TONSILLITIS

Fahad zakwan
MD5

Contents
Overviews
Clinical

presentations

Ddx
Complications
Investigations
Treatment

& managements.
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ANATOMY
The tonsils are 3 masses of tissue:
- lingual tonsil
- pharyngeal (adenoid) tonsil
- palatine or fascial tonsil
Together they form Waldeyer's ring
are lymphoid tissue
covered by respiratory epithelium
- pseudostratified ciliated
columnar epithelium

..
produce

lymphocytes
are active in the synthesis of immunoglobulins
a ring of lymphoid tissue in the oropharynx
and nasopharynx
are thefirst lymphoid aggregates in the
aerodigestive tract thought to play a role in
immunity
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Normal Tonsils

Anatomycont
Ovoid-shaped
are located laterally in the oropharynx
are bordered by the following tissues:
- Deep - Superior constrictor muscle
- Anterior - Palatoglossus muscle
- Posterior - Palatopharyngeus muscle
- Superior - Soft palate
- Inferior - Lingual tonsil

Blood supply
through the external
carotid artery branches:
Superior pole

Ascending pharyngeal artery

(tonsilar branches)
Lesser palatine artery

Inferior pole

Facial artery branches

Dorsal lingual artery
Ascending palatine artery
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..
Venous

outflow - by the plexus around the

tonsilar capsule, the lingual vein, and the
pharyngeal plexus.
Lymphatic drainage - the superior deep
cervical nodes, the jugulodigastric nodes.
Sensory supply - the glossopharyngeal
nerve, the lesser palatine nerve
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Anatomic & physiologic diff btn

normal Adenoid and Tonsil
ADENOID

1.Anatomic location
2.Gross

posterior wall of
nasopharynx
Triangular shape
few crypts

TONSIL

lateral wall of oropharynx

ovoid shape
20-30 crypts

3.microscopic

Transitional antigen
processing.
No afferent fibers

Specilized antigen
processing.
No afferent fibers

4.physiology

Muciliary clearance
Antigem processing
Immune survellence

Mucilliary clearance
Antigen processing
Immune survellence
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Tonsillitis
Tonsillitis

is inflammation of the pharyngeal

tonsils.
The inflammation usually extends to the
adenoid and the lingual tonsils; therefore, the
term pharyngitis may also be used.
Lingual tonsillitis refers to isolated
inflammation of the lymphoid tissue at the
tongue base.
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Classification
Infection/inflammation
Acute tonsilitis
Recurrent tonsilitis
Chronic(persistent) tonsilitis
Tonsiliolithiasis
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obstructions
Nasopharyngeal
oropharyngeal
combined
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Pathophysiology and Etiology

Viral or bacterial infections and immunologic factors lead to

tonsillitis and its complications. Overcrowded conditions and
malnourishment promote tonsillitis. Most episodes of acute
pharyngitis and acute tonsillitis are caused by viruses such as
the following:

Herpes simplex virus

Epstein-Barr virus (EBV)
Cytomegalovirus
Other herpes viruses
Adenovirus
Measles virus
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Bacteria cause 15-30% of cases of pharyngotonsillitis.

Anaerobic bacteria play an important role in tonsillar
disease.
Most cases of bacterial tonsillitis are caused by group A
beta-hemolytic Streptococcus pyogenes (GABHS).
S pyogenes adheres to adhesin receptors that are located
on the tonsillar epithelium.
Immunoglobulin coating of pathogens may be important
in the initial induction of bacterial tonsillitis.

Mycoplasma pneumoniae, Corynebacterium diphtheriae,

and Chlamydia pneumoniae rarely cause acute pharyngitis.
Neisseria gonorrhea may cause pharyngitis in sexually
active persons.
Arcanobacterium haemolyticum is an important cause of
pharyngitis in Scandinavia and the United Kingdom but is
not recognized as such in the United States.
A rash similar to that of scarlet fever accompanies A
haemolyticum pharyngitis.

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ACUTE TONSILITIS
This

is the commonest URTI in children.

