Anatomy of Inner Waldayer's

ring
By

Dr. T. Balasubramanian
Introduction:

A ring of lympnoid tissue surround the naso pharynx and oro pharynx. These lymphoid tissue
are collectively known as the waldayer's ring. Waldayer's ring has two components, namely the
inner and outer rings. The cervical lymph nodes constitute the outer ring.

The inner Waldayer's ring is formed by:

1. Adenoid at the roof of nasopharynx

2. Tubal tonsil of Gerlac surrounding the pharyngeal ends of eustachean tube

3. Palatine tonsils on either side of oropharynx

4. Lingual tonsil

5. Lymphoid tissue in the submucosal plane of posterior pharyngeal wall

At this juncture it should be borne in mind that all these components are interconnected in the
submucosal plane. If one component of the inner ring is inflammed, it goes without saying the
other components also would be affected in varying degrees.

Role played by the components of Waldayer's ring :

Components of Waldayer's ring serve as antigen sampling centre for the immune system of the
body. Antigen from the inspired air is sampled by adenoid and tubal tonsils, processed and
presented to the immune system.The processed antigen are presented to B lymphocytes so
that immunoglobulins against the antigen can be secreted. To increase the efficiency of antigen
trapping the surface of adenoid has numerous furrows. These furrows not only increases the
surface area of adenoid but also increases the efficiency of antigen sampling function of
adenoid. Similarly palatine tonsils sample ingested antigen. The surface area of tonsil is
increased by the presence of crypts. Each palatine tonsil has about 20 crypts. The largest of
the crypt is known as crypta magna. The largest crypt of palatine tonsil is also known as
supratonsillar cleft. This is a remnant of ventral portion of second pharyngeal pouch. These
crypts increase the surface area of palatine tonsil thereby increasing its antigen trapping ability.
Diagram showing components of Waldayer's ring
 Anatomy of Palatine tonsil

Embryology:
Developmentally this largest member of Waldayer's ring develops from the ventral portion of
second pharyngeal pouch. This portion of the second pharyngeal pouch has been ideally
christened as sinus tonsillaris. Remnants of this portion of the second pharyngeal pouch is
seen in the fully developed tonsillar tissue as supra tonsillar cleft.

Diagram showing development of palatine tonsil

Position:

Palatine tonsils are lodged in the tonsillar fossa on edither side of oropharynx. The tonsillar
fossa is bounded anteriorly by anterior pillar (which is a mucosal fold raised by the underlying
palatoglossus muscle) and posteriorly by the posterior pillar (mucosal fold raised by
palatopharyngeus muscle).

The outer wall of palatine tonsil is encapsulated. This capsule is formed by condensation of
pharyngobasilar fascia. This fascia is also known to extend into the tonsillar tissue to form
septa that conducts blood vessels and nerves into the tonsillar tissue. Deep to this capsular
tissue lie the superior constrictor muscle. Lateral to this muscle is the buccopharyngeal
fascia.

Figure showing anatomical relationships of palatine tonsil

In the lower part of tonsillar fossa the glossopharyngeal nerve and stylohyoid ligament pass
downwards and forwards beneath the lower edge of superior constrictor. All these structures
collectively take part in the formation of tonsillar bed.

Structures forming the tonsillar bed include:

1. Superior constrictor of pharynx

2. Pterygomandibular raphe ­ here superior constrictor and buccinator are inserted

3. Middle constrictor of pharynx

4. Tonsillar branch of facial artery

5. Glossopharyngeal nerve

6. Stylohyoid ligament

Medial surface of tonsil is free and it faces the oropharynx. This surface is covered with non­
keratinizing stratified squamous epithelium which is the epithelium that lines the oral cavity. A
triangular fold of mucous membrane extends back from the palatoglossal fold to cover the
antero­inferior portion of the tonsil. This fold of mucous membrane is known as plica
triangularis. In childhood this fold of mucous membrane is invaded by lymphoid tissue which
gets incorporated into the tonsil.
A semilunar fold of mucous membrane passes from the upper aspect of palatopharyngeal
arch towards the upper pole of tonsil. This fold of mucous membrane known as plica
semilunaris separates the tonsillar tissue from uvula.

