Adenoids: prevention and treatment. Pirogov-Waldeyer pharyngeal lymphoid ring Lymphoid ring
At the border of the oral cavity and pharynx in the mucous membrane there are significant accumulations of lymphoid tissue. Together they form a lymphoepithelial pharyngeal ring surrounding the entrance to the respiratory and digestive tracts. The largest clusters of this ring are called tonsils. Based on their location, the palatine tonsils, pharyngeal tonsil, and lingual tonsil are distinguished. In addition to the listed tonsils, in the mucous membrane of the anterior part of the digestive tube there are a number of accumulations of lymphoid tissue, of which the largest are the accumulations in the area of the auditory tubes - tubal tonsils and in the ventricle of the larynx - laryngeal tonsils.
The palatine tonsils are formed in the 9th week of embryogenesis in the form of a depression in the pseudostratified ciliated epithelium of the lateral wall of the pharynx, under which lie compactly located mesenchymal cells and numerous blood vessels. At the 11-12th week, the tonsillar sinus is formed, the epithelium of which is reconstructed into a multilayered squamous one, and reticular tissue is differentiated from the mesenchyme; vessels appear, including postcapillary venules with high endothelial cells. The organ is populated with lymphocytes. At week 14, mainly T-lymphocytes (21%) and a few B-lymphocytes (1%) are detected among lymphocytes. At 17-18 weeks, the first lymph nodes appear. By the 19th week, the content of T-lymphocytes increases to 60%, and B-lymphocytes - to 3%. The growth of the epithelium is accompanied by the formation of plugs of keratinizing cells in the epithelial cords.
We continue to publish reports on meetings that take place as part of our project “How to Maintain the Health of a Schoolchild.” This time, the siblings talked with otolaryngologist Gennady MELIXETOV, who, on the eve of the cold season, spoke about two “popular” diagnoses among children: adenoids and tonsillitis.
The Fellowship of the Ring
We are not talking about the ring of omnipotence at all, but about Pirogov-Waldeyer lymphoid ring. This is the first line that our body sets in the path of infections. And since the easiest way for infections to enter is through the air (we cannot breathe or swallow), the lymphoid ring is located on the border of the oral cavity and pharynx.
(Click on the picture to enlarge)
The Pirogov-Waldeyer ring consists of tonsils (areas of accumulation of lymphoid tissue) - palatine, tubal, pharyngeal and lingual, and also of individual lymphoid ridges and granules. They are the first to neutralize harmful microorganisms and viruses and set up the immune system for a full-scale response. However, sometimes the defense mechanism fails. For various reasons, the tonsils cease to cope with their duties and, instead of neutralizing microbes, become their “native home” - a breeding ground for infection. The “weak link” in the brotherhood of the Pirogov-Waldeyer ring most often turns out to be the palatine and pharyngeal tonsils.
Adenoids - pharyngeal tonsil, which has crossed all boundaries
A healthy child does not have adenoids - there is a pharyngeal tonsil on the back wall of the nasopharynx (it is also called the “third tonsil”), an honest worker of the Pirogov ring. However, the pharyngeal tonsil often grows - this hypertrophied tissue is called adenoids. Inflammation of the overgrown tissue of the pharyngeal tonsil is a separate disease, adenoiditis, but adenoids, even without any inflammation, cause children a lot of trouble.
Causes of adenoids
The reasons that provoke the growth of adenoids are quite varied.
Adenoids can occur due to illness - frequent colds or a single acute respiratory infection, but it is severe. Affects the likelihood of adenoid growth and the course of the mother’s pregnancy, for example, taking antibiotics or allergic reactions. Finally, there is a hereditary tendency to pathological proliferation of lymphoid tissue.
How do adenoids manifest themselves?
Parents may suspect that their child has adenoids based on several signs:
difficulty breathing through the nose;
frequent colds;
snoring “like an adult”;
night apnea - a short-term cessation of breathing, which usually frightens parents;
hearing loss.
Often parents are angry with the child, believing that he is capricious, ignoring their appeals and requests. In fact, he simply does not hear them: pay attention to what volume the baby watches TV or listens to music at.
Diagnosis of adenoids
As you can see, it is not difficult even for an inexperienced mother to suspect that a child has adenoids. However, only a doctor can make a final diagnosis.
