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Tonsil and Adenoid Anatomy
Updated: Jul 20, 2015
Author: B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg); Chief Editor: Arlen D Meyers,
MD, MBA more...
OVERVIEW
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 mucosaassociated lymphoid tissue. It is situated in the roof and
posterior wall of the nasopharynx. [2] The adenoid was first described in 1868 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 2025 mm in vertical and 1015 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]
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Tonsils and adenoids, anterior and sagittal view.
View Media Gallery
Palatine tonsils.
View Media Gallery
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Flexible nasopharyngoscopy demonstrating adenoids and tonsils from perspective of nose and nasopharynx.
This view is very different from view obtained by looking through mouth and yields better approximation of
degree of obstruction caused by adenoids and tonsils. Video courtesy of Ravindhra G Elluru, MD, PhD.
View Media Gallery
View of tonsils and adenoids through mouth. CroweDavis mouth gag has been used to open oral cavity.
Endotracheal tube can be visualized going from mouth through vocal folds into trachea. Palatine tonsils
located on either lateral aspect of oropharynx can be easily visualized. Lingual tonsils are at base of tongue
directly below endotracheal tube at point where tongue meets epiglottis. Adenoids are visualized via 120
degree endoscope. Adenoids lie in nasopharynx, lined laterally by torus tubarius. Choanae (posterior openings
to nose and posterior septum) can be seen at far side of picture. Video courtesy of Ravindhra G Elluru, MD,
PhD.
View Media Gallery
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 1020 pits. The openings of the crypts are
fissurelike, and the walls of the crypt lumina are collapsed and in contact with each other. [2]
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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 46 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 Gerlach’s 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]
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Endoscopic view of adenoid.
View Media Gallery
View of nasopharynx after adenoidectomy performed with suction cautery. Charred area is residual adenoid
pad. Torus tubarius, choanae, and posterior septum are much more visible after removal of adenoids. Video
courtesy of Ravindhra G Elluru, MD, PhD.
View Media Gallery
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
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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.
View Media Gallery
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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 810 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]
References
1. Kenna MA, Amin A. Anatomy and physiology of the oral cavity. Snow JB, Wackym PA.
Ballenger’s Otorhinolaryngology Head and Neck Surgery. 17th ed. Shelton: BC Decker Inc;
2009. 769774.
2. Susan S, Harold E, Jermiah CH, David J, Andrew W. Pharynx (chapter 35). Gray’s Anatomy:
The Anatomical Basis of Clinical Practice. 39th ed. Philadelphia: Elsevier; 2005. 619631.
https://emedicine.medscape.com/article/1899367-overview#a4 7/10
1/15/2018 Tonsil and Adenoid Anatomy: Overview, Gross Anatomy, Microscopic Anatomy
3. Wiatrak BJ, Woolley AL. Pharyngitis and adenotonsillar disease. Cummings CW, Fredrickson
JM , Harker LA, Crause CJ, Schuller DE, Richardson MA. Otolaryngology Head and Neck
Surgery. 3rd ed. London: Mosby; 1998. 188215.
4. William JL, Lawrence SS, Steven P, William JS. Human Embryology. 3rd ed. Philadelphia:
Elsevier; 2001. 375376.
5. Beasley P. Anatomy of the pharynx and oesophagus. Kerr AG, Gleeson M. ScottBrown’s
Otorhinolaryngology. 6th ed. India: ButterworthHeinemann publications; 1997. 1: 1/10/1 to
1/10/40.
6. Robb PJ. The adenoid and adenoidectomy. Gleeson M. ScottBrown’s Otorhinolaryngology,
Head and Neck Surgery. 7th ed. London: Hodder Arnold; 2008. 1: 10941101.
Media Gallery
Palatine tonsils.
Endoscopic view of adenoid.
Microphotograph of adenoid showing lymphoid follicles and connective tissue septa.
Tonsils and adenoids, anterior and sagittal view.
Flexible nasopharyngoscopy demonstrating adenoids and tonsils from perspective of nose
and nasopharynx. This view is very different from view obtained by looking through mouth
and yields better approximation of degree of obstruction caused by adenoids and tonsils.
Video courtesy of Ravindhra G Elluru, MD, PhD.
https://emedicine.medscape.com/article/1899367-overview#a4 8/10
1/15/2018 Tonsil and Adenoid Anatomy: Overview, Gross Anatomy, Microscopic Anatomy
View of tonsils and adenoids through mouth. CroweDavis mouth gag has been used to open
oral cavity. Endotracheal tube can be visualized going from mouth through vocal folds into
trachea. Palatine tonsils located on either lateral aspect of oropharynx can be easily
visualized. Lingual tonsils are at base of tongue directly below endotracheal tube at point
where tongue meets epiglottis. Adenoids are visualized via 120 degree endoscope. Adenoids
lie in nasopharynx, lined laterally by torus tubarius. Choanae (posterior openings to nose and
posterior septum) can be seen at far side of picture. Video courtesy of Ravindhra G Elluru,
MD, PhD.
View of nasopharynx after adenoidectomy performed with suction cautery. Charred area is
residual adenoid pad. Torus tubarius, choanae, and posterior septum are much more visible
after removal of adenoids. Video courtesy of Ravindhra G Elluru, MD, PhD.
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Contributor Information and Disclosures
Author
B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) Professor of Otolaryngology (ENT), Sri
Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute,
India
B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) is a member of the following medical
societies: Association of Otolaryngologists of India, Indian Medical Association, Indian Society of
Otology
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of
Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of
Facial Plastic and Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck
Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians
Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians
Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for
consulting; .
Acknowledgements
The authors would like to thank their teachers and family members for their encouragement.
Medscape Reference thanks Ravindhra G Elluru, MD, PhD, Associate Professor, Department of
Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine; Pediatric
Otolaryngologist, Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, for
the video contributions to this article.
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