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The tonsil and adenoid problem
T H E T O N S I L AND A D E N O I D P R O B L E M THE
SYSTEMIC I N F L U E N C E
OF U P P E R
I%ESPIRATORY IN F EC TIO N
GEOI~GE MORRISON COATES, M.D., AND WILI~IAM GORDON, M.D. PHILADELPIKIA~ P A .
T E R E S T in this subject has been recently revived by a n u m b e r of I Nexcellent symposiums conducted here and abroad. In 1931 J. M. Le M6e, oi' Paris, presented his v e r y thorough study of this question, and in 1933, under the auspices of such distingiushed laryngologists as H e r b e r t Tilley, J. A. Glover, Dan McKenzie, and others, the Fellowship of Medicine in London took up certain phases of this subject in the form of a " d e b a t e . " It was discussed in great detail by Lee W. Dean at the 1934 meeting of the American Medical Association, by Kaiser, Nissen and 1Kosher at the recent American Academy meeting in Chicago, by the writers in May, 1934, a t a symposium before the Philadelphia County Medical Society, and by the American A c a d e m y of Pediatrics, Region II, at San Antonio, Texas, Nov. 14, ]934, Mitchell, Dean, Shea, MeCul]och, and 1KcLaurin participating. Many years ago J o h n Nolan MacKenzie, of Baltimore, startled the profession with his " M a s s a c r e of the Tonsils," while the L o n d o n thesis was " t h a t operations for removal of tonsils are too often p e r f o r m e d without adequate cause." In order to discuss these questions in a logical and rational manner, let us review v e r y briefly the clinical anatomy, histopathology, and clinical pathology of the lymphoid structures in the p h a r y n x in general, and the tonsils and adenoids in particular. Following this, we shall discuss the physiology and function of these structures, the relationship of tonsillar sepsis to oro'anic disease elsewhere, and what constitutes a p r o p e r diagnosis of tonsillar infection. Finally, the entire theme will conclude with a few concepts, which, it is hoped, will lead to a closer understanding, and therefore a fuller cooperation, between the internist, pediatrician, and the o tolaryngologist. The fauci~fl tonsils, two in number, consist in the main of a fibrous capsule from which trabeeulae pass into the p a r e n e h y m a of tile tonsil. These trabeeulae c a r r y blood vessels, nerves, and efferent lymphatics, i.e., lympimtie channels away from the tonsil, there being no afferent lymphatics. The p a r e n c h y m a of the tonsil consists of the germinating follicles and the interfol]icular tissue, all of which are located between R e a d before the combined m e e t i n g of t h e Section on Otolaryngoto~-~W of the College of P h y s i c i a n s of P h i l a d e l p h i a and t he P h i l a d e l p h i a I~'ediatric Society, Dec. 11, 1934. 70
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the trabeculae. The free surface of the tonsil presents i n g r o w t h s of surface epithelium of the stratified squamous type. The epithelium dips in to f o r m the crypts. L y m p h o i d cells infiltrate the c r y p t a l epithelium to such an extent t h a t there m a y be, and u s u a l l y are, two or three layers of epithelium s e p a r a t i n g the lumen of the c r y p t f r o m the tonsil p a r e n c h y m a . Grossly the faucial, or palatine, tonsils are two m o r e or less almondshaped masses of adenoid tissue placed one on each side of the orop h a r y n x and b e t w e e n the pillars of the fauces. I n childhood t h e y are more globular but recede as age advances. On the free or mesial surface, there are present a n u m b e r of pits or c r y p t s v a r y i n g in depth f r o m 1 ram. to 1 cm. or even more, the l a r g e r crypts" often e x p a n d i n g below the orifice so t h a t r e t e n t i o n of l a r g e quantities of secretion or d~bris can t a k e place. N o t i n f r e q u e n t l y the mouths of these c r y p t s become sealed b y reason of acute or chronic inflammation, and the sac then has no outlet a n d m a y t a k e on some of the characteristics of an acute or chronic abscess. No mucus glands open into the bottoms of these crypts. The c r y p t s of the lingual tonsil are short a n d wide, and their openings are funnel shaped. T h e y do not easily h a r b o r dSbris, as p o i n t e d out b y Dean. The p h a r y n g e a l tonsil, or adenoid, often spoken of as the t h i r d or L u s e h k a ' s tonsil, occupies the v a u l t of the p h a r y n x , at times almost completely filling this cavity. W i t h the g r o w t h of the individual, the t e n d e n c y of the adenoid to a t r o p h y is more m a r k e d t h a n in the case of the faucial tonsil, and, indeed, it is c o m p a r a t i v e l y r a r e to find any g r e a t a m o u n t r e m a i n i n g a f t e r adolescence. The adenoid is a ]obulated o r g a n h a v i n g a succession of grooves and ridges r a n g i n g in n u m b e r f r o m three to five. While focal infection is often a t t r i b u t e d to the faucial tonsils, the adenoid as a focus is commonly overlooked, although it m a y be the true source of the disease. This is because the adenoid is out of sight behind the velum of the palate and because, in adults, it is assumed t h a t it has u n d e r g o n e atrophy. D e a n tells us t h a t the p h a r y n g e a l tonsil and the i n f r a t o n s i l l a r nodules, i. e., the lymphoid structures at the base of the tongue in the l a r y n g o p h a r y n x , contain c r y p t s which become m o r e r e a d i l y i m p a c t e d with d~bris t h a n those of the lingual tonsils and less easily i m p a c t e d t h a n those of the faucial tonsils. Histopathologic e x a m i n a t i o n of these s t r u c t u r e s presents a v a r i e t y of cellular elements, n o t a b l y p l a s m a cells, eosinophiles, and p o l y n u c l e a r leucocytes in the tonsillar p a r e n e h y m a and in the crypts. So m u c h for the anatomic a n d histopathologic considerations. The physiology and function of the tonsils and l y m p h o i d s t r u c t u r e s in the p h a r y n x has long been a moot question. Some physiologists
