Hypertrophy of Palatine Tonsils: Classification, Diagnosis, Treatment

Hypertrophy of palatine tonsils (HPT) is a transitory condition characterized by an enlargement of the lymphoid tissue of the palatine tonsils, located in the oral cavity between the anterior and posterior palatine arches, without signs of chronic inflammation.

Classification

By degree of tonsillar hypertrophy:

• First-degree hypertrophy;
• Second-degree hypertrophy;
• Third-degree hypertrophy.

By localization of the process:

• Unilateral hypertrophy;
• Bilateral hypertrophy.

Etiology

Hypertrophy of palatine tonsils is one of the most common conditions in preschool and school-age children (about 25 per 1000 children). It can be combined with hypertrophy of the nasopharyngeal tonsil (adenoids), or occur independently. This disease occurs equally in males and females, with the highest peak in children aged 3 years to adolescence, followed by involution of lymphoid tissue (immunity has formed). However, in some individuals, hypertrophy persists throughout life.

This disease is polyetiological; in addition to adaptive causes, it can arise due to allergic disorders (presence of lymphatic-hypoplastic diathesis) and endocrine disorders (adrenal hypofunction). It should be noted that palatine tonsils hypertrophy in response to external irritation by factors such as mucus dripping down the posterior pharyngeal wall from the nasopharynx, constant mouth breathing due to difficult nasal breathing during inflammation of the nasopharyngeal tonsil. Recently, the presence of GERD (gastroesophageal reflux disease) and the irritating effect of hydrochloric acid have been identified as a separate cause.

Tonsils are an organ of the immune system and participate in the local protection of the mucosa of the upper respiratory tract. Transitory hypertrophy is the body’s response to contact with unfamiliar antigens (viruses, bacteria), during which acquired immunity is formed in the lymphoid tissue of the palatine tonsils and IgA and IgG are produced (primary immune response). Upon repeated contact with the same pathogens, T-lymphocytes are produced with the help of already formed immunoglobulins (forming a more powerful secondary immune response). However, due to the immaturity of the immune system, T-lymphocytes are formed incompletely and compensatorily much more of them are produced, resulting in active proliferation of lymphoid tissue.

Anatomy

The degree of hypertrophy of the palatine tonsils depends on their location relative to the pharyngeal lumen – Preobrazhensky B.S. classification:

• I Art. – tonsil tissue occupies less than 1/3 of the distance from the edge of the anterior palatine sulcus to the uvula or midline of the pharynx;
• II st. – The hypertrophied tonsil fills 2/3 of the aforementioned space;
• Grade III – the tonsils reach the uvula of the soft palate, touch each other or overlap.

As noted above, the palatine tonsils may be hypertrophied asymmetrically. The altered tissues are pale pink, loose, bumpy, glossy, heterogeneous, and in some cases have convoluted lacunae.

The tonsils should not be adhered to the palatine arches or be scarred; upon palpation, they are easily dislocated from the palatine niches, and the presence of pathological contents in the lacunae is not characteristic (these signs indicate the presence of chronic inflammation).

Histologically, hyperplastic lymphoid tissue predominates, in which there is an increase in the area of follicles, but plasma cells and macrophages are absent.

Clinical manifestations

The enlargement of pharyngeal and palatine tonsils can be asymptomatic or accompanied by certain patient complaints (in hypertrophy of grades 2-3). Often, the only problem that parents seek help for is the presence of snoring in the child. When collecting the medical history, it is revealed that snoring is constant and does not depend on the sleeping position. Frequent night awakenings occur and, as a result, fatigue and inattentiveness during the day; when combined with adenoid hypertrophy, apnea (breathing stops during sleep) may be noted. In pronounced hypertrophy, choking while eating and a feeling of a lump in the throat are characteristic; it’s as if something is bothering the child. When talking to the child, a nasal speech quality, indistinctness, and dysphonia are noticeable. With high placement of the upper poles of the palatine tonsils and their pronounced hypertrophy, there is a blockage of the opening of the auditory tubes, which is accompanied by congestion in the middle ear cavity and the development of otitis media with effusion, and hearing decreases.

Diagnosis

To diagnose HPT, oropharyngoscopy and anamnesis collection are sufficient; laboratory diagnostics are not performed.

It is necessary to conduct differential diagnosis with pathologies such as chronic tonsillitis, hematopoietic system diseases (leukemia), and neoplasms of the palatine tonsils, especially in cases of unilateral hypertrophy.

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Treatment of Hypertrophied Palatine Tonsils

If indicated, surgical treatment is performed – excision of the palatine tonsils. For preschool children, tonsillotomy is predominantly performed – trimming of hypertrophied areas, while for older individuals, tonsillectomy is performed – removal of all palatine tonsil tissue with the capsule within the tonsillar niches. If indicated, adenotomy (excision of the pharyngeal tonsil) is additionally performed. The main indication for surgical intervention is apnea, recurrent exudative otitis media, and pronounced speech disorders. Surgical intervention is performed electively, under general anesthesia in a hospital setting, in the absence of contraindications (blood clotting disorders, acute inflammatory processes). Conservative treatment is generally ineffective; in some cases, homeopathy, phytotherapy, and physiotherapy are used, however, there is currently no scientific data proving the effectiveness of these treatment methods.