The two most commonly used methods are visual (examination of the throat and nose using a nasal speculum) and endoscopic (an endoscope is an optical device, a flexible tube that can be easily inserted into the nasopharynx either through the nose or through the mouth). The latter is much more informative - it is he who can give an idea of the degree of growth of the adenoids.
There are three degrees of adenoid development
1st degree - an enlarged pharyngeal tonsil covers only the upper part of the nasal passages.
2nd degree - enlarged pharyngeal tonsil covers 2/3 of the height of the nasal passages.
3rd degree - an enlarged pharyngeal tonsil closes the nasal passages almost completely.
If your child has been diagnosed with adenoids...
It is important to begin full-scale treatment on time, since the consequences of impaired nasal breathing can be the most serious: the child’s hearing decreases, attention is distracted, due to constant breathing through the mouth, the baby gets sick more often and caries may even appear. If you continue to ignore the adenoids after this, the consequences will become difficult to reverse: the child’s facial skeleton will become deformed and the bite will deteriorate.
Adenoid type of face
Treatment of adenoids
Treatment can be divided into two types - conservative and surgical.
Conservative methods of treating adenoids
First, as a rule, the doctor suggests trying conservative methods: treatment with glucocorticosteroids or silver preparations.
Many parents are worried when they hear that their child will be treated with hormonal drugs - glucocorticosteroids. And it’s completely in vain - when used locally, they do not enter the bloodstream, and an overdose is almost impossible.
Physiotherapy complements drug treatment.
First of all, these are devices for laser therapy - “Matrix”, “Lasmik”. They provide a powerful immunomodulatory effect, and lymphoid tissue is reduced to almost normal. I am confident that this is the optimal treatment for children, because the procedure is completely painless.
Salt caves are also beneficial for adenoids, which are recommended, generally speaking, for all ENT pathologies.
Surgical treatment of adenoids
Difficulty breathing causes oxygen starvation - hypoxia, enlarged adenoids provoke hearing loss, the child cannot concentrate - at school this can cause huge problems with studies. Therefore, if the child is already five to six years old and we are talking about the second and third degree of adenoid proliferation, then surgical treatment is most effective.
Those mothers and fathers who themselves underwent this operation in childhood do their best to resist the doctor’s proposal, trying to protect their children from, to put it mildly, unpleasant sensations. If your childhood went without cutting out the adenoids, we will briefly describe how it happened: the child was fixed (sometimes simply tied) in a chair, then the nasopharynx was anesthetized, after which the doctor tried to “cut off everything unnecessary.” The child, of course, was scared, uncomfortable, blood flowed into his throat... It was impossible to remove all the lymphoid tissue, so after a year or two the “torture” most likely had to be repeated. Can you imagine all this? Now - forget it!
Adenoid removal today occurs only under general anesthesia! This allows the doctor to remove the lymphoid tissue completely, which means avoiding relapses. For the child, the operation is, of course, completely painless; he does not experience the slightest discomfort, either during or after the operation.
TONSILS (tonsillae) - accumulation of lymphoid tissue in the thickness of the mucous membrane at the border of the nasal, oral cavities and pharynx. Depending on the location, there are palatal M. (tonsillae palatinae), pharyngeal M. (tonsilla pharyngea), lingual M. (tonsilla lingualis), and tubal M. (tonsillae tubariae). They form the main part of the Pirogov-Waldeyer pharyngeal lymphoepithelial ring (Fig. 1). In addition to M., this ring includes accumulations of lymphadenoid tissue embedded in the mucous membrane of the outer parts of the posterior wall of the oropharynx, parallel to the velopharyngeal arches, the so-called. lateral ridges of the pharynx, as well as single follicles scattered in the mucous membrane of the pharynx (folliculi lymphatici pharyngei). M. are part of a single lymphoepithelial apparatus that develops in the mucous membrane of the digestive, respiratory, and genitourinary systems in the form of solitary lymphatic follicles (folliculi lymphatici solitarii) or group lymphatic follicles (folliculi lymphatici aggregati). During the process of phylogenesis, the accumulation of lymphoid tissue in the mucous membrane at the border of the pharynx and the oral and nasal cavities in the form of M. was first noted in mammals.
