Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Hypertrophy of the tonsils is most commonly met with in children between five and ten years of age, and is often associated with adenoid vegetations in the naso-pharynx and chronic thickening of the pharyngeal mucous membrane.

The whole tonsil is enlarged, the mucous membrane thickened, and the connective tissue more or less sclerosed. The crypts appear on the surface as deep clefts or fissures, and the lymph follicles are enlarged and prominent. Secretion accumulates in the crypts, and a calculus may form from the deposit of lime salts. Sometimes food particles lodge in the crypts, and they may collect and form accumulations of considerable size, requiring the use of a scoop to dislodge them.

Clinical Features.—The hypertrophy is bilateral, but not always symmetrical. Sometimes the tonsils project to such an extent as almost to meet in the middle line; sometimes they scarcely pass beyond the level of the pillars of the fauces. They are usually sessile, but sometimes the base is so narrow as almost to form a pedicle. During childhood they are usually soft and spongy, but when they persist into adolescence or adult life they become firm and indurated. This sclerotic change is due to the repeated attacks of catarrhal or suppurative tonsillitis to which the patient is subject. The lymph glands behind the angle of the jaw are frequently enlarged. Swallowing is sometimes interfered with, and the patient is liable to attacks of nausea and vomiting. Respiration is always more or less impeded; the patient breathes through the open mouth, and snores loudly during sleep; and the hindrance to respiration interferes with the development of the chest. In some cases alarming suffocative attacks occasionally supervene during sleep, but the difficulty in breathing disappears as soon as the child is wakened. The voice is characteristically thick and nasal, especially when adenoids are present, and in many cases the patient has a vacant and stupid expression. Hearing is often impaired from obstruction of the Eustachian tube.

Treatment.—In early and mild cases, the tonsils should be painted with glycerine of tannic acid, or some other astringent, and an antiseptic mouth-wash, or spray of hydrogen peroxide, should be used several times a day. When the condition is interfering with the general health or with the development of the chest, or when there is deafness or disturbance of sleep, the tonsils should be removed.

Calculi composed of phosphate or carbonate of lime are sometimes formed in the crypts of enlarged tonsils; as a rule they are about the size of a pea, but they may be much larger. They cause a sharp stabbing pain on swallowing, and sometimes a persistent hacking cough. They are easily shelled out through a small incision into the tonsil.

Syphilis.—The fauces and tonsils are occasionally the seat of a hard chancre, and the condition may simulate malignant disease. The submaxillary glands, however, become enlarged sooner and increase more rapidly than in cancer, and they are tender. The secondary manifestations of the disease usually appear before the chancre has healed.

Early in secondary syphilis, mucous patches and superficial ulcers are frequently met with. Later, severe phagedænic ulceration sometimes occurs, especially in alcoholic subjects, and may rapidly eat through the soft palate, leading to marked deformity from contraction when cicatrisation takes place.

In the tertiary stage, a diffuse gummatous infiltration occurs, and is liable to be followed by ulceration, which spreads to the pharyngeal wall and soft palate, and, by causing cicatricial contraction and adhesions, may lead to narrowing or even complete occlusion of the communication between the pharynx and the naso-pharynx.

Tuberculous lesions of the fauces and tonsils are almost invariably secondary to tubercle of the larynx or lungs, or to lupus of the face or naso-pharynx. They are attended with more pain than syphilitic lesions; are less prone to spread to the palate and cause perforation; but, when cicatrisation takes place, they are equally liable to produce contraction and deformity.

Tumours.—Innocent tumours—fibroma, lipoma, myoma—are comparatively rare. When sessile they cause inconvenience only by their bulk; when pedunculated they may hang down into the pharynx and interfere with swallowing and breathing. They may be shelled out, or ligated at the base and cut off, according to circumstances.