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and pathologists say that the tonsils possess a defensive mechanism against r e s p i r a t o r y infection though clinicians on a series of controlled studies were unable to confirm this. Many believe that the eytogenic function of the tonsil is the most plausible one. This t h e o r y suggests that the healthy tonsil helps to confer immunity by protecting against b a c t e r i a l invasion. N i e r o a n a t o m i e studies in the l a b o r a t o r y have shown t h a t white corpuscles can migrate from the lymphoid tissue of the tonsils into the crypts between the stratified squamous epithelium, gMning entrance into the p h a r y n x where t h e y destroy microorganisms. Pilot, Davis, and others are not in accord with this idea. Though m a n y m a y differ in minor details r e g a r d i n g the probable method of how tonsils help in immunity, almost everyone who has given careful s t u d y to this subject agrees in principle that the healthy tonsil does help in immunity, p a r t i c u l a r l y during the early years of life, and that u n d e r six years of age it has a protective function. It is then the first line of defense, while the cervical glands are the second line of defense. Histologically lymphoeytes m a y be observed migrating' t h r o u g h the e r y p t a l epithelium into the crypts, r e t u r n i n g into the lymph nodules where the baeteria are destr9yed. It has been t a u g h t for a good m a n y years that the crypts are virtual test tubes where microorganisms multiply and elaborate toxins. These toxins are absorbed with resultant autoimmunization. W a l d a p f e l believes t h e y are concerned in filtering out. particulate m a t t e r from the blood stream. It has been shown that they produce lymphocytes, that t h e y react against stimulants, bacteria, and any toxin which may penet r a t e into the lymphoid tissue. It is k n o w n that t h e y develop a f t e r birth and continue to function but should involute at puberty. Hormone production, internal secretions, digestive ferments, blood forming, and protection for the lower r e s p i r a t o r y t r a c t are among some of the functions ascribed to these structures b y many, though some of these theories have more adherents than others. In connection with the foregoing it is well to state at this point that we f u l l y appreciate the fact t h a t a healthy tonsil does have one or more functions and t h a t these are most active during the early years of life. Our n e x t consideration will be as to what constitutes a p r o p e r diagnosis of tonsillar infection. This is obtained by a careful history and examination of the lymphoid elements in the p h a r y n x . The h i s t e r y of local tonsillar inflammation, acute or chronic, regardless of the organisms present, or repeated attacks of tonsillitis ( H a j e k ' s dictum) is absolute evidence of tonsiltar infection. One or more attacks of quinsy, repeated coryzas beginning with sore throat, soreness and discomfort in the tonsillar region, enlargement or tenderness of the node at the angle of the jaw (G. B. W o o d ) , cervical a d e n o p a t h y otherwise unaeeou~Jtable, c a t a r r h a l or suppurative otitis media, rheu-
COATES AND GORDON:
TONSIL AND ADENOID PROBLE1V[
~3
marie or arthritic manifestations, endoearditis, nephritis, pyelitis, lower r e s p i r a t o r y infection, ocular infections, or other distant symptoms require a most careful investigation of the lymphoid structures in the p h a r y n x . Simple inspection of the fauces will usually fail to determine with any accuracy w h e t h e r or not a tonsil is infected, and it may be stated hero t h a t an absolutely negative r e p o r t is n e v e r possible until the tonsil has been removed and studied histologically and bacteriologically. Small, sealed crypts deep in the tonsil substance are not uncommon and are often impossible of detection even with the transillumination method of Freneh. A careful inspection of the fauces wilt often reveal a purplish red tinge limited to the anterior pillar which is supposed to have some pathologic significance, especially where the infecting organism is a streptococcus. Often masses of cheesy dgbris m a y be observed filling the crypts if the a n t e r i o r pillar is w i t h d r a w n by a pillar retractor. If, in addition, pressure is made external to the meridian of the tonsil, cheesy masses or liquid grayish or yellowish pus or mueopus will flow from one or more crypts, the superior ones in the u p p e r pole being those in which this secretion is most apt to accumulate. Adenoid examination is less f r e q u e n t l y made, but where undertaken, after removal, the presence of large numbers of polynuclear leucocytes is r e p o r t e d b y the pathologist. As long as the body resistance and the immunologic powers of the individual are able to cope with the bacteria and their toxins elaborated in the crypts and the p a r e n e h y m a of the lymphoid structures, no deleterious systemic lesions are produced. As soon as these vital powers are diminished, however, the bacteria and their toxins are enabled to attack i m p o r t a n t organs and may set np irreparable patho]ogic changes. The toxins may enter tile p a r e n c h y m a from the crypts and either be absorbed b y the venous capillaries or be removed b y the efferent lymphatics. Soluble toxins m a y be absorbed directly from the tonsil into the blood stream, thus accounting for the early intoxication in acute tonsillitis. Infection m a y also spread along the perivaseular lymph spaces, sometimes c o n t r a r y to the direction of the blood stream (Dean). I t is not generally appr6ciated t h a t the adenoid m a y have just as serious focal possibilities as the tonsils, teeth, or sinuses. Bacterial multiplication readily takes place in the deep crypts, in which, after removal, pus is often noted. F r o m this source infection m a y travel down the n a s o p h a r y n x to the o r o p h a r y n x and l a r y n g o p h a r y n x and to the traeheobronehia] tree. Cultures t a k e n from the crypts of adenoid masses show growth in 100 per cent of cases. The adenoid, in simple h y p e r t r o p h y , is of greater significance than the tonsil because of its location, for it m a y impair nasal respiration.