Embryology
M.'s anlage occurs during the prenatal period of development in the area of the head intestine. There is a certain sequence in their formation and development. First of all, the palatine, then the pharyngeal, lingual and tubal M. appears. The palatine M. are laid at the bottom of the second gill pouch at the end of the 2nd - beginning of the 3rd month in the form of a protrusion of the endoderm. The latter gives rise to the epithelial cover and crypt system of the M. Lymphoid tissue of the M develops from the surrounding mesenchyme. At the 8th month of intrauterine development of the fetus, lymph follicles of the M. (folliculi lymphatici tonsillares) appear, and by the end of the 1st month of the child’s life, they appear reproduction centers (centrum multiplicationis). Pharyngeal M. is formed in the 3rd-4th month in the form of 4-6 folds of the mucous membrane in the area of the pharyngeal vault. At the 6th month, lymph follicles appear for the first time, and at the 2nd - 3rd month after birth, reproductive centers appear. Lingual M. is formed as a paired formation in the 5th month in the form of longitudinal folds of the mucous membrane of the root of the tongue. At the 6th month, the folds fragment, at the 7th month, follicles appear, and at the 3rd - 4th month after birth, reproductive centers appear. Tubal M. are formed in the 8th month in the form of separate accumulations of lymphocytes around the pharyngeal opening of the auditory tube. By the birth of a child, follicles are formed, and in the first year of life, reproductive centers are formed.
Anatomy
Palatal M. is a paired formation located in the M. pits (fossae tonsillares) of the lateral walls of the pharynx between the palatoglossus arch (areus palatoglossus) and the velopharyngeal arch (areus palatopharyngeus). It has an oval shape, its long axis runs from top to bottom and somewhat from front to back. In a newborn, the size of the palatine m. in the vertical direction is 10 mm, in the transverse direction 9 mm, thickness 2.1 mm; in an adult, respectively, 15-30 mm, 15-20 mm, 12-20 mm. In the palatal M., two surfaces are distinguished: internal (free) and external, facing the wall of the pharynx. The inner surface is uneven, covered with a mucous membrane, has 8-20 irregularly shaped tonsillar dimples (fossulae tonsillares), which are the mouths of tonsillar crypts (cryptae tonsillares), which, branching, penetrate the thickness of the palatine membrane. The crypts increase the free surface area of each palatine membrane up to 300 cm2. When swallowing, the palatine membranes are slightly displaced, and their crypts are freed from their contents. The outer surface of the palatine membranes is covered with a capsule (capsula tonsillae) up to 1 mm thick; on it lies a layer of loose paratonsillar tissue, the edges go down to the root of the tongue, in front it communicates with the tissue of the palatoglossal arch, at the top - with the submucous base of the soft palate. In an adult, the distance to the internal carotid artery from the upper pole of the palatine M. is 28 mm, from the lower pole 11-17 mm, to the external carotid artery 41 mm and 23-39 mm, respectively. The upper corner of the M.'s fossa remains free and is called the supratonsillaris fossa. Sometimes there is an additional palatine M. - the palatine lobe of the palatine M., the edges can extend deep into the soft palate and not have a direct connection with the main palatine M. (Fig. 2). In these cases, it represents an additional intrapalatine M. (tonsilla intrapalatina accessoria), the edges usually contain a deep branched crypt - the sinus of Tourtuali, which plays a certain role in the pathology of the M.
Pharyngeal M. (syn.: nasopharyngeal M., Lushka's tonsil, third M.) is located on the border of the upper and posterior walls of the pharynx (see), has the appearance of a round-shaped plate with 4-8 folds of the mucous membrane diverging on its surface, protruding into the cavity nasopharynx. The pharyngeal M. is well developed only in childhood; with the onset of puberty, its reverse development occurs.
lingual M. (syn. fourth M.) is located in the region of the root of the tongue (see), occupying almost the entire surface of the root of the tongue. Its shape is often ovoid, the surface is uneven, and lingual follicles (folliculi linguales) are located on the mucous membrane, divided by grooves into a number of folds. M.'s crypts are shallow, at the bottom of many crypts the excretory ducts of the salivary glands open, the secretion of which helps to wash and cleanse the crypts. In a newborn, the lingual M. is well developed, its size is longitudinal 6 mm, transverse 9 mm. After 40 years, a gradual reduction of lingual M occurs.
