A 12-year-old boy was admitted to the hospital complaining of a severe sore throat and bilateral earache. He had a history of frequent infections of the palatine tonsils, which had all been treated successfully with antibiotics; however, the infections had become progressively more severe and he had missed a considerable amount of school. This bout of tonsillitis was also treated with antibiotics successfully, but the boy's physician suggested that a tonsillectomy be performed to eliminate the problem once and for all. The boy was readmitted to the hospital for surgery two weeks after his most recent infection had cleared up. The surgery was proceeding well when suddenly there was a massive amount of bleeding. After a short period, the surgeon was able to locate the bleeder and ligate it, following which the wound was closed and the patient's recovery was uneventful.
Questions to consider:
- Where is the palatine tonsil located? The lingual tonsil? The pharyngeal tonsil?
The palatine tonsil is a collection of lymphatic tissue found beneath the mucous membrane between the palatoglossal and palatopharyngeal arches. The lingual and pharyngeal tonsils are also lymphatic tissue; the lingual tonsil is located on the posterior aspect of the tongue and the pharyngeal tonsil, or adenoid, is found on the upper part of the posterior pharyngeal wall.
- What blood vessels are found near the palatine tonsil and may have been responsible for the bleeding?
The palatine tonsil is supplied by five arterial branches: the ascending palatine and tonsillar branches of the facial artery, the palatine branch of the ascending pharyngeal artery, the dorsal lingual branch of the lingual artery, and the descending palatine branch of the maxillary artery. The primary source of hemorrhage, however, is usually the external palatine vein. The internal carotid artery is usually safe during tonsillectomy, but may be damaged if it is located unusually close to the lateral side of the tonsil.
- What nerves are at risk during a tonsillectomy?
The glossopharyngeal nerve accompanies the tonsillar artery on the lateral wall of the pharynx and is particularly vulnerable during a tonsillectomy. In addition, a careless surgeon may damage the lingual nerve, which passes lateral to the pharyngeal wall, just anterior to the tonsil.
- What lymphatic structures are often secondarily affected in tonsillitis?
Tonsillitis of the palatine tonsil may spread to the lingual and pharyngeal tonsils, which are associated in a grouping designated the tonsillar (Waldeyer's) ring. The tonsillar ring is assumed to have protective significance during ingestion. The tonsils drain through the superior deep cervical lymph nodes, and thus these may also be affected. The jugulodigastric (tonsillar) node, into which most tonsillar lymphatic vessels drain, is particularly vulnerable.
- How do you explain the patient's complaint about pain in both ears?
The earache was due to spread of the infection causing swelling of the torus tubarius and subsequent closing of the auditory tube. This forces the tympanic membrane to compensate for pressure changes due to altitude or temperature, which may cause severe pain or even deafness. This condition, as well as otitis media, is commonly associated with infection of the pharyngeal tonsil.
- What is a quinsy?
A quinsy is a peritonsillar abscess in the loose connective tissue outside the capsule of the tonsil. It occurs when microorganisms manage to escape from the capsule and infiltrate the infratonsillar cleft.
References:
Moore, Clinically Oriented Anatomy p. 1158-72; 1194, 1199.
W&B p. 235-41; 280-1.
