ALMONDS (tonsillae) — accumulation of an adenoid tissue in the thickness of a mucous membrane on border of nasal, oral cavities and drinks. Depending on an arrangement distinguish palatal M. (tonsillae palatinae), pharyngeal M. (tonsilla pharyngea), lingual M. (tonsilla lingualis), pipe M. (tonsillae tubariae). They form the main part of a pharyngeal limfoepitelialny ring of Pirogov — Valdeyera (fig. 1). In addition to M., this ring includes the accumulations of lymphadenoid fabric put in a mucous membrane of outside departments of a back wall of a stomatopharynx parallel to palatopharyngeal handles, so-called side rollers of a throat, and also the single follicles disseminated in a mucous membrane of a throat (folliculi lymphatici pharyngei). M are a part of the uniform limfoepitelialny device developing in a mucous membrane of digestive, respiratory and urinogenital systems in the form of solitary lymphatic follicles (folliculi lymphatici solitarii) or group lymphatic follicles (folliculi lymphatici aggregati). In the course of phylogenesis accumulation of an adenoid tissue in a mucous membrane on border of a throat and oral cavities and a nose in the form of M. is for the first time noted at mammals.
Bookmark M. occurs in the pre-natal period of development in the field of a head gut. In their bookmark and development a certain sequence is observed. First of all there is palatal, then pharyngeal, lingual and pipe a M. Palatal M. are put at the bottom of the second visceral furrow at the end of the 2nd — the beginning of the 3rd month in the form of protrusion of an entoderm. The last gives rise to an epithelial cover and system of crypts of M. From a surrounding mesenchyma the adenoid tissue of M develops. On the 8th month of pre-natal fetation appear limf, M.'s (folliculi lymphatici tonsillares) follicles, and by the end of the 1st month of life of the child in them arise the centers of reproduction (centrum multiplicationis). Pharyngeal M. is put on 3 — - the 4th month in the form of 4 — 6 folds of a mucous membrane in the field of a vault of the farynx. On the 6th month for the first time arise limf, follicles, on 2 — the 3rd month after the birth — the centers of reproduction. Lingual M. is put as pair education on the 5th month in the form of longitudinal folds of a mucous membrane of a root of language. On the 6th month of a fold are fragmented, on the 7th month there are follicles, on 3 — the 4th month after the birth — the centers of reproduction. Pipe M. are put on the 8th month in the form of separate accumulations of lymphocytes in a circle of a pharyngeal opening of an acoustical pipe. By the birth of the child follicles, on the first year of life — the centers of reproduction form.
Palatal M — the pair education located in M.'s (fossae tonsillares) poles of sidewalls of a pharynx between a palatoglossal handle (areus palatoglossus) and a palatopharyngeal handle (areus palatopharyngeus). It has the oval form, its long axis passes from top to down and several in front back. The newborn has palatal M.'s size in the vertical direction of 10 mm, in cross 9 mm, thickness is 2,1 mm; the adult has respectively 15 — 30 mm, 15 — 20 mm, 12 — 20 mm. In palatal M. distinguish two surfaces: internal (free) and outside, turned to a wall of a pharynx. The pulled inner surface, is covered with a mucous membrane, has 8 — 20 irregular shapes of mindalikovy dimples (fossulae tonsillares) which are mouths of mindalikovy crypts (cryptae tonsillares) to-rye, branching, penetrate thickness of M. Crypts increase the area of a free surface of each palatal M. to 300 cm2. During the swallowing palatal M. are a little displaced, and their crypts are exempted from contents. The outer surface of palatal M. is covered with the capsule (capsula tonsillae) up to 1 mm thick; on it the layer of a friable peritonsillar fat lies, edges goes down down to a root of language, is in front reported with cellulose of a palatoglossal handle, above — with a submucosa of a soft palate. At the adult the distance to an internal carotid artery from an upper pole of palatal M. makes 28 mm, from the lower pole of 11 — 17 mm, to an outside carotid artery respectively 41 mm and 23 — 39 mm. The upper corner of a pole of M. remains free and is called a nadmindalikovy pole (fossa supratonsillaris). Sometimes there is additional palatal M. — a palatal segment of palatal M., edges can deeply come into a soft palate and not have a direct connection from the main palatal M. (fig. 2). In these cases it represents additional intra palatal M. (tonsilla intrapalatina accessoria), edges usually contains a deep branchy crypt — Turtyual's (sinus Tourtuali) sine playing a part in pathology of M.