Occurs up to the age of 15
Its common in all sexes
Viral: HSV, EBV,CMV, Adenovirus, Measles.
Bacteral: anaerobes, group A beta hemolytic
strepto pyogens, mycoplasma, chlamydia,
N.gonorrhea.
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ACUTE TONSILLITIS-TYPES
Acute catarrhal/superficial here tonsillitis is a part of
generalized pharyngitis, mostly seen in viral infections
Acute follicular infection spread into the crypts with purulent
material, presenting at the opening of crypts as yellow spots
Acute parenchymatous tonsil in uniformly enlarged and
congested
Acute membranous follows stage of acute follicular tonsillitis
where exudates coalesce to form membrane on the surface

Acute catarrhal/superficial

Acute follicular

Acute membranous

SIGNS
Halitosis
Coated

tongue
Congestion of pillars, soft palate and
uvula
Jugulo-digastric nodes enlarged and
tender
Tonsils are congested and enlarged
depending on type of acute tonsillitis

TREATMENT
Bed

rest
Plenty of oral fluids
Analgesics
Antimicrobial therapy penicillin
In case of penicillin sensitivity
macrolides are given

COMPLICATIONS
chronic

tonsillitis
peritonsillar abscess
parapharyngeal abscess
cervical abscess
acute otitis media
rheumatic fever
acute glomerulo nephritis
sub acute bacterial endocarditis

DIFFERENTIAL DIAGNOSIS OF
MEMBRANE OVER THE TONSIL
Membranous tonsillitis
Diphtheria
Vincents angina
Infectious mononucleosis
Agranulocytosis
Leukaemia
Traumatic ulcer
Aphthous ulcer
malignancy

CHRONIC TONSILLITIS
Aetiology:
Complication

of acute tonsillitis
Sub clinical infection of tonsil
Chronic sinusitis or dental sepsis
Mostly affects children and young
adults

TYPES OF CHRONIC TONSILLITIS

Chronic

follicular tonsillitis
Chronic parenchymatous tonsillitis :
tonsils are very much enlarged uniformly
and may interfere with speech, deglutition
and respiration, long standing cases may
develop pulmonary hypertension
Chronic fibroid tonsillitis

CLINICAL FEATURES
recurrent

attacks of sore throat

chronic irritation in throat with cough
halitosis
dysphagia
odynophagia
thick speech

SIGNS
Tonsil

may show varying degree of

enlargement depending on the type
Irwin-moore sign pressure on the anterior
pillar expresses frank pus or cheesy material
mainly seen in fibroid type
Flushing of the anterior pillar compared to
rest of the pharyngeal mucosa
Enlargement of the jugulo-digastric node
soft non tender

TREATMENT
conservative

management
tonsillectomy

COMPLICATIONS
Peritonsillar

abscess
Parapharyngeal abscess
Retro pharyngeal abscess
Intra tonsillar abscess
Tonsillar cyst
Tonsillolith
Focus of infection for RF, AGN

Clinical presentation
1.HISTORY
Individuals with acute tonsillitis present with fever, sore
throat, foul breath, dysphagia, odynophagia and tender
cervical lymph nodes.
Airway obstruction may manifest as mouth breathing,
snoring, sleep-disordered breathing, nocturnal breathing
pauses, or sleep apnea.
Lethargy and malaise are common.
Symptoms usually resolve in 3-4 days but may last up to 2
weeks despite adequate therapy.
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 Recurrent

streptococcal tonsillitis is diagnosed when an

individual has

7 culture-proven episodes in 1 year ,

5 infections in 2 consecutive years, or
3 infections each year for 3 years consecutively .

Individuals

with chronic tonsillitis may present with

chronic sore throat, halitosis, tonsillitis, and persistent
tender cervical nodes.
Children are most susceptible to infection by those in the
carrier state.
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Individuals

with peritonsillar
abscess (PTA) present with severe
throat pain, fever, drooling, foul
breath, trismus (difficulty opening
the mouth), and altered voice
quality (the hot-potato voice).
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2.PHYSICAL EXAM..
Should

begin by determining the degree of distress

regarding airways and swallowing.
Examination of pharynx may be facilitated by mouth
opening without tongue protrusion, followed by
gentle central depression of the tongue.
Full assessment of oral mucosa, dentation, and
salivary ducts may then be performed by gently
walking a tongue depressor about the lateral oral
cavity.
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36

Flexible fiberoptic nasopharyngoscopy may be useful in

selected cases.
Acute tonsilitis reveals fever and enlarged inflammed
tonsil that may have exudates.
Open mouth breathing and voice changes result from
obstructive tonsilar enlargement.
Voice change in acute tonsilitis is not as severe as that
assc with peritonsilar abscess.

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In PTA , pharyngeal edema and trismus cause a hot

potato voice.
Tender cervical nodes and neck stiffness observed in
acute tonsilitis.
Examine skine and mucosa for sign of dehydration.
Chronic tonsilitis,express pus on squeezing the tonsil and
excess tonsilar debris(tonsiliolith)
Hypertrophic inflammed tonsil for childrens and atrophic
tonsil in adult.