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It m a y not be amiss, at this point, to outline v e r y briefly some of the conclusions of the Le ~VI~e s t u d y conducted a few years ago, reference to which has been made at the beginning of this paper. J. ~ . Le M4e sent out a questionnaire on this subject to clinicians all over the world. The r e f e r e n d u m was not addressed to a n y p a r t i c u l a r group but to internists, pediatricians, orthopedic a n d general surgeons, opthalmologists, otolaryngologists, and pathologists. N e a r l y e v e r y medical center in the world was represented. The replies of the respondents, several h u n d r e d in number, c a r e f u l l y tabulated and p r i n t e d in book form, are of interest as presenting a cross-section of world opinion. H e r e are a few of the most apropos questions and a s u m m a r y of the answers to them. Question: "D o you believe t h a t the tonsils may constitute a portal of e n t r y and a focus for secondary i n f e c t i o n s ? " Affirmative answers were almost unanimous. Question: " W h a t place do you assign to the tonsils among generally accepted foei, namely, the teeth, ears, gallbladder, and prostate.~'" Answer : In f o u r classes : Class I (60 per cent of the replies) assigned first place to the tonsils. Class I I (18 per cent) assigned second place to the tonsils, giving first place to the teeth. Class I I I (12 per cent) held t h a t the tonsils shared equally with other foci. Class IV (10 per cent) assigned first place to the tonsils in children and first place to the teeth in adults. Question: "Relation between the tonsils and various forms of rheumatism (acute, chronic, and deformans)?'~ A n s w e r : I. Affirmative replies, 90 per cent. A. Almost unanimous for acute rheumatism. B. F o r a relation to chronic rheumatic infections, 45 per cent. I m p r o v e m e n t here is v e r y f r e q u e n t a f t e r tonsillectomy. C. Rheuraatism (arthritis) deformans, 5 per cent. Tonsillectomy is almost n e v e r followed b y improvement. II. Doubtful, 10 per cent. To the question, " O n what signs do you base y o u r opinion t h a t the tonsils are septic and m a y be a cause of s e c o n d a r y infection?"' the collective answer is as follows: 1. Escape of pus from the crypts spontaneously or a f t e r pressure on the anterior pillar (50 per cent of the replies). 2. Repeated exacerbations of acute tonsillitis or peritonsillar abscess (65 per cent). 3. Congestion of the anterior pillars (50 per cent). 4:. Cervical adenopas (40 per cent). 5. Presence or r e t e n t i o n of caseous m a t t e r (20 per cent). In the opinion of those who gave this answer the caseum unaccompanied b y pus suffices to characterize the tonsil as a " b a d " or " r e s p o n s i b l e " one.
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6. Buried, small, or " a d h e r e n t " tonsils (20 per cent). (George B. Wood protests against the term " a d h e r e n t . " W h a t is meant is that b y the deposit of fibrous tissue a r o u n d the capsule, due to chronic or repeated acute infections, the tonsil is more or less immobilized and can be dislocated from its fossa with great difficulty.) The buried, small, or adherent tonsil is p a r t i e u l a r l y suspected b y English and American writers. 7. Simple tonsillar h y p e r t r o p h y with enlargement of the cryptal orifices and eventually the presence of small ulcero-congestive lesions at their borders (10 per cent). 8. Bacterial examination (5 per cent), especially if streptococcus is recovered. J u d s o n Daland has often spoken and w r i t t e n advocating this method of diagnosis, ttis dependence is placed upon the type of organism recovered and the n u m b e r of colonies produced. To make a diagnosis of tonsi]lar infection, then, we must make use of all the above mentioned points, but the clinical evidence should always be studied in its possible relationship to the h i s t o r y before the tonsil is c o n d e m n e d - - t h a t is, if we wish to be conservative, as, we believe, we should. That the tonsils often act as portals of e n t r y f o r infection manifested in other parts of the body is generally aecepted, as well as t h a t chronic disease of the tonsils m a y be a p r i m a r y eause of infectious processes of foeM origin elsewhere in the body. It is often overlooked t h a t the infected tonsil m a y be only one of several such agencies, although perhaps the p r i m a r y one. P e m b e r t 0 n called attention to the f a c t that even though focal infection was responsible for m a n y kinds of disease, m a n y individuals get well even in the presence of surgical foci of ~nfection. This led to a series of detailed studies that were v e r y revealing. Metabolic studies, glucose tolerance tests, blood chemistry, blood gas studies, studies of the blood vascular system, blood flow, sweat, body mechanics, and elimination were undertaken. He believed t h a t each ease had to be studied t h o r o u g h l y and that there existed no panacea for rheumatism. His conclusion was that, in addition to the removal of loci of infection, all measures calculated to normalize metabolism, to promote blood flow, to dilate the peripheral vessels, to minimize toxemias, to lessen the b o d y load, and to promote elimination should be used in a p r o p e r l y studied and t r e a t e d ease. While the tonsils m a y be p r o v e d to be, beyond question, infected, we are unable thus far to say with c e r t a i n t y w h e t h e r or not t h e y are the absolute, or primary, cause of the systemic disease in any given case. There m a y be multiple causes present, and t h e y should all be dealt with as t h o r o u g h l y as possible. The infected tonsil m a y cause or p e r p e t u a t e a n o t h e r focus which m a y be directly responsible, as for example one in the gastrointestinM tract. Other foei of infee~ion,
