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Overview
The palatine tonsils are dense compact bodies of lymphoid tissue that are located in the lateral
wall of the oropharynx, bounded by the palatoglossus muscle anteriorly and the
palatopharyngeus and superior constrictor muscles posteriorly and laterally.[1]
The adenoid is a median mass of mucosa-associated lymphoid tissue. It is situated in the roof and
posterior wall of the nasopharynx.[2] The adenoid was first described in 1968 by the Danish
physician Meyer in his paper Adenoid Vegetations in the Nasopharyngeal Cavity.[3]
Both tonsils and adenoid are part of the Waldeyer ring, which is a ring of lymphoid tissue found
in the pharynx. The lymphoid tissue in this ring provides defense against pathogens. The
Waldeyer ring is involved in the production of immunoglobulins and the development of both B
cells and T cells.[1]

Gross Anatomy
Tonsil
The tonsils begin developing early in the third month of fetal life. They arise from the endoderm
lining, the second pharyngeal pouch, and the mesoderm of the second pharyngeal membrane and
adjacent regions of the first and second arches. The epithelium of the second pouch proliferates
to form solid endodermal buds, growing into the underlying mesoderm; these buds give rise to
tonsillar stroma. Central cells of the buds later die and slough, converting the solid buds into
hollow tonsillar crypts, which are infiltrated by lymphoid tissue.[4]
Both right and left tonsils form part of the circumpharyngeal lymphoid ring. The size of the
tonsil varies according to the age, individuality, and pathologic status. At the fifth or sixth year of
life, the tonsils rapidly increase in size, reaching their maximum size at puberty. At puberty, the
tonsils measure 20-25 mm in vertical and 10-15 mm in transverse diameters.[2]
Anatomic relations
Anteriorly and posteriorly, the tonsil is related to the palatoglossus and palatopharyngeus
muscles, lying within their respective folds. A few fibers of the palatopharyngeus are found in
the tonsil bed and are attached to the lower part of the capsule along with the fibers of the
palatoglossus. Superiorly, the tonsil extends into the edge of the soft palate; inferiorly, the
tonsillar capsule is firmly attached to the side of the tongue (see the images and videos below).[5]

Tonsils and adenoids, anterior and sagittal view.


On the lateral surface, the tonsil has a thin distinct capsule, which is formed from condensation
of pharyngobasilar fascia. This fascia extends into the tonsil itself, forming septa, which allow
passage of nerves and vessels.[1]
Deep to the pharyngobasilar fascia, in the upper part of the fossa, is the superior constrictor ;
below it is the styloglossus passing forward into the tongue. The buccopharyngeal fascia is
situated lateral to the superior constrictor . The glossopharyngeal nerve and stylohyoid ligament
pass obliquely downward and forwards beneath the lower edge of the superior constrictor in the
lower part of the tonsillar fossa. The paratonsillar vein descends from the soft palate across the
lateral aspect of the capsule of the tonsil before piercing the pharyngeal wall to join the
pharyngeal plexus.[5]
The medial free surface projects into the oropharynx and is covered by a thin layer of stratified
squamous epithelium, which extends from the surface deep into the tonsil, forming crypts.[1] The
medial surface has a pitted appearance; each tonsil has 10-20 pits. The openings of the crypts are
fissurelike, and the walls of the crypt lumina are collapsed and in contact with each other.[2]
The mouth of the supratonsillar fossa (intratonsillar cleft) opens in the upper part of the medial
surface of the tonsil. The mouth of the cleft is semilunar, curving parallel to the convex dorsum
of the tongue in the parasagittal plane.[2] It is thought to represent a persistent part of the ventral
portion of the second pharyngeal pouch.[5]

A triangular fold of mucus membrane is present during fetal life, extending from the lower part
of the palatoglossal fold to the anteroinferior part of the tonsil. During childhood, this fold is
invaded by lymphoid tissue and is incorporated into the tonsil. A semilunar fold of mucus
membrane is present between the palatopharyngeal arch and the upper pole of the tonsil. This
fold separates the upper pole of the tonsil from the base of the uvula. A tonsillolingual sulcus
separates the tonsils from the base of the tongue.[5]
Vascular supply
The arterial supply of the tonsils is derived from the following arteries:
1. Tonsillar artery
2. Ascending pharyngeal artery
3. Tonsillar branch of the facial artery
4. Dorsal lingual branch of the lingual artery
5. Ascending palatine branches of the facial artery
Venous blood drains through a peritonsillar plexus. The plexus drains into the lingual and
pharyngeal veins, which in turn drain into the internal jugular vein.[3]
Nerve supply
The tonsils are innervated via tonsillar branches of the maxillary nerve and the glossopharyngeal
nerve.[2]
Lymphatic supply
Tonsils do not posses afferent lymphatics. Efferent lymphatics drain directly to the
jugulodigastric nodes and upper deep cervical nymph nodes and indirectly through the
retropharyngeal lymph nodes.[2]