Pipe M. is a paired formation, which is an accumulation of lymphoid tissue in the thickness of the mucous membrane of the nasopharynx at the pharyngeal opening of the Eustachian tube (see Auditory tube). In a newborn, the tubal M. is well defined, approx. 7.5 mm, diameter approx. 3.5 mm. Tubal M. reaches its greatest development at 5-7 years of age; later it gradually atrophies and becomes almost invisible.
The blood supply of the M. lymphoepithelial pharyngeal ring, including the palatine M. (Fig. 3), is carried out by arterial branches (aa. tonsillares), extending directly from the external carotid artery or its branches: the ascending pharyngeal (a. pharyngea ascendens), lingual (a. . lingualis), facial (a. facialis), descending palatine (a. palatina descendens). M.'s veins are formed in the parenchyma, accompany the arteries and flow into the pharyngeal venous plexus (plexus venosus pharyngeus), lingual vein (v. lingualis), and pterygoid venous plexus (plexus venosus pterygoideus). M. does not have afferent lymphatic vessels. The draining lymph vessels flow into the lymph nodes: parotid, retropharyngeal, lingual, submandibular. M.'s innervation is carried out by the branches of the V, IX, X pairs of cranial nerves and the cervical part of the sympathetic trunk. In the subepithelial layer of connective tissue septa, M.'s parenchyma, there are individual nerve cells, their clusters, pulpy and non-pulpate nerve fibers, various types of nerve endings, and extensive receptor fields. The blood supply and innervation of the muscle change with age.
Histology
M. consist of stroma and parenchyma (Fig. 4). The stroma forms the connective tissue framework of M., formed by collagen and elastic fibers. They form a capsule (shell) around the M.’s circumference, from which connective tissue crossbars (trabeculae) extend into the M.’s depth. In the thickness of the crossbars there are blood and lymphatic vessels and nerves of the M., and sometimes the secretory sections of small salivary glands. M.'s parenchyma is represented by lymphoid tissue (see), the cellular basis of the cut is lymphocytes, macrophages, and plasma cells. Elements of lymphoid tissue form in some places round-shaped clusters - follicles, which are located parallel to the epithelium along the free surface of the tumor and along the crypts. The centers of the follicles can be light - the so-called. reproduction centers, or reactive centers. The free surface of the M. is covered with a mucous membrane with multi-row squamous non-keratinized epithelium. In the area of the crypts it is thinner and in places broken; the basement membrane is also fragmented, which contributes to better contact of the lymphoid tissue with the environment.
Physiology
Having a common structure with other lymphatic organs (see Lymphoid tissue), M. perform similar functions - hematopoietic (lymphocytopoiesis) and protective (barrier). The follicular apparatus, embedded in the mucous membranes, is a lymphoid barrier, biol, whose role is the neutralization of toxic substances and inf. agents that enter mucous membranes from the environment. In human M. there are both thymus-dependent and thymus-independent populations of lymphocytes (see), which carry out reactions of both cellular and humoral immunity (see). M. are a peripheral organ of immunity that has a certain uniqueness. Firstly, they have a lymphoepithelial structure, secondly, they are the entrance gates for microbial antigens and, thirdly, they lack lymphatic vessels. It is known that M. contain cells that produce antibodies of the IgE class, which are believed to perform a protective function. It has been shown that lymphocytes of M.'s lymphoid tissue produce interferon (see), which is a nonspecific factor of antiviral immunity.
Research methods
M. can be examined with posterior rhinoscopy (see) - pharyngeal and tubal, with pharyngoscopy (see) - palatine, lingual, lateral ridges and lymphoid follicles (granules) of the posterior wall of the pharynx. The method of palpation and probing of lacunae is used. The palatal m. are examined by rotating or dislocating them using two spatulas, and the contents of the lacunae and its nature are determined. There is usually no content in the M. lacunae of a healthy person. The M.'s rotation is performed with a tonsillorotator or a wire spatula, which is pressed on the palatoglossus (anterior palatine) arch, which entails the rotation of the M. with the free surface forward. In this case, the mouths of the lacunae open and their contents are squeezed out - plugs, pus (Fig. 5).