Figure showing plica semilunaris

Blood supply of palatine tonsil:

1. Tonsillar branch of facial artery is the main supply. It enters the tonsil close to its lower
pole piercing the superior constrictor muscle just above the styloglossus muscle.

2. Dorsal lingual branches from lingual artery

3. Ascending palatine branch of facial artery

4. Ascending pharyngeal branch of external carotid artery

Venous drainage from tonsil is through the paratonsillar vein. This vein may join the facial
vein or pharyngeal plexus after piercing the superior constrictor. Injury to this vein is the
commonest cause of venous bleeding following tonsillectomy.

Palatine tonsils have only efferent lymphatics. These lymphatics pierce the
buccopharyngeal facia and pass to the upper deep cervical node especially the
jugulodigastric group.

Caution: Internal carotid artery lies 2.5 cms behind and lateral to the tonsil.

Nerve supply to palatine tonsil:

Glossopharyngeal nerve supplies the tonsil. During epidemics of polio it has been
postulated that polio virus may reach the medulla of brain via this nerve causing bulbar
poliomyelitis. That is the reason why tonsillectomy is contraindicated during epidemics of
polio.
The sphenopalatine ganglion supplies the tonsil via the lesser palatine nerves.

Histology of tonsil:

Tonsil is made up of lymphoid follicles within a fine connective tissue matrix. Lymphocytes
are closely packed over the periphery of the follicles. At the centre lymphocytes are less
closely packed because multiplication of lymphocytes occur here, hence this area is known
as germinal centres. The medial surface of the tonsil is characterised by 15 ­ 20 openings
at irregular intervals. These openings lead to blind narrow recesses known as crypts.
These crypts penetrate nearly the whole of the tonsillar tissue. The mucous membrane
covering the tonsil is of non keratinizing stratified squamous type. This epithelium dips
inside to line the crypts. These crypts may contain desquamated epithelial debris. The
largest of these crypts is known as crypta magna, which is present close to the superior
pole of tonsil.
Image showing histology of palatine tonsil

Immunology:

Immunologically tonsils and adenoid are predominantly B cell organs. B lymphocytes

constitute nearly 60% of all lymphoid cell population while the T lymphocytes make up for
the rest 40%.
Immunologically potent cells are found in 4 different zones of tonsil. These zones are:

1. Reticular cell epithelium

2. Extra follicular areas

3. Mantle zone

4. Germinal centre follicles

Human tonsillar cells are immunologically most active between 4­10 years of age.
Tonsillar involution begins after puberty resulting in a decrease in the ratio of T:B cells. In
patients with inflammation of tonsils and adenoid there is sheading of immune cells and
these cells are eventually replaced by stratified squamous epithelium. These changes
thus cause a reduction in the number of B cells leading on to a general reduction in the
body's immunity.
Figure showing immunoglobulin

Adenoid:

This is a collection of lymphoid tissue in the mucous membrane overlying the

basisphenoid area. It is oblong shaped (more or less like a truncated pyramid). It virtually
hangs from the roof of nasopharynx. The anterior edge of adenoid is vertical and lie in
the same plane as the post nasal aperture. Its posterior edge merges imperceptibly into
the posterior nasopharyngeal wall. Its lateral edges incline towards the midline. Its
surface is lined by ciliated columnar epithelium. The surface of adenoid is covered with
furrows. On touch adenoid feels like a bag of worms.

Endoscopic view of adenoid tissue

Blood supply of adenoid:

Adenoid is supplied by

1. Ascending pharyngeal artery

2. Ascending palatine artery

3. Pharyngeal branch of internal maxillary artery

4. Artery of pterygoid canal

5. Contributions from branches of tonsillar branch of facial artery

Venous drainage of adenoid is via the pharyngeal plexus which in turn drain into the
internal jugular vein.

Adenoid enlargement causes a peculiar type of face known as adenoid facies. It is

characterised by:

1. Elongated face

2. Pinched nostrils

3. Open mouth

4. High arched palate

5. Shortened upper lip

6. Vacant idiotic look.

 Xray lateral view of skull showing enlarged adenoid

Adenoid Tonsil

Unencapsulated Encapsulated

Single Two in number

Has furrows Has crypts

Lined by ciliated columnar cells Lined by squamous cells

Present in nasopharynx Present in oropharynx

Has efferent and afferent Has efferent lymphatics only

lymphatics