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therefore, should not be overlooked when considering a tonsillectomy because of a diagnosis of septic tonsils. Sueh feel m a y well be in the teeth, sinuses, possibly the ears, gallbladder, gastrointestinal tract, and prostate. However that may be, whether tile tonsils and adenoids are responsible, in whole or in p a r t f o r the systemic infection, or w h e t h e r t h e y have no relationship to it w h a t s o e v e r ; once the f a c t t h a t t h e y are definitely infected is established, t h e y should be removed. We do not wish to go on record as believing t h a t e v e r y tonsil is infected, but we eannot with a n y assurance say t h a t a given tonsil is not infected unless t h a t tonsiI is r e m o v e d and subjected to a careful bacteriologic and pathologic examination. H o w often have we rem o v e d a fairly innocuous a p p e a r i n g tonsil, only to see it gush pus f r o m e v e r y c r y p t w h e n squeezed b y the snare or guillotine? To cert i f y t h a t a n y given tonsil is definitely not a focus is to court diagnostic disaster. F r o m a conservative s t a n d p o i n t , before tonsillectomy is p e r f o r m e d , in consideration of systemic infection, it m u s t be decided w h e t h e r the tonsillar infection is p r o b a b l y a c t u a l l y eausing d a m a g e or is likely to cause it in the future. R e g a r d i n g p r o p h y l a x i s , there is g r e a t divergenee of opinion. Kaiser, in a t e n - y e a r s t u d y of the school ehildren of Rochester, N. Y., seems to. show statistically t h a t prophylactic tonsillectomy did not m a k e f o r g r e a t i m m u n i t y to r e c u r r e n t infections of the u p p e r respirat o r y tract, to aeute contagious disease or to r h e u m a t i s m , and indeed, t h a t lower r e s p i r a t o r y infections occurred with g r e a t e r f r e q u e n c y in. tonsilleetomized children t h a n in those in w h o m the tonsils were not removed. The studies of H o r a c e Williams in the P h i l a d e l p h i a Hospital for Co.ntagious Diseases, o.ver a similar period, showed r a t h e r conelusively t h a t the children in this hospital who h a d middle ear supp u r a t i o n and its complications were almost all not tonsilleetomized. Dean, in c o m m e n t i n g on K a i s e r ' s r e p o r t of the increased incidence of laryngitis, bronchitis, and p n e u m o n i a in tonsilleetomized ehildren, believes t h a t this is due to the f a c t t h a t at the time of the tonsil operation, nasal sinusitis was present and t h a t this nasal sinusitis is responsible f o r the p u h n o n a r y disease. F u r t h e r , he believes t h a t most of the nasal sinus conditions can be controlled b y dietetic and hygienic treatm e n t following the tonsil a n d adenoid operation. D a n MeKenzie doubts the value of statistics used to disprove the efficacy of a w e l l - p e r f o r m e d tonsil operation a n d asks w h e t h e r the figures are reliable, w h e t h e r in fact, in those eases in which focal disease has developed a f t e r tonsillectomy, we h a v e a n y statistics to p r o v e t h a t the tonsils w e r e eompletely removed, or w h e t h e r the ade-
COATES AND (~OI~DON :
'I'ONSIL A N D ADENOID PROBLEM:
~
noids were not alone r e m o v e d in some eases, and w h e t h e r a recurrenee of this l y m p h o i d tissue was exeluded b y competent examination. I-t~erbert Tilley deprecates the wholesale r e m o v a l of the tonsils as a p r o p h y l a c t i c m e a s u r e but believes t h a t a definite septic tonsil should be removed. His m e t h o d of diagnosis of a septic tonsil is substantially as outlined above, and above all he urges a careful s t u d y of the whole physical condition of the patient. The diagnosis of tonsillar sepsis in relation to focal infection requires the most cooperative study. I f it is a question of middle ear or sinus disease, the o t o l a r y n g o l o g i s t m a y well decide upon the p r o p e r procedure. When, however, the ease is one of arthritis, let us say, other problems arise, and tile ease should have the most careful s t u d y by .all the physicians associated with the case. I t will not do for the laryngologist who finds the infected tonsils to order i m m e d i a t e rem o v a l on the chance t h a t t h e y are the sole, or even the main cause, of the arthritis. Other loci m u s t be sought, or causes other t h a n infection, and the diagnosis of tonsil infection as the etiologic f a c t o r in the case m u s t be a r r i v e d at b y general consultation and consideration of all the evidence. P e m b e r t o n has b r o u g h t this out v e r y clearly, and he n e v e r allows a tonsillectomy, or a n y other surgical r e m o v a l of a focus of infection, not only until the p a t i e n t has been t h o r o u g h l y studied, b u t also until he has been p u t in such. physical condition that the operation will, at least, do no h a r m . Kaiser well says t h a t the reaction agaiIlst indiscriminate tonsillect o m y followed the less striking beneficial results when the tonsils were r e m o v e d for v a g u e indications, while statistical a n d clinical s t u d y justifies enthusiasm for this p r o c e d u r e in p r o p e r l y selected children. Nissen, in his v e r y excellent p r e s e n t a t i o n of the subject, insists that a f t e r infection in the tonsils is determined, the s t u d y must be extended to all other p a r t s of the b o d y to d e m o n s t r a t e systemic disorder. Depending on the type of case, this m a y necessitate a p p r o p r i a t e blood and urine studies, metabolic and endocrine tests, careful investigation of the cardiovascular system, r e s p i r a t o r y tract, neurologie, gastrointestinal, k i d n e y function, bones, joints, b o d y mechanics, etc. I f then, the systemic disorder is discovered, the relationship between t h tonsillar infection and the systemic disorder must be proved. This will require close clinical observation b y the physician and f r e q u e n t r e p o r t s of subjective s y m p t o m s b y the p a t i e n t over a considerable period of time. F r o m the l a r y n g o l o g i c s t a n d p o i n t alone, certain principles t h a t were w r i t t e n elsewhere m a y be emphasized here. E v e r y p a r t of the p h a r y n x a n d fauces should be examined with care. I t is not enough to k n o w t h a t a tonsil operation has been p e r f o r m e d . The fossae m u s t be examined for stumps, tags, regrowths, small crypts concealed behind the
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pillars or beneath scar tissue, eompsensatory hypertrophies of the lateral pharyngeal folds, and isolated lymphatic masses in the posterior pharyngeal wall, infected adenoid remnants, infected lymphoid structures at the base of the tongue (the infratonsillar nodules in the laryngopharynx), whose importance has been emphasized by French, as well as for the gravitation of infected secretions from an infection of the posterior series of sinuses or an extension of an inflamed mucosa. CONCLUSIONS
1. The ultimate diagnosis of infection of the tonsils, adenoids, and the other lymphoid structures of the pharynx rests with the laryngologist. 2. By painstaking examination, either the presence or probable absence of sepsis will, therefore, be determined. 3. I f infection is demonstrated, then a prophylactic clean-up of the lymphoid elements of the pharynx may give striking results. 4. No tonsil and adenoid operation should ever be performed after a hasty and inadequate examination. 5. When a septic tonsiI is discovered in association with some systemic disorder, the diagnosis of tonsillar infection as the cause of this disorder can only be satisfactorily arrived at after meticulous study and consultation, often repeated if necessary, on the part of the laryngologist with the attending" pediatrician, internist, or surgeon.
