ACUTE TONSILLOPHARYNGITIS, ITS

SUPPURATIVE COMPLICATION
AND
ACUTE OTITIS MEDIA

Dr Birtukan A.
ACUTE TONSILLOPHARYNGITIS

 Definition- an inflammation of tonsils and

pharynx, including erythema,edema,
exudates, or an enanthem (ulcers,
vesicles).
ETIOLOGY
 Environmental exposures, such as tobacco
smoke, air pollutants and allergens
 Contact with caustic substances, hot food,
and liquids
 Infectious agents
 Viruses; common in < 3 years
 Bacterias; GAS causes 15-30% of tonsilo
pharyngitis in school-age children.
INFECTIOUS ETIOLOGIES
DIAGNOSIS
 Peak age 3-6 years, but common in 3-15yrs
 History and P/E
 Fever, sore throat, dysphagia, dry tongue
 Tonsillar or pharyngeal exudates- a white, grayish, or
yellow exudate that may be blood-tinged
 Erythematous enlarged tonsils
 Palatal petechiae
 Swollen or tender anterior cervical adenopathy
 Absence of cough
CONT…

 Investigation

 Throat culture:

 gold standard for diagnosis

 Rapid antigen detection test (RADT)

 When throat culture is impractical or

inappropriate
 TREATMENT
Goals of therapy
 Reducing duration and severity of clinical signs and
symptoms, including suppurative complications
 Reducing incidence of nonsuppurative
complications
 Highly effective when started within 9 days of onset of
illness.
 Reducing transmission to close contacts by reducing
infectivity
CONT…

 Specific therapy is unavailable for most viral

tonsilopharyngitis. However, nonspecific,
symptomatic therapy can be an important part
of the overall treatment.

 An oral antipyretic/analgesic agent

(acetaminophen or ibuprofen) can relieve fever
and sore throat pain.
CONT…

 Antibiotic therapy of bacterial pharyngitis

depends on the organism identified.

 Early antibiotic therapy hastens clinical

recovery by 12-24 hr.
RECOMMENDED TREATMENT FOR ACUTE
STREPTOCOCCAL TONSILLOPHARYNGITIS
CONT…

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Surgery
 Recurrent Acute Tonsillitis
 Seven episodes in a single year
 Five or more episodes in each of 2 years
 Three or more episodes in each of 3 years

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COMPLICATION

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1. Suppurative complications:
 Bacteremia,
 lymphadenitis
 Endocarditis,
 mastoiditis
 Meningitis, OM
 Peritonsillar abscess and/or cellulitis,
 pneumonia
 Retropharyngeal abscess 12

 sinusitis
CONT…
2. Nonsuppurative complications

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 Glomerulonephritis
 Acute rheumatic fever
 Scarlet fever
 Is a diffuse erythematous eruption that generally occurs
in association with pharyngitis.
 It result of delayed-type skin reactivity to pyrogenic
exotoxin (erythrogenic toxin, usually types A, B or C)
produced by the organism
 PANDAS (Pediatric Autoimmune Neuropsychiatric
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Disorder associated with group A Streptococci)
 PERITONSILLAR CELLULITIS AND/OR
ABSCESS

 Caused by bacterial invasion through the

capsule of the tonsil, leading to cellulitis
and/or abscess formation in the surrounding
tissues.
CONT…
 Most common in adolescents with
antecedent sore throat, improvement prior
to worsening Sxs
 Signs & Symptoms

 Appear acutely ill

 Fever
 sore throat
 Dysphagia
 Trismus
CONT…
 On physical exam
 May note bilateral tonsillar erythema & exudate
 Uvula may be displace away from affected tonsil
 Involved tonsil is anteriorly & medially displaced
 Cervical adenopathy often present

 Peritonsillarspace: superior aspect of tonsil & area

lateral to adenoids and to the area of pyriform sinus
CONT…
Diffuse tonsillar
& pharyngeal
Erythema
Intense erythema
with
acute tonsillar
enlargement
&
palatal
petechiae

highly suggestive
Of Gp A beta-
streptococcal
Infection
Exudative tonsillitis
Seen with either Group A
Beta hemolytic streptococcal
Or EB virus infection.
CONT…
 Diagnosis

