Tonsils and Adenoid Disease Referral Guidelines

Diagnosis/Definition

• Palatine tonsils are paired lymphatic structures located in the oropharynx and have a physiologic role in antigen processing and immune surveillance.
• The adenoid pad is a midline structure in the nasopharynx similar to the tonsils in function and histology.
• Pathology of the tonsils and adenoid most commonly involves infection and/or hyperplasia.

Initial Diagnosis and Management

• Infections: Patients will typically present with severe throat pain, fever, and sometimes headache. The physical exam will show enlarged/swollen tonsils with purulence on them. The step test may or may not be positive.
• Hypertrophy: The most common problem associated with tonsil/adenoid hypertrophy is obstruction – specifically obstructive sleep apnea (see separate section on sleep apnea). Sometimes children will present with difficulty swallowing solid food and adults may present with halitosis or frequent debris on the tonsils (tonsiliths).
• Ancillary Tests:
  ◦Throat culture
  ◦Monospot as appropriate
  ◦CBC
  ◦X-ray of adenoid bed as appropriate (lateral soft tissue of the neck)

• Initial Management for Tonsilitis: The initial management of adenotonsillitis is the institution of appropriate medical therapy. This includes adequate hydration and pain relief as well as antibiotic coverage if indicated.
• If a peritonsillar abscess is suspected, referral to ENT by contacting the ENT Clinic during duty hours or the ENT resident on call after duty hours.
• Initial Management for Hypertrophy producing obstruction: no medical treatment has been shown to be of lasting benefit in treating tonsillar enlargement. For enlarged adenoids only, topical steroid sprays may be beneficial in mild cases. For cases where obstructive sleep apnea is suspected, overnight sleep study may be necessary to further evaluate the patients (see separate section on sleep apnea)

Indications for Specialty Care Referral

• Recurrent infection: three or more infections of tonsils and/or adenoids per year that produce significant quality of life impairment despite adequate therapy
• Suspicion of peri-tonsillar abscess, neck abscess, or retropharyngeal abscess
• Hypertrophy causing upper airway obstruction or severe dysphagia
• Hypertrophy causing dental malocclusion or adversely affecting oro-facial growth documented by orthodontist.
• Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy.
• Chronic adenotonsillitis not responding to beta-lactamase resistant antibiotics.
• Unilateral tonsillar hypertrophy.
• Any other symptom or clinical findings that are of concern by the referring provider.