Pharyngeal M (synonym: nasopharyngeal M., Lushki's almond, the third M.) is on border of upper and back walls drinks (see), has an appearance of a plate of rounded shape with 4 — 8 folds of a mucous membrane dispersing on its surface acting in a cavity of a nasopharynx. Pharyngeal M. is well developed only at children's age, from the beginning of puberty there comes its involution.
Lingual The m (a synonym the fourth M.) is located in the field of a root language (see), occupying almost all surface of a root of language. The form is more often than it an ovoidny, pulled surface, on the mucous membrane divided by furrows into a number of folds lingual follicles (folliculi linguales) are located. M.'s crypts — superficial, at the bottom of many crypts open output channels of sialadens, a secret to-rykh promotes washing and clarification of crypts. At the newborn lingual M. is well developed, its size — longitudinal 6 mm, cross 9 mm. After 40 years there is a gradual reduction lingual M.
Pipe M — the pair education representing accumulation of an adenoid tissue in the thickness of a mucous membrane of a nasopharynx at a pharyngeal opening of an Eustachian tube (see. Acoustical pipe ). At the newborn pipe M. is well-marked, in length apprx. 7,5 mm, in the diameter apprx. 3,5 mm. Pipe M. reaches the greatest development in 5 — 7 years, further it gradually atrophies and becomes almost imperceptible.
M.'s blood supply a limfoepitelialny pharyngeal ring, including palatal M. (fig. 3), is carried out by arterial branches (aa. tonsillares) departing directly from an outside carotid artery or its branches: ascending pharyngeal (a. pharyngea ascendens), lingual (and. lingualis), front (a. facialis), descending palatal (a. palatina descendens). Veins M. form in a parenchyma, accompany arteries and fall into a pharyngeal veniplex (plexus venosus pharyngeus), a lingual vein (v. lingualis), an alate veniplex (plexus venosus pterygoideus). Bringing limf, have no M.'s vessels. Taking away limf, vessels fall in limf, nodes: parotid, retropharyngeal, lingual, Submandibular. M.'s innervation is carried out by branches V, IX, X pairs of cranial nerves, a cervical part of a sympathetic trunk. In a subepithelial layer of connective tissue partitions, M.'s parenchyma there are separate nervous cells, their accumulations, pulpy and amyelenic nerve fibrils, various look nerve terminations, extensive receptor fields. Blood supply and M.'s innervation change with age.
M. consist of a stroma and a parenchyma (fig. 4). The stroma forms the connective tissue framework of M. created by collagenic and elastic fibers. They form the capsule (cover) on M.'s circle, from a cut in M.'s depth connective tissue crossbeams (trabeculas) depart. In the thickness of crossbeams are circulatory and limf, vessels and M.'s nerves, and sometimes and secretory departments of small sialadens. M.'s parenchyma is presented adenoid tissue (see), a cellular basis a cut are lymphocytes, macrophages, plasmocytes. Elements of an adenoid tissue form places of rounded shape of accumulation — follicles, to-rye are located parallel to an epithelium along a free surface of M. and along crypts. The centers of follicles can be light — the so-called centers of reproduction, or the reactive centers. The free surface of M. is covered with a mucous membrane with a multirow flat not keratosic epithelium. In the field of crypts it is thinner, and is broken by places, the basal membrane is also fragmented that promotes the best contact of an adenoid tissue with the environment.
Having the general with other limf, bodies a structure (see. Adenoid tissue ), M. perform also similar functions — hemopoietic (lymphocytopoiesis) and protective (barrier). The follicular device put in mucous membranes is a lymphoid barrier, biol, a role to-rogo — neutralization of toxicants and inf. the agents getting on mucous membranes from the environment. In M. of the person there are both timuszavisimy, and timusnezavisimy populations lymphocytes (see), to-rye carry out reactions both cellular, and humoral immunity (see). M are the peripheral body of immunity having a nek-swarm an originality. First, they have a limfoepitelialny structure, secondly, are entrance gate for microbic antigen and, thirdly, in them there are no vessels bringing limf. It is known that M. contain the cells producing antibodies of the class IgE to-rye as assume, perform protective function. It is shown that lymphocytes of an adenoid tissue of M. develop interferon (see), being a nonspecific factor of virus-induced immunity.