Pathology
Developmental anomalies. Developmental anomalies include the palatine lobule and the accessory palatine M. Sometimes, instead of one palatine M, two M develop on each side. Additional lobules hanging on the stem have been described. As a rule, these anomalies do not require treatment.
Damage- burns, wounds of M. are rare in isolation; more often they are combined with internal and external injuries of the pharynx (see).
Foreign bodies- most often fish bones, which can penetrate into the muscle tissue, causing pain when swallowing. Remove them with tweezers or special forceps. After removal, a disinfectant rinse and a gentle diet are recommended for one to two days (see Foreign bodies, pharynx).
Diseases
Acute disease of palatine M. - spicy tonsillitis , or sore throat(cm.). Chron, inflammation of the palatine M. - tonsillitis (see). Hyperplasia of the palatine membranes occurs in children; there are no signs of inflammation. M. are only increased in size. If hyperplasia causes difficulty breathing or swallowing, children undergo surgery - tonsillotomy (Fig. 6), i.e. partial cutting off of the protruding part of the M. Before the operation, a full wedge examination is necessary.
The operation is low-painful, most often done without anesthesia, on an outpatient basis, with a special instrument - a guillotine knife - a tonsillotome, the size of which is selected according to the size of the removed muscle. Hyperplasia of the palatine muscles is in most cases accompanied by the proliferation of adenoid tissue of the nasopharynx, therefore tonsillotomy is often combined with adenotomy (see . Adenoids). Bleeding after tonsillotomy is usually minor and stops quickly. The child should remain under medical supervision for 2-3 hours. It is recommended to observe bed rest for 1-2 days, then semi-bed rest for 3-4 days. Food should be liquid and mushy, at room temperature.
Acute inflammation of the pharyngeal M., or acute adenoiditis(see), observed mainly in children. In this case, the tubal M. may also be involved in the inflammatory process. Inflammation is catarrhal, follicular or fibrinous in nature. Due to the anatomical proximity of the mouth of the auditory tube, symptoms of tubo-otitis may occur (see).
Isolated disease of the lingual M. is much less common. It occurs in middle-aged and elderly people and may be accompanied by an abscess of the lingual M.; occurs with high fever, difficulty swallowing and speaking, and severe pain when protruding the tongue.
With angina of the lateral ridges of the pharynx, inflammation occurs in the lymphoid follicles scattered along the back wall and in the lateral lymphoid ridges (columns). Often a whitish dotted coating appears on individual follicles of the posterior pharyngeal wall.
A disease of the lymphoid tissue of the larynx is called laryngeal sore throat; it is manifested by high fever, general malaise, sharp pain when swallowing food and palpating the larynx area. Plaques are often visible, and there may be swelling of the outer ring of the larynx (see Laryngitis).
In addition to the primary lesion of M., changes in the lymphoid tissue of the pharyngeal ring occur in blood diseases. With leukemia (see), infectious mononucleosis (see Infectious mononucleosis), lymphogranulomatosis (see), an increase in palatal M. can cause difficulty breathing and swallowing. Ulcerative changes in the palatine muscles, such as necrotizing tonsillitis, are also possible.
With syphilis, the palatine M. are affected in all stages of the disease. There are descriptions of hard chancroid M.: against a limited hyperemic background in the upper part of M. a hard infiltrate appears with painless erosion in the center, the edges soon turn into an ulcer with compacted edges and bottom; the lesion is unilateral, characterized by regional lymphadenitis (see). In stage II of syphilis, syphilitic tonsillitis occurs: round or oval plaques, separate and confluent, appear on the muscle, rising above the surface of the muscle, surrounded by a reddish rim, easily ulcerating; characterized by bilateral lesions; the entire M. is enlarged, dense, covered with plaque; Papules are found on the mucous membrane in the corners of the mouth, on the palatine arches, and along the edge of the tongue. In stage III, gumma can lead to the disintegration of M., which threatens bleeding from large vessels. Treatment - see Syphilis.
Primary M. tuberculosis is rare; its main symptom is difficulty swallowing and nasal breathing as a result of concomitant M. hyperplasia. Secondary M. damage can be observed in patients with pulmonary tuberculosis. Both forms can occur hidden, simulating a banal chronic condition, tonsillitis. Treatment - see Tuberculosis.
