronic source of infection.

In addition to the above-described methods of tonsillotomy, other methods of destructive treatment of chronic tonsillitis and removal of "excess" tonsil tissue were developed at different times. Thus, at the beginning of the 20th century, the French otolaryngologist E. Escat (1908) developed a method of electrotomy of the palatine tonsils using a heating loop connected to a source of electric current. The loop was put on the body of the tonsil, when the electric current was turned on, it heated up to a red color and by gradually squeezing the tonsil burned it. Later, this method was used in the USA with the only difference 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 burning of the tonsil tissue and its separation from the main mass.

The principle of diathermocoagulation was used to develop deep coagulation of the palatine tonsils over their entire surface. Despite the apparent advantages of this method (bloodlessness, ability to regenerate the remaining lymphoid tissue) over those listed above, it has a number of significant drawbacks: the exact depth of coagulation is never known, it is difficult to dose it, there is a high risk of coagulation of large arteries with subsequent erosive bleeding, it is impossible to radically remove the entire tonsil. Under the cover of coagulated tissue, there always remain "active" lacunae containing microorganisms and the products of their activity. Cysts are formed from the resulting closed lacunar spaces, etc. Cryosurgery of the palatine tonsils, which became quite widespread at the end of the 20th century, is based on the same principle.

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Further management

Oral hygiene, gargling with antiseptics, timely dental sanitation.

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Prevention of hypertrophy of the palatine tonsils

Timely removal of adenoids, after which the irritating effect of infected mucus from the nasopharynx on the palatine tonsils stops in the case of frequently recurring adenoiditis, free nasal breathing and protective mechanisms of the nasal cavity are restored, the child stops breathing through the mouth, the tonsils are not exposed to constant cooling and infection, and sensitization of the body is reduced.

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Forecast

After tonsillotomy, normal breathing, swallowing and the formation of intelligible speech in young children are restored. With moderate hypertrophy of the palatine tonsils, usually over time, after the age of 10, these "physiological hypertrophied tonsils" undergo reverse development. Sometimes this involution is delayed, then even in adults one can observe relatively large tonsils without inflammatory phenomena. If hypertrophy of the tonsils develops as a consequence of repeated inflammatory processes, further development and wrinkling of the connective tissue lead to a decrease and atrophy of the tonsils.

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