Methods of a research
The m can be examined at back rinoskopiya (see) — pharyngeal and pipe, at faringoskopiya (see) — palatal, lingual, side rollers and lymphoid follicles (granules) of a back wall of a throat. The method of a palpation, sounding of lacunas is applied. Palatal M. investigate by their rotation or a vyvikhivaniye by means of two pallets, define contents of lacunas and its character. In M.'s lacunas of the healthy person there are no contents usually. M.'s rotation is made by the tonsillorotator or the wire pallet, the Crimea press on palatoglossal (a lobby palatal) a handle that involves turn M. by a free surface forward. At the same time mouths of lacunas reveal and from there squeeze out their contents — traffic jams, pus (fig. 5).
Anomalies of development. The palatal segment and additional palatal M. Inogda instead of one palatal M. on each party belong to anomalies of development two M. Opisana the additional segments hanging on a leg develop. As a rule, these anomalies of treatment do not demand.
Damages — burns, M.'s wounds — separately meet seldom; more often they are combined with internal and outside damages drinks (see).
Foreign bodys — most often fish stones, to-rye can be implemented into fabric M., causing pain during the swallowing. Delete them with tweezers or special nippers. After removal the antiseptic gargle, a sparing diet within one-two days is recommended (see. Foreign bodys, drinks ).
Acute disease of palatal M. — acute tonsillitis, or quinsy (see). Hron, palatal M.' inflammation — tonsillitis (see). Palatal M.' hyperplasia occurs at children; signs of an inflammation at the same time are absent. M are only increased in sizes. If the hyperplasia causes difficulty of breath or swallowing, do to children operation — a tonsillotomy (fig. 6), i.e. partial cutting off of the acting part M. Before operation carrying out full a wedge, inspections is necessary.
Operation of a maloboleznenn, most often becomes without anesthesia, on an outpatient basis, the special tool — a gilyotinoobrazny knife — a tonsillotome, the size to-rogo is selected according to the size deleted by M. Giperplaziya of palatal M. in most cases is followed by growth of adenoid tissue of nasopharynx therefore the tonsillotomy is often combined with an adenotomy (see. Adenoides ). Bleeding after a tonsillotomy usually insignificant and quickly stops. The child shall remain under observation of the doctor 2 — 3 hours. It is recommended to observe 1 — 2 day a bed rest, then 3 — 4 days — semi-bed. Food shall be liquid and kashitseobrazny, room temperature.
Acute inflammation of pharyngeal M., or acute adenoiditis (see), it is observed preferential at children. At the same time in inflammatory process it can be involved and pipe M. Vospaleniye has catarral, follicular or fibrinous character. Due to the anatomic proximity of the mouth of an acoustical pipe symptoms can join tubo-otitis (see).
Much less often the isolated disease lingual M meets. It arises at persons of middle and advanced age, can be followed by lingual M.'s abscess; proceeds with high temperature, difficulty of swallowing and the speech, sharp morbidity at protrusion of language is noted.
At quinsy of side rollers of a throat the inflammation arises in the lymphoid follicles scattered on a back wall and in side lymphoid rollers (columns). Quite often the whitish dot plaque on separate follicles of back joins: walls of a throat.
The disease of an adenoid tissue of a throat is called guttural quinsy; it is shown by high temperature, a febricula, sharp pain during the swallowing of food and palpation of area of a throat. Plaques are often visible, there can be hypostasis of an outside ring of a throat (see. Laryngitis ).
Except primary defeat of M., change in an adenoid tissue of a pharyngeal ring arise at diseases of blood. At leukoses (see), an infectious mononucleosis (see. Mononucleosis infectious ), lymphogranulomatosis (see) palatal M.' increase can cause difficulty of breath and swallowing. Also ulcer changes in palatal M. like necrotic quinsy are possible.
At syphilis palatal M. are surprised in all stages of a disease. There are descriptions of a hard ulcer of M.: on restrictedly hyperemic background in an upper part of M. solid infiltrate with a painless erosion in the center appears, edges soon turns into an ulcer with the condensed edges and a bottom; hemilesion, regional is characteristic lymphadenitis (see). In the II stage of syphilis there is syphilitic quinsy: on M. the round or oval plaques separate and the drain, towering over a surface M. surrounded with a reddish rim easily ulcerating appear; twosideness of defeat is characteristic; all M. is increased, dense, pruinose; on a mucous membrane in corners of a mouth, on palatal handles, on edge of language papules are found. In the III stage the gumma can lead to M.'s disintegration that threatens with bleeding from large vessels. Treatment — see. Syphilis .