SYSTEMIC I N F L U E N C E
OF U P P E R
I%ESPIRATORY IN F EC TIO N
GEOI~GE MORRISON COATES, M.D., AND WILI~IAM GORDON, M.D. PHILADELPIKIA~ P A .
T E R E S T in this subject has been recently revived by a n u m b e r of I Nexcellent symposiums conducted here and abroad. In 1931 J. M. Le M6e, oi' Paris, presented his v e r y thorough study of this question, and in 1933, under the auspices of such distingiushed laryngologists as H e r b e r t Tilley, J. A. Glover, Dan McKenzie, and others, the Fellowship of Medicine in London took up certain phases of this subject in the form of a " d e b a t e . " It was discussed in great detail by Lee W. Dean at the 1934 meeting of the American Medical Association, by Kaiser, Nissen and 1Kosher at the recent American Academy meeting in Chicago, by the writers in May, 1934, a t a symposium before the Philadelphia County Medical Society, and by the American A c a d e m y of Pediatrics, Region II, at San Antonio, Texas, Nov. 14, ]934, Mitchell, Dean, Shea, MeCul]och, and 1KcLaurin participating. Many years ago J o h n Nolan MacKenzie, of Baltimore, startled the profession with his " M a s s a c r e of the Tonsils," while the L o n d o n thesis was " t h a t operations for removal of tonsils are too often p e r f o r m e d without adequate cause." In order to discuss these questions in a logical and rational manner, let us review v e r y briefly the clinical anatomy, histopathology, and clinical pathology of the lymphoid structures in the p h a r y n x in general, and the tonsils and adenoids in particular. Following this, we shall discuss the physiology and function of these structures, the relationship of tonsillar sepsis to oro'anic disease elsewhere, and what constitutes a p r o p e r diagnosis of tonsillar infection. Finally, the entire theme will conclude with a few concepts, which, it is hoped, will lead to a closer understanding, and therefore a fuller cooperation, between the internist, pediatrician, and the o tolaryngologist. The fauci~fl tonsils, two in number, consist in the main of a fibrous capsule from which trabeeulae pass into the p a r e n e h y m a of tile tonsil. These trabeeulae c a r r y blood vessels, nerves, and efferent lymphatics, i.e., lympimtie channels away from the tonsil, there being no afferent lymphatics. The p a r e n c h y m a of the tonsil consists of the germinating follicles and the interfol]icular tissue, all of which are located between R e a d before the combined m e e t i n g of t h e Section on Otolaryngoto~-~W of the College of P h y s i c i a n s of P h i l a d e l p h i a and t he P h i l a d e l p h i a I~'ediatric Society, Dec. 11, 1934. 70
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the trabeculae. The free surface of the tonsil presents i n g r o w t h s of surface epithelium of the stratified squamous type. The epithelium dips in to f o r m the crypts. L y m p h o i d cells infiltrate the c r y p t a l epithelium to such an extent t h a t there m a y be, and u s u a l l y are, two or three layers of epithelium s e p a r a t i n g the lumen of the c r y p t f r o m the tonsil p a r e n c h y m a . Grossly the faucial, or palatine, tonsils are two m o r e or less almondshaped masses of adenoid tissue placed one on each side of the orop h a r y n x and b e t w e e n the pillars of the fauces. I n childhood t h e y are more globular but recede as age advances. On the free or mesial surface, there are present a n u m b e r of pits or c r y p t s v a r y i n g in depth f r o m 1 ram. to 1 cm. or even more, the l a r g e r crypts" often e x p a n d i n g below the orifice so t h a t r e t e n t i o n of l a r g e quantities of secretion or d~bris can t a k e place. N o t i n f r e q u e n t l y the mouths of these c r y p t s become sealed b y reason of acute or chronic inflammation, and the sac then has no outlet a n d m a y t a k e on some of the characteristics of an acute or chronic abscess. No mucus glands open into the bottoms of these crypts. The c r y p t s of the lingual tonsil are short a n d wide, and their openings are funnel shaped. T h e y do not easily h a r b o r dSbris, as p o i n t e d out b y Dean. The p h a r y n g e a l tonsil, or adenoid, often spoken of as the t h i r d or L u s e h k a ' s tonsil, occupies the v a u l t of the p h a r y n x , at times almost completely filling this cavity. W i t h the g r o w t h of the individual, the t e n d e n c y of the adenoid to a t r o p h y is more m a r k e d t h a n in the case of the faucial tonsil, and, indeed, it is c o m p a r a t i v e l y r a r e to find any g r e a t a m o u n t r e m a i n i n g a f t e r adolescence. The adenoid is a ]obulated o r g a n h a v i n g a succession of grooves and ridges r a n g i n g in n u m b e r f r o m three to five. While focal infection is often a t t r i b u t e d to the faucial tonsils, the adenoid as a focus is commonly overlooked, although it m a y be the true source of the disease. This is because the adenoid is out of sight behind the velum of the palate and because, in adults, it is assumed t h a t it has u n d e r g o n e atrophy. D e a n tells us t h a t the p h a r y n g e a l tonsil and the i n f r a t o n s i l l a r nodules, i. e., the lymphoid structures at the base of the tongue in the l a r y n g o p h a r y n x , contain c r y p t s which become m o r e r e a d i l y i m p a c t e d with d~bris t h a n those of the lingual tonsils and less easily i m p a c t e d t h a n those of the faucial tonsils. Histopathologic e x a m i n a t i o n of these s t r u c t u r e s presents a v a r i e t y of cellular elements, n o t a b l y p l a s m a cells, eosinophiles, and p o l y n u c l e a r leucocytes in the tonsillar p a r e n e h y m a and in the crypts. So m u c h for the anatomic a n d histopathologic considerations. The physiology and function of the tonsils and l y m p h o i d s t r u c t u r e s in the p h a r y n x has long been a moot question. Some physiologists