Tumors
There are benign and malignant tumors of M. Benign tumors can be epithelial - papilloma (see Papilloma, papillomatosis), adenoma (see) and non-epithelial connective tissue - fibroma (see Fibroma, fibromatosis), angioma (see), lipoma (see. ); neurogenic - neurinoma (see), chemodectoma (see Paraganglioma), myogenic - fibroids (see). Malignant tumors can also be epithelial - squamous cell carcinoma, glandular carcinoma, undifferentiated transitional cell carcinoma (see Cancer), lymphoepithelioma (see) and non-epithelial - sarcoma (see), fibrosarcoma (see). angiosarcoma (see), chondrosarcoma (see), reticulosarcoma (see) and lymphosarcoma (see).
Most palatal tumors are characterized by slow growth, moderate hyperemia, and mild induration over a long period of time. Squamous cell carcinoma is characterized by ulcerative-infiltrative growth. Sarcoma is characterized by a slowly progressive increase in M. with ulceration in the late period. The transitional cell form of cancer and lymphoepithelioma are characterized by rapid growth with the involvement of surrounding tissues, early regional and distant metastasis. The initial symptoms of the tumor are difficulty swallowing, the sensation of a foreign body in the throat, and an increase in muscle mass; later pain occurs when swallowing, radiating to the ear, lower jaw, and neck. Tumors of the palatine M. can spread to the soft palate, arches, lateral wall of the pharynx, and root of the tongue.
When pharyngeal M. is affected, patients complain of difficulty breathing through the nose, ear congestion, and hypersecretion of mucus with ichor appears. When the tumor disintegrates, bleeding and an unpleasant odor occur. The tumor quickly metastasizes and grows into the cranial cavity. Biopsy results are decisive in diagnosis. Benign tumors of M. are treated surgically. For malignant tumors, due to their high radiosensitivity and tendency to early metastasis, radiation therapy is indicated.
Radiation therapy for malignant tumors of M. is carried out by the method of external radiation therapy using gamma installations, linear electron accelerators, and betatrons. Additionally, intraoral close-focus radiotherapy is used (see Radiation therapy).
In the absence of metastases, in addition to the tumor and the area of its most likely subclinical spread, the area of the retropharyngeal, submandibular, upper and middle deep cervical lymph nodes is also irradiated. In case of metastases on the affected side or on both sides of the neck, all lymph nodes up to the level of the clavicle are irradiated, respectively, on one or both sides.
Irradiation of the primary focus is carried out using a static (2-4 fields) or rotational mode, and lymph nodes of the lower parts of the neck - from one or two anterior or anterior and posterior fields. The larynx, trachea and spinal cord are protected with lead blocks. The total doses to the primary tumor focus and metastases are 5000-7000 rad (50-70 Gy) for 5-7 weeks, while it is advisable to deliver 1000-1200 rad (10 - 12 Gy) directly to the tumor area from the target fields, and to zones of subclinical tumor spread 4000-4500 rad (40-45 Gy) in 4-4.5 weeks. Radiation therapy begins only after sanitation of the oral cavity (see). During irradiation, substances that mechanically, thermally and chemically irritate the mucous membrane are excluded from the diet.
Simultaneously with radiation, chemotherapy is carried out with cyclophosphamide, olivomycin, 5-fluorouracil, methotrexate, and vinblastine. For highly radiosensitive tumors (eg, lymphoepithelioma, lymphosarcoma), cyclophosphamide, or olivomycin (30-40 minutes before irradiation), or vinblastine (5-10 mg intravenously once every 5-7 days) is used. For relatively radioresistant tumors (for example, squamous cell carcinoma, angiosarcomas, etc.), 5-fluorouracil (30-40 minutes before irradiation) or methotrexate 5 mg daily is used. In cases of relapse or lack of effect, either surgical treatment or repeated courses of chemotherapy are recommended.
During surgical treatment of palatine tumors that do not infiltrate the medial pterygoid muscle, a transoral approach to the tumor is possible. For more common tumors and relapses after radiation therapy, various types of lateral pharyngotomies are performed (see). The widest access, which makes it possible to perform radical surgery, provides a transmandibular approach to the tumor.
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N. A. Preobrazhensky; L. F. Gavrilov (an.), G. V. Muravskaya (medical rad.).