Adenoid
The adenoid develops as a midline structure by fusion of 2 lateral primordia that become visible
during early fetal life.[3] Lymphoid tissue can be identified at 4-6 weeks of gestation, lying within
the mucous membrane of the roof and the posterior wall of the nasopharynx.[6] The adenoid is
fully developed during the seventh month of gestation and continues to grow until the fifth year
of life.[3] The lymphoid tissue of the adenoid may extend to the fossa of Rosenmuller and to the
eustachian tube orifice as Gerlachs tonsil.[6]
A fully grown adenoid is shaped like a truncated pyramid with its base at the junction of the roof
and the posterior wall of the nasopharynx and its apex pointing toward the nasal septum (see the

image and the video below).[2] It does not contain crypts and is not surrounded by a distinct
capsule. The adenoid is formed by vertical folds of respiratory epithelium from which Arey
glands extend.[1] These folds radiate forward and laterally from a median blind recess, the
pharyngeal bursa (bursa of Luschka).[2]

Endoscopic view of adenoid.


Vascular supply
The arterial supply of the adenoid is derived from the following arteries:
1. Ascending pharyngeal artery
2. Ascending palatine artery
3. Tonsillar branch of the facial artery
4. Pharyngeal branch of the maxillary artery
5. Artery of the pterygoid canal
6. Basisphenoid artery
Venous drainage is to the pharyngeal plexus, which communicates with the pterygoid plexus and
then drains into the internal jugular and facial veins.[1, 2, 3]
Nerve supply
The adenoid receives its nerve supply from the pharyngeal plexus.

Lymphatic supply
The lymphatic of the adenoid drains into the retropharyngeal and pharyngomaxillary space
lymph nodes.

Microscopic Anatomy
Tonsil
The tonsil consists of a mass of lymphoid follicles supported by a connective tissue framework.
The lymphocytes are dense in the center of each nodule, an area commonly referred to as the
germinal center (because multiplication of lymphocytes takes place at this center). The tonsillar
crypts penetrate nearly the whole thickness of the tonsil and distinguish it histologically from
other lymphoid organs.[5] The luminal surface of the tonsil is covered with nonkeratinizing
stratified squamous epithelium, and it is continuous with that of the remainder of the oropharynx.
[1, 2]

Adenoid
The adenoid is covered by a pseudostratified ciliated columnar epithelium that is plicated to form
numerous surface folds.[3] The nasopharyngeal epithelium lines a series of mucosal folds, around
which the lymphoid parenchyma is organized into follicles and is subdivided into 4 lobes by
connective tissue septa (see the image below). Seromucous glands lie within the connective
tissue, and their ducts extend through the parenchyma and reach the nasopharyngeal surface.[1]

Microphotograph of adenoid showing


lymphoid follicles and connective tissue septa.

Natural Variants
Tonsil
The tonsil is more active in childhood and gradually becomes smaller during puberty. Its
appearance may give a misleading estimate of its size. Some tonsils appear to lie mostly on the
surface of the throat, with a shallow tonsillar fossa; others appear to be mostly buried in a deep
tonsillar fossa.[5]

Adenoid
A median fold may pass forward from the pharyngeal bursa toward the nasal septum, or a fissure
may extend forward from the bursa, dividing the adenoid into 2 parts, in a reflection of its paired
developmental origin.[2]

Pathophysiologic Variants
Tonsil
Tonsillar involution begins at puberty; by old age, only a little tonsillar tissue remains.[2] Tonsillar
crypts may contain desquamated epithelial debris and cells. Usually, this debris is cleared from
the crypts. Rarely, the debris may remain in the crypts and become hardened and yellow in
appearance.[5]

Adenoid
The adenoid grows rapidly after birth and usually undergoes a degree of involution and atrophy
from the age of 8-10 years. It is rarely seen in adults.[1, 2, 3]

Other Considerations
Tonsils
The lateral surface of the tonsil is covered by fibrous capsule, and it is separated from the
oropharynx by loose areolar tissue. This separation makes dissection of tonsil easy during
tonsillectomy.[5]

Adenoid
The bed of the nasopharyngeal tonsil is supplied by the basisphenoid artery; this is a possible
source of persistent postadenoidectomy hemorrhage in some patients.[2]