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and pathologists say that the tonsils possess a defensive mechanism against r e s p i r a t o r y infection though clinicians on a series of controlled studies were unable to confirm this. Many believe that the eytogenic function of the tonsil is the most plausible one. This t h e o r y suggests that the healthy tonsil helps to confer immunity by protecting against b a c t e r i a l invasion. N i e r o a n a t o m i e studies in the l a b o r a t o r y have shown t h a t white corpuscles can migrate from the lymphoid tissue of the tonsils into the crypts between the stratified squamous epithelium, gMning entrance into the p h a r y n x where t h e y destroy microorganisms. Pilot, Davis, and others are not in accord with this idea. Though m a n y m a y differ in minor details r e g a r d i n g the probable method of how tonsils help in immunity, almost everyone who has given careful s t u d y to this subject agrees in principle that the healthy tonsil does help in immunity, p a r t i c u l a r l y during the early years of life, and that u n d e r six years of age it has a protective function. It is then the first line of defense, while the cervical glands are the second line of defense. Histologically lymphoeytes m a y be observed migrating' t h r o u g h the e r y p t a l epithelium into the crypts, r e t u r n i n g into the lymph nodules where the baeteria are destr9yed. It has been t a u g h t for a good m a n y years that the crypts are virtual test tubes where microorganisms multiply and elaborate toxins. These toxins are absorbed with resultant autoimmunization. W a l d a p f e l believes t h e y are concerned in filtering out. particulate m a t t e r from the blood stream. It has been shown that they produce lymphocytes, that t h e y react against stimulants, bacteria, and any toxin which may penet r a t e into the lymphoid tissue. It is k n o w n that t h e y develop a f t e r birth and continue to function but should involute at puberty. Hormone production, internal secretions, digestive ferments, blood forming, and protection for the lower r e s p i r a t o r y t r a c t are among some of the functions ascribed to these structures b y many, though some of these theories have more adherents than others. In connection with the foregoing it is well to state at this point that we f u l l y appreciate the fact t h a t a healthy tonsil does have one or more functions and t h a t these are most active during the early years of life. Our n e x t consideration will be as to what constitutes a p r o p e r diagnosis of tonsillar infection. This is obtained by a careful history and examination of the lymphoid elements in the p h a r y n x . The h i s t e r y of local tonsillar inflammation, acute or chronic, regardless of the organisms present, or repeated attacks of tonsillitis ( H a j e k ' s dictum) is absolute evidence of tonsiltar infection. One or more attacks of quinsy, repeated coryzas beginning with sore throat, soreness and discomfort in the tonsillar region, enlargement or tenderness of the node at the angle of the jaw (G. B. W o o d ) , cervical a d e n o p a t h y otherwise unaeeou~Jtable, c a t a r r h a l or suppurative otitis media, rheu-
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TONSIL AND ADENOID PROBLE1V[
~3
marie or arthritic manifestations, endoearditis, nephritis, pyelitis, lower r e s p i r a t o r y infection, ocular infections, or other distant symptoms require a most careful investigation of the lymphoid structures in the p h a r y n x . Simple inspection of the fauces will usually fail to determine with any accuracy w h e t h e r or not a tonsil is infected, and it may be stated hero t h a t an absolutely negative r e p o r t is n e v e r possible until the tonsil has been removed and studied histologically and bacteriologically. Small, sealed crypts deep in the tonsil substance are not uncommon and are often impossible of detection even with the transillumination method of Freneh. A careful inspection of the fauces wilt often reveal a purplish red tinge limited to the anterior pillar which is supposed to have some pathologic significance, especially where the infecting organism is a streptococcus. Often masses of cheesy dgbris m a y be observed filling the crypts if the a n t e r i o r pillar is w i t h d r a w n by a pillar retractor. If, in addition, pressure is made external to the meridian of the tonsil, cheesy masses or liquid grayish or yellowish pus or mueopus will flow from one or more crypts, the superior ones in the u p p e r pole being those in which this secretion is most apt to accumulate. Adenoid examination is less f r e q u e n t l y made, but where undertaken, after removal, the presence of large numbers of polynuclear leucocytes is r e p o r t e d b y the pathologist. As long as the body resistance and the immunologic powers of the individual are able to cope with the bacteria and their toxins elaborated in the crypts and the p a r e n e h y m a of the lymphoid structures, no deleterious systemic lesions are produced. As soon as these vital powers are diminished, however, the bacteria and their toxins are enabled to attack i m p o r t a n t organs and may set np irreparable patho]ogic changes. The toxins may enter tile p a r e n c h y m a from the crypts and either be absorbed b y the venous capillaries or be removed b y the efferent lymphatics. Soluble toxins m a y be absorbed directly from the tonsil into the blood stream, thus accounting for the early intoxication in acute tonsillitis. Infection m a y also spread along the perivaseular lymph spaces, sometimes c o n t r a r y to the direction of the blood stream (Dean). I t is not generally appr6ciated t h a t the adenoid m a y have just as serious focal possibilities as the tonsils, teeth, or sinuses. Bacterial multiplication readily takes place in the deep crypts, in which, after removal, pus is often noted. F r o m this source infection m a y travel down the n a s o p h a r y n x to the o r o p h a r y n x and l a r y n g o p h a r y n x and to the traeheobronehia] tree. Cultures t a k e n from the crypts of adenoid masses show growth in 100 per cent of cases. The adenoid, in simple h y p e r t r o p h y , is of greater significance than the tonsil because of its location, for it m a y impair nasal respiration.