Primary tuberculosis of M. meets seldom, its main symptom — difficulty of swallowing and nasal breath as a result of the accompanying hyperplasia of M. Secondary defeat of M. can be observed at suffering from tuberculosis lungs. Both forms can proceed is hidden, imitating banal hron, tonsillitis. Treatment — see. Tuberculosis .
Distinguish benign and malignant tumors of M. Benign tumors can be epithelial — papilloma (see. Papilloma, papillomatosis ), adenoma (see) and not epithelial connective tissue — fibroma (see. Fibroma, fibromatosis ), angioma (see), lipoma (see); neurogenic — neurinoma (see), a hemodektoma (see. Paraganglioma ), myogenetic — myoma (see). Malignant tumors can also be epithelial — cancer planocellular, ferruterous, transitional cell undifferentiated (see. Cancer ), lymphoepithelioma (see) and not epithelial — sarcoma (see), fibrosarcoma (see). angiosarcoma (see), chondrosarcoma (see), reticulosarcoma (see) and lymphosarcoma (see).
Slow growth, their moderate hyperemia and unsharp consolidation is characteristic of the majority of tumors of palatal M. for a long time. Planocellular cancer differs in ulcer and infiltrative growth. At sarcoma slowly progressing M.'s increase with an ulceration in the late period is characteristic. Rapid growth with involvement of surrounding fabrics, the early regional and remote innidiation is inherent in a transitional cell form of cancer and a lymphoepithelioma. Initial symptoms of a tumor are difficulty of swallowing, feeling of a foreign body in a throat, M.'s increase; later the pain during the swallowing irradiating in an ear, a mandible, a neck joins. Palatal M.' tumors can extend to a soft palate, handles, a sidewall of a throat, a root of language.
At pharyngeal M.'s defeat patients complain of difficulty of breath in Nov, a congestion of an ear, hypersecretion of slime with an ichor appears. At disintegration of a tumor bleeding, off-flavor joins. The tumor quickly metastasizes and burgeons in a head cavity. Results of a biopsy are solving in diagnosis. Benign tumors of M. treat in the operational way. At malignant tumors owing to their high radio sensitivity and tendency to early innidiation radiation therapy is shown.
Radiation therapy of malignant tumors of M. is carried out by method of outside radiation therapy by means of gamma-ray irradiation plants, linear dynamitrons, betatrons. In addition use an intra oral short-distance roentgenotherapy (see. Radiation therapy ).
In the absence of metastasises, except a tumor and a zone of her most probable subclinical distribution, irradiates also area retropharyngeal, submaxillary, upper and average deep cervical limf, nodes. At metastasises on the party of defeat or on both sides of a neck all limf irradiate, nodes to the level of a clavicle according to one or both parties.
Radiation of primary center is carried out with use static (2 — the 4th fields) or the rotational mode, and limf, nodes of lower parts of a neck — from one-two front or front and back fields. The throat, a trachea and a spinal cord are protected lead blocks. Total doses on primary tumoral center and metastasises make 5000 — 7000 is glad (50 — 70 Gr) for 5 — 7 weeks, at the same time 1000 — 1200 is glad (10 — 12 Gr) reasonablly to bring directly on area of a tumor from aim fields, and on zones of subclinical spread of a tumor 4000 — 4500 is glad (40 — 45 Gr) for 4 — 4,5 weeks. Radiation therapy is begun only later sanitation of an oral cavity (see). In the course of radiation exclude substances from a diet mechanically, thermally and chemically irritating a mucous membrane.
Along with radiation carry out chemotherapy by Cyclophosphanum, Olivomycinum, 5-ftoruratsily, a methotrexate, vinblastine. At high-radio sensitive tumors (e.g., a lymphoepithelioma, a lymphosarcoma) apply Cyclophosphanum, or Olivomycinum (in 30 — 40 min. prior to radiation), or vinblastine (intravenously on 5 — 10 mg once in 5 — 7 days). At relatively radio resistant tumors (e.g., planocellular cancer, angiosarcomas, etc.) apply 5-ftoruratsit (in 30 — 40 min. prior to radiation) or a methotrexate 5 mg daily. In cases of a recurrence or lack of effect either operational treatment, or carrying out repeated courses of chemotherapy is recommended.
At operational treatment of tumors of palatal M., not infiltriruyushchy a medial alate muscle, the method of approach to a tumor is possible chrezrotovy. At more widespread tumors and a recurrence after radiation therapy make different types of side pharyngotomies (see). The broadest access, to-ry gives the chance of carrying out radical operation, provides chrezmandibulyarny approach to a tumor.
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