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Tonsil in this pt were so swollen that

they caused resp distress
necessitating tonsillectomy

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Palatine tonsil which are bright

red,swollen and coated

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Peritonsilar abscess

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INVESTIGATIONS
Tonsillitis and peritonsillar abscess (PTA) are clinical diagnoses.
Testing is indicated when group A beta-hemolytic
Streptococcus pyogenes (GABHS) infection is suspected.
Throat cultures (sensitivity 90-95%) are the criterion standard
for detecting GABHS.
For patients in whom acute tonsillitis is suspected to have
spread to deep neck structures radiologic imaging using plain
films of the lateral neck or CT scans with contrast is warranted.
In cases of PTA, CT scanning with contrast is indicated

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Lab Studies
Throat

cultures are the criterion standard for

detecting group A beta-hemolytic Streptococcus
pyogenes (GABHS).
GABHS is the principal organism for which antibiotic
therapy (sensitivity 90-95%) is definitely indicated.
Relying only on clinical criteria, such as the presence
of exudate, erythema, fever, and lymphadenopathy,
is not an accurate method for distinguishing GABHS
from viral tonsillitis.
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rapid antigen detection test (RADT), also known as

the rapid streptococcal test, detects the presence of
GABHS cell wall carbohydrate from swabbed material
and is considered less sensitive than throat cultures;
however, the test has a specificity of 95% or more
and produces a result in significantly less time than
that required for throat cultures.
A negative RADT requires that a throat culture be
obtained before excluding GABHS infection.
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Imaging
Routine

imaging is not useful in cases of

acute tonsillitis.
For pts whom acute tonsillitis is suspected to
have spread to deep neck structures (i.e.
beyond the facial planes of the
oropharynx),radiologic imaging using plain
films of lateral neck or CT scan with contrast
is warranted.
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Peritonsilar

abscess CT scan with

contrast is indicated in general for
unusual presentation(e.g. inferior pole
abscess) and for pts at high risk of
drainage procedures.
CTscan may be used to guide needle
aspiration for draining PTA.
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Histology
-

If tonsils are asymmetric

- they should be submitted
separately
- examined histologically to
rule out cancer
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..
Mgt
Medical
-corticosteroids(shorten the duration of fever and
pharyngitis.
- antibiotics(oral penicillin for 10 days),im for non
compliant pt of oral therapy.
- anaelgesics
Surgical
- tonsillectomy
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INDICATIONS FOR TONSILLECTOMY

The

American Academy of Otolaryngology

Head and Neck Surgery (AAO-HNS):
Enlarged

tonsils that cause upper airway

obstruction, severe dysphagia, sleep disorders
Recurrent peritonsillar abscess
Unilateral tonsil hypertrophy that is presumed to
be neoplastic (tumour tonsillectomy)
Chronic or recurrent tonsillitis, Cor pulmonale
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contraindications
Bleeding

disorders

Anemia
Acute

infection
Uncontrolled medical illness
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TONSILLECTOMY
Place

the patient in the Rose

position with a shoulder roll.
Carefully, insert a Davis Boyles
mouth gauge, open and suspend it.
Apply an Alyss clamp to the tonsil to
allow for traction during dissection.
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ROSE POSITION

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..

Variations in dissection methods include the following

- cold steel (eg, scissors, curettes)
- monopolar cautery
- bipolar cautery
- radiofrequency ablation/coblation (can be used to shrink tonsils)
- harmonic scalpel with vibrating titanium blades
- microdebrider - for an intracapsular technique

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..

Variations in haemostasis methods include the following:

- pressure with sponge for several minutes
- bismuth subgallate
- ties
- cautery

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TONSILLECTOMY

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Complications
Haemorrhage
- the most common complication
- intraoperative/primary (occurring within the first 24hrs)
- secondary (occurring between 24hrs and 10 days)
Pain (sore throat, otalgia)
Dehydration (children - do not eat because of pain)
Fever (not common, usually related to local infection)
Postoperative airway obstruction (uvular oedema,
haematoma, aspirated material)

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..
Local

trauma to oral tissues

Temporomandibular joint dislocation
Psychological trauma, night terrors, or depression
Nasopharyngeal stenosis
Death
- uncommon
- bleeding
- or anaesthetic complications
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Refferences.
Head & Neck ENT surgery 4th ed
ABC of ENT
Pubmedcurrent articles 2013
Current diagnosis & treatment in otolaryngology..

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