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It m a y not be amiss, at this point, to outline v e r y briefly some of the conclusions of the Le ~VI~e s t u d y conducted a few years ago, reference to which has been made at the beginning of this paper. J. ~ . Le M4e sent out a questionnaire on this subject to clinicians all over the world. The r e f e r e n d u m was not addressed to a n y p a r t i c u l a r group but to internists, pediatricians, orthopedic a n d general surgeons, opthalmologists, otolaryngologists, and pathologists. N e a r l y e v e r y medical center in the world was represented. The replies of the respondents, several h u n d r e d in number, c a r e f u l l y tabulated and p r i n t e d in book form, are of interest as presenting a cross-section of world opinion. H e r e are a few of the most apropos questions and a s u m m a r y of the answers to them. Question: "D o you believe t h a t the tonsils may constitute a portal of e n t r y and a focus for secondary i n f e c t i o n s ? " Affirmative answers were almost unanimous. Question: " W h a t place do you assign to the tonsils among generally accepted foei, namely, the teeth, ears, gallbladder, and prostate.~'" Answer : In f o u r classes : Class I (60 per cent of the replies) assigned first place to the tonsils. Class I I (18 per cent) assigned second place to the tonsils, giving first place to the teeth. Class I I I (12 per cent) held t h a t the tonsils shared equally with other foci. Class IV (10 per cent) assigned first place to the tonsils in children and first place to the teeth in adults. Question: "Relation between the tonsils and various forms of rheumatism (acute, chronic, and deformans)?'~ A n s w e r : I. Affirmative replies, 90 per cent. A. Almost unanimous for acute rheumatism. B. F o r a relation to chronic rheumatic infections, 45 per cent. I m p r o v e m e n t here is v e r y f r e q u e n t a f t e r tonsillectomy. C. Rheuraatism (arthritis) deformans, 5 per cent. Tonsillectomy is almost n e v e r followed b y improvement. II. Doubtful, 10 per cent. To the question, " O n what signs do you base y o u r opinion t h a t the tonsils are septic and m a y be a cause of s e c o n d a r y infection?"' the collective answer is as follows: 1. Escape of pus from the crypts spontaneously or a f t e r pressure on the anterior pillar (50 per cent of the replies). 2. Repeated exacerbations of acute tonsillitis or peritonsillar abscess (65 per cent). 3. Congestion of the anterior pillars (50 per cent). 4:. Cervical adenopas (40 per cent). 5. Presence or r e t e n t i o n of caseous m a t t e r (20 per cent). In the opinion of those who gave this answer the caseum unaccompanied b y pus suffices to characterize the tonsil as a " b a d " or " r e s p o n s i b l e " one.
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6. Buried, small, or " a d h e r e n t " tonsils (20 per cent). (George B. Wood protests against the term " a d h e r e n t . " W h a t is meant is that b y the deposit of fibrous tissue a r o u n d the capsule, due to chronic or repeated acute infections, the tonsil is more or less immobilized and can be dislocated from its fossa with great difficulty.) The buried, small, or adherent tonsil is p a r t i e u l a r l y suspected b y English and American writers. 7. Simple tonsillar h y p e r t r o p h y with enlargement of the cryptal orifices and eventually the presence of small ulcero-congestive lesions at their borders (10 per cent). 8. Bacterial examination (5 per cent), especially if streptococcus is recovered. J u d s o n Daland has often spoken and w r i t t e n advocating this method of diagnosis, ttis dependence is placed upon the type of organism recovered and the n u m b e r of colonies produced. To make a diagnosis of tonsi]lar infection, then, we must make use of all the above mentioned points, but the clinical evidence should always be studied in its possible relationship to the h i s t o r y before the tonsil is c o n d e m n e d - - t h a t is, if we wish to be conservative, as, we believe, we should. That the tonsils often act as portals of e n t r y f o r infection manifested in other parts of the body is generally aecepted, as well as t h a t chronic disease of the tonsils m a y be a p r i m a r y eause of infectious processes of foeM origin elsewhere in the body. It is often overlooked t h a t the infected tonsil m a y be only one of several such agencies, although perhaps the p r i m a r y one. P e m b e r t 0 n called attention to the f a c t that even though focal infection was responsible for m a n y kinds of disease, m a n y individuals get well even in the presence of surgical foci of ~nfection. This led to a series of detailed studies that were v e r y revealing. Metabolic studies, glucose tolerance tests, blood chemistry, blood gas studies, studies of the blood vascular system, blood flow, sweat, body mechanics, and elimination were undertaken. He believed t h a t each ease had to be studied t h o r o u g h l y and that there existed no panacea for rheumatism. His conclusion was that, in addition to the removal of loci of infection, all measures calculated to normalize metabolism, to promote blood flow, to dilate the peripheral vessels, to minimize toxemias, to lessen the b o d y load, and to promote elimination should be used in a p r o p e r l y studied and t r e a t e d ease. While the tonsils m a y be p r o v e d to be, beyond question, infected, we are unable thus far to say with c e r t a i n t y w h e t h e r or not t h e y are the absolute, or primary, cause of the systemic disease in any given case. There m a y be multiple causes present, and t h e y should all be dealt with as t h o r o u g h l y as possible. The infected tonsil m a y cause or p e r p e t u a t e a n o t h e r focus which m a y be directly responsible, as for example one in the gastrointestinM tract. Other foei of infee~ion,