The Pirogov–Waldeyer lymphoid ring is a large accumulation of lymphoid tissue in the mucous membrane of the pharynx, root of the tongue and nasal pharynx. Represented by the tonsils: Ø Lingual (unpaired) Ø Pharyngeal (unpaired) Ø Tubal (steamed) Ø Palatine (steamed)
Functions of the lymphoid ring Ø Lymphopoiesis Ø Formation of immunity: - Local - Systemic Ø Enzymatic function
Lingual tonsil (unpaired) Ø Lies in the lamina propria of the mucous membrane of the root of the tongue Ø The mucous membrane above the tonsil forms crypt depressions, the walls of which are formed by multilayered squamous non-keratinizing epithelium infiltrated with lymphocytes. Ø It reaches its largest size in children and adolescents.
Pharyngeal tonsil (unpaired) Ø Located in the area of the fornix and partly of the posterior wall of the pharynx between the pharyngeal openings of the right and left auditory tubes. Ø In this place there are 4-6 transversely and obliquely oriented folds of the mucous membrane, inside of which there is the lymphoid tissue of the pharyngeal tonsil. Ø Reaches its largest size at 8-20 years, after 30 years its size gradually decreases.
Tubal tonsil (paired) Ø Located in the area of the tubal ridge, which limits the pharyngeal opening of the auditory tube from behind. Ø It is an accumulation of lymphoid tissue in the lamina propria of the mucous membrane of the auditory tube near its pharyngeal opening. The mucous membrane is covered with stratified squamous non-keratinizing epithelium. Ø Reaches its largest size at the age of 4-7 years.
Palatine tonsil (paired) Ø Located in the tonsil fossa, which is a depression between the palatoglossal and palatopharyngeal arches. Ø On the medial free surface of the tonsil, up to 20 tonsil openings of the same name crypts, which are depressions of the mucous membrane, are visible. The mucous membrane is covered with stratified squamous non-keratinizing epithelium, which is infiltrated with lymphocytes. Ø Reach their largest size by the age of 13 and maintain this size until approximately 30 years.
Chronic tonsillitis ØB Chronic inflammation involves the pathological process of the palatine tonsils. the nervous apparatus of the tonsils, which serves as a cause of disruption of the receptor Caused by group A streptococcus, staphylococcus, adenoviruses or the function of the tonsils and neurofungi. their reflex connection with some internal organs, in particular with Ø Clinic: unpleasant smell of the apparatus, heart. Changes in the nervous system of the mouth, pain or tingling, sometimes affecting the trophism of lymphoid tissue, dryness or the presence of a foreign body aggravate those caused by chronic throat pain. Possible relapses of tonsillitis, inflammation of functional paratonsillitis, paratonsillar disorders and structural abnormalities of abscesses, as well as various tonsils, thereby deepening pathological reactions from the violation of their barrier function in distant organs. contributes to the development of decompensation.
Adenoids Ø Enlargement of the pharyngeal tonsil, caused by hyperplasia of its lymphoid tissue. Ø Their development is promoted by diseases that cause inflammation of the mucous membrane of the nasal cavity and tonsils. There are three degrees of enlargement of the pharyngeal tonsil.
1. Difficulty in nasal breathing and nasal discharge. Children sleep with their mouths open, snore; As a result, sleep is disturbed. The consequence is lethargy, apathy, weakening of memory, and schoolchildren’s academic performance decreases. Hearing decreases and voice changes. 2. The mouth is constantly open, the nasolabial folds are smoothed, which gives the face a so-called adenoid expression. Laryngospasm. Deformations of the facial skull and chest, shortness of breath and cough occur, and anemia develops due to reduced blood oxygenation.
At the border of the oral cavity and pharynx in the mucous membrane there are large accumulations of lymphoid tissue. Together they form a lymphoepithelial pharyngeal ring surrounding the entrance to the respiratory and digestive tracts. The largest clusters of this ring are called tonsils. Based on their location, the palatine tonsils, pharyngeal tonsil, and lingual tonsil are distinguished. In addition to the listed tonsils, in the mucous membrane of the anterior part of the digestive tube there are a number of accumulations of lymphoid tissue, of which the largest are the accumulations in the area of the auditory tubes - tubal tonsils and in the ventricle of the larynx - laryngeal tonsils.