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therefore, should not be overlooked when considering a tonsillectomy because of a diagnosis of septic tonsils. Sueh feel m a y well be in the teeth, sinuses, possibly the ears, gallbladder, gastrointestinal tract, and prostate. However that may be, whether tile tonsils and adenoids are responsible, in whole or in p a r t f o r the systemic infection, or w h e t h e r t h e y have no relationship to it w h a t s o e v e r ; once the f a c t t h a t t h e y are definitely infected is established, t h e y should be removed. We do not wish to go on record as believing t h a t e v e r y tonsil is infected, but we eannot with a n y assurance say t h a t a given tonsil is not infected unless t h a t tonsiI is r e m o v e d and subjected to a careful bacteriologic and pathologic examination. H o w often have we rem o v e d a fairly innocuous a p p e a r i n g tonsil, only to see it gush pus f r o m e v e r y c r y p t w h e n squeezed b y the snare or guillotine? To cert i f y t h a t a n y given tonsil is definitely not a focus is to court diagnostic disaster. F r o m a conservative s t a n d p o i n t , before tonsillectomy is p e r f o r m e d , in consideration of systemic infection, it m u s t be decided w h e t h e r the tonsillar infection is p r o b a b l y a c t u a l l y eausing d a m a g e or is likely to cause it in the future. R e g a r d i n g p r o p h y l a x i s , there is g r e a t divergenee of opinion. Kaiser, in a t e n - y e a r s t u d y of the school ehildren of Rochester, N. Y., seems to. show statistically t h a t prophylactic tonsillectomy did not m a k e f o r g r e a t i m m u n i t y to r e c u r r e n t infections of the u p p e r respirat o r y tract, to aeute contagious disease or to r h e u m a t i s m , and indeed, t h a t lower r e s p i r a t o r y infections occurred with g r e a t e r f r e q u e n c y in. tonsilleetomized children t h a n in those in w h o m the tonsils were not removed. The studies of H o r a c e Williams in the P h i l a d e l p h i a Hospital for Co.ntagious Diseases, o.ver a similar period, showed r a t h e r conelusively t h a t the children in this hospital who h a d middle ear supp u r a t i o n and its complications were almost all not tonsilleetomized. Dean, in c o m m e n t i n g on K a i s e r ' s r e p o r t of the increased incidence of laryngitis, bronchitis, and p n e u m o n i a in tonsilleetomized ehildren, believes t h a t this is due to the f a c t t h a t at the time of the tonsil operation, nasal sinusitis was present and t h a t this nasal sinusitis is responsible f o r the p u h n o n a r y disease. F u r t h e r , he believes t h a t most of the nasal sinus conditions can be controlled b y dietetic and hygienic treatm e n t following the tonsil a n d adenoid operation. D a n MeKenzie doubts the value of statistics used to disprove the efficacy of a w e l l - p e r f o r m e d tonsil operation a n d asks w h e t h e r the figures are reliable, w h e t h e r in fact, in those eases in which focal disease has developed a f t e r tonsillectomy, we h a v e a n y statistics to p r o v e t h a t the tonsils w e r e eompletely removed, or w h e t h e r the ade-
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~
noids were not alone r e m o v e d in some eases, and w h e t h e r a recurrenee of this l y m p h o i d tissue was exeluded b y competent examination. I-t~erbert Tilley deprecates the wholesale r e m o v a l of the tonsils as a p r o p h y l a c t i c m e a s u r e but believes t h a t a definite septic tonsil should be removed. His m e t h o d of diagnosis of a septic tonsil is substantially as outlined above, and above all he urges a careful s t u d y of the whole physical condition of the patient. The diagnosis of tonsillar sepsis in relation to focal infection requires the most cooperative study. I f it is a question of middle ear or sinus disease, the o t o l a r y n g o l o g i s t m a y well decide upon the p r o p e r procedure. When, however, the ease is one of arthritis, let us say, other problems arise, and tile ease should have the most careful s t u d y by .all the physicians associated with the case. I t will not do for the laryngologist who finds the infected tonsils to order i m m e d i a t e rem o v a l on the chance t h a t t h e y are the sole, or even the main cause, of the arthritis. Other loci m u s t be sought, or causes other t h a n infection, and the diagnosis of tonsil infection as the etiologic f a c t o r in the case m u s t be a r r i v e d at b y general consultation and consideration of all the evidence. P e m b e r t o n has b r o u g h t this out v e r y clearly, and he n e v e r allows a tonsillectomy, or a n y other surgical r e m o v a l of a focus of infection, not only until the p a t i e n t has been t h o r o u g h l y studied, b u t also until he has been p u t in such. physical condition that the operation will, at least, do no h a r m . Kaiser well says t h a t the reaction agaiIlst indiscriminate tonsillect o m y followed the less striking beneficial results when the tonsils were r e m o v e d for v a g u e indications, while statistical a n d clinical s t u d y justifies enthusiasm for this p r o c e d u r e in p r o p e r l y selected children. Nissen, in his v e r y excellent p r e s e n t a t i o n of the subject, insists that a f t e r infection in the tonsils is determined, the s t u d y must be extended to all other p a r t s of the b o d y to d e m o n s t r a t e systemic disorder. Depending on the type of case, this m a y necessitate a p p r o p r i a t e blood and urine studies, metabolic and endocrine tests, careful investigation of the cardiovascular system, r e s p i r a t o r y tract, neurologie, gastrointestinal, k i d n e y function, bones, joints, b o d y mechanics, etc. I f then, the systemic disorder is discovered, the relationship between t h tonsillar infection and the systemic disorder must be proved. This will require close clinical observation b y the physician and f r e q u e n t r e p o r t s of subjective s y m p t o m s b y the p a t i e n t over a considerable period of time. F r o m the l a r y n g o l o g i c s t a n d p o i n t alone, certain principles t h a t were w r i t t e n elsewhere m a y be emphasized here. E v e r y p a r t of the p h a r y n x a n d fauces should be examined with care. I t is not enough to k n o w t h a t a tonsil operation has been p e r f o r m e d . The fossae m u s t be examined for stumps, tags, regrowths, small crypts concealed behind the
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pillars or beneath scar tissue, eompsensatory hypertrophies of the lateral pharyngeal folds, and isolated lymphatic masses in the posterior pharyngeal wall, infected adenoid remnants, infected lymphoid structures at the base of the tongue (the infratonsillar nodules in the laryngopharynx), whose importance has been emphasized by French, as well as for the gravitation of infected secretions from an infection of the posterior series of sinuses or an extension of an inflamed mucosa. CONCLUSIONS
1. The ultimate diagnosis of infection of the tonsils, adenoids, and the other lymphoid structures of the pharynx rests with the laryngologist. 2. By painstaking examination, either the presence or probable absence of sepsis will, therefore, be determined. 3. I f infection is demonstrated, then a prophylactic clean-up of the lymphoid elements of the pharynx may give striking results. 4. No tonsil and adenoid operation should ever be performed after a hasty and inadequate examination. 5. When a septic tonsiI is discovered in association with some systemic disorder, the diagnosis of tonsillar infection as the cause of this disorder can only be satisfactorily arrived at after meticulous study and consultation, often repeated if necessary, on the part of the laryngologist with the attending" pediatrician, internist, or surgeon.