Tonsils perform an important protective function in the body, neutralizing microbes that constantly enter the body from the external environment through the nasal and oral openings. Along with other organs containing lymphoid tissue, they provide the formation of lymphocytes involved in the reactions of humoral and cellular immunity.
Development. The palatine tonsils are formed in the 9th week of embryogenesis in the form of a depression in the pseudostratified ciliated epithelium of the lateral wall of the pharynx, under which lie compactly located mesenchymal cells and numerous blood vessels. At the 11-12th week, the tonsillar sinus is formed, the epithelium of which is reconstructed into a multilayered squamous one, and reticular tissue is differentiated from the mesenchyme; vessels appear, including postcapillary venules with high endothelial cells. The organ is populated with lymphocytes. At week 14, mainly T-lymphocytes (21%) and a few B-lymphocytes (1%) are detected among lymphocytes. At 17-18 weeks, the first lymph nodes appear. By the 19th week, the content of T-lymphocytes increases to 60%, and B-lymphocytes - to 3%. The growth of the epithelium is accompanied by the formation of plugs of keratinizing cells in the epithelial cords.
The pharyngeal tonsil develops in the 4th month of the prenatal period from the epithelium and underlying mesenchyme of the dorsal wall of the pharynx. In the embryo, it is covered with multirow ciliated epithelium. The lingual tonsil develops in the 5th month.
The tonsils reach their maximum development in childhood. The onset of tonsil involution coincides with puberty.
Palatine tonsils in the adult body they are represented by two oval-shaped bodies located on both sides of the pharynx between the palatine arches. Each tonsil consists of several folds of the mucous membrane, in the lamina propria of which there are numerous lymph nodes ( noduli lymphatici). 10–20 crypts extend from the surface of the tonsil deep into the organ ( criptae tonsillares), which branch and form secondary crypts. The mucous membrane is covered with stratified squamous non-keratinizing epithelium. In many places, especially in the crypts, the epithelium is often infiltrated (populated) with lymphocytes and granulocytes. Leukocytes that penetrate into the thickness of the epithelium usually come to its surface in greater or lesser numbers and migrate towards bacteria that enter the oral cavity along with food and air. Microbes in the tonsil are actively phagocytosed by leukocytes and macrophages, and some of the leukocytes die. Under the influence of microbes and various enzymes secreted by leukocytes, the epithelium of the tonsil is often destroyed. However, after some time, due to the proliferation of cells of the epithelial layer, these areas are restored.
The lamina propria of the mucous membrane forms small papillae that protrude into the epithelium. The loose fibrous connective tissue of this layer contains numerous lymph nodes. In the centers of some nodules, lighter areas are clearly visible - germinal centers. Lymphoid nodules of the tonsils are most often separated from each other by thin layers of connective tissue. However, some nodules may merge. The muscular plate of the mucous membrane is not expressed.
The submucosa, located under a cluster of lymphoid nodules, forms a capsule around the tonsil, from which connective tissue septa extend deep into the tonsil. This layer contains the main blood and lymphatic vessels of the tonsil and the branches of the glossopharyngeal nerve that innervate it. The secretory sections of the small salivary glands are also located here. The ducts of these glands open on the surface of the mucous membrane located around the tonsil. Outside the submucosa lie the striated muscles of the pharynx - an analogue of the muscular coat.
Pharyngeal tonsil located in the area of the dorsal wall of the pharynx, lying between the openings of the auditory tubes. Its structure is similar to other tonsils. In the adult body, it is lined with multilayered squamous non-keratinizing epithelium. However, in the crypts of the pharyngeal tonsil and in adults, areas of pseudostratified ciliated epithelium, characteristic of the embryonic period of development, are sometimes found.
In some pathological conditions, the pharyngeal tonsil can be very enlarged (the so-called adenoids).
Lingual tonsil located in the mucous membrane of the root of the tongue. The epithelium covering the surface of the tonsil and lining the crypts is stratified squamous, non-keratinizing. The epithelium and the underlying lamina propria are infiltrated by lymphocytes penetrating here from the lymph nodes. At the bottom of many crypts, the excretory ducts of the salivary glands of the tongue open. Their secretion helps to wash and cleanse the crypts.
81. Large salivary glands, their structure. Teeth and their development.