 Uvular deviation
 Marked soft palate displacement
 Severe trismus
 Airway compromise
 Localized areas of fluctuance
 CT scan
 CONT…
Treatment
 Surgicaldrainage and antibiotic therapy effective against
group A streptococci and anaerobes. through ;
 needle aspiration,
 incision and drainage, or
 tonsillectomy
 Tonsillectomy should be considered if there is
 Failure to improve within 24 hr of antibiotic therapy and
needle aspiration,
 History of recurrent peritonsillar abscess or recurrent
tonsillitis, or
 Complications from peritonsillar abscess.
RETROPHARNGEAL AND LATERAL
PHARYNGEAL ABSCESS
 Occurs most commonly in children
younger than 3-4 yr of age.
 Rare after 5 yrs of age b/c
retropharyngeal lymph nodes involute
after 5 yrs.
 Evolve over days after minor URI or after
localized trauma to posterior pharyngeal
wall. i.e. fall with stick or object in mouth.
CONT…
 Anatomy
 Retropharyngeal space between
buccopharygeal fascia and prevertebral
fascia
 Extends from skull base to level of T1 or T2
 Two major cervical chains that drain
nasopharynx, adenoids and posterior
paranasal sinuses enter into this potential
space
CONT…
 Etiologic organisms-usually mixed flora
 S. aureus, s. pyogenes, S. viridans, and Klebsiella,
 Anaerobes-Peptostreptococcus, Fusobacterium, and
Bacteroides.
 Signs & Symptoms
 High fever --Dysphagia
 Irritability --Muffled voice
 Meningismus --Persistently hyperext. neck
 ↓ Oral intake --Possible resp. distress
 Stridor
 bulging of the posterior or lateral pharyngeal
wall
 Cervical lymphadenopathy
CONT…
Diagnosis
 Lateral neck XR-neck extended during
inspiration
 show increased width or an air–fluid level in the
retropharyngeal space.
 Culture of an abscessed node provides the
definitive diagnosis,
 CT scan; can reveal central lucency, ring
enhancement, or scalloping of the walls of a
lymph node.
CONT…
 Treatment
 Intubation if acute respiratory distress
 Intravenous antibiotics with or without
surgical drainage.
 Retropharyngeal cellulitis and very small
abscess may be treated with ATBX alone
Large abscess will need I&D by ENT
 Consult ENT for definitive treatment options
 A third-generation cephalosporin combined with
ampicillin-sulbactam or clindamycin to provide
anaerobic coverage is effective .
CONT…
Complications
 upper airway obstruction

 rupture leading to aspiration pneumonia, and

extension to the mediastinum.
 Thrombophlebitis of the internal jugular vein and
erosion of the carotid artery sheath can also
occur.
ACUTE OTITIS MEDIA
ANATOMY OF THE EAR

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 2/12/2019
Definition
 Acute Otitis Media (AOM)
 “acute onset of symptoms, evidence of a middle ear
effusion, and signs or symptoms of middle ear
inflammation.”
 Otitis Media with effusion (OME)
 “Presence of MEE without signs or symptoms of
infection, previously named: secretory,
nonsuppurative, serous, or glue ear. ”
32
CONT…

 The peak incidence and prevalence of OM is

during the 1st 2 yr of life. More than 80% of
children will have experienced at least 1 episode
of OM by the age of 3 yr.

 OM is also the most common cause of hearing

loss in children.
RISK FACTORS

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 Age (<2 yrs),  Exposure to tobacco
 Gender(boys), smoke,
 Race (Native  Exposure to other

American, Inuit, and children,

indigenous Australian  Presence or absence of
children), respiratory allergy,
 Genetic background,  Season of the yr (cold

 Socioeconomic status weather),

(poor),  Vaccination status,

 Breast milk feeding  Congenital craniofacial

(protective) anomalies
34
 ETIOLOGY
Viruses
 Respiratory syncytial virus (RSV
 Influenza viruses
 Parainfluenza viruses
 Rhinovirus
 Adenovirus
Bacteria
 Streptococcus pneumoniae
 Haemphilius influenzae
 Moraxella catarrhalis
 Escherichia coli ,Klebsiella species and 35
Pseudomonas aeruginosa.
CLINICAL FEATURES

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Local Symptoms :
- Otalgia
- Otorrhea ( mucoid )
- Rubbing or tugging of the infected ear
- Hearing loss

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Systemic signs

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 Headache
 Fever
 Anorexia
 Nausea & Vomiting
 Irritability and poor sleep
 There may be a preceding history of upper
respiratory symptoms including :
 Cough
 Rhinorrhoea

37
CONT…

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Otoscopic examination
- When performed correctly, this technique is 90%
sensitive and 80% specific for diagnosis of AOM
 Findings;

 Bulging
 Erythema
 Opacity
 Decreased mobility
 Middle ear effusion (MEE)

38
DIAGNOSIS

A diagnosis of AOM according to the 2013

guideline from the American Academy of Pediatrics
should be made in children who present with:
◆ Moderate to severe bulging of the TM or new-
onset otorrhea not caused by otitis externa
◆ Mild bulging of the TM and recent (<48 hr) onset
of ear pain or intense TM erythema
 A diagnosis of AOM should not be made in children
without MEE.
Normal tympanic membrane Bulged , erythematous ,
opaque TM

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TREATMENT

2/12/2019
 Observation without use of antibacterial
agents in a child with uncomplicated
AOM is an option for selected children
based on diagnostic uncertainty, for >2
years of age, mild illness
 watchful waiting and follow-up

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 CONT…

Analgesics :

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 Paracetamol and ibuprofen

Antibiotics :
 Amoxicillin : 80-90mg/kg

 Amoxacilline and clavulinic acid

 Cefridin, ceftriaxone ( a 3rd generation

cephalosporin ) in combination with
tympanocentesis .

42
 CONT…

For children who are allergic to penicillin:

 Cephalosporins

 Trimethoprim-sulfamethoxazole

 Macrolides

 Fluoroquinolone ( Levofloxacin )

2/12/2019
CONT…

2/12/2019
In uncomplicated AOM :

 Younger than 2 years should be treated with a

10-day.

 Older than 2 years may be treated with a 5- to

7-day.

In severe/recurrent

 All should be treated for a minimum of 10

44
days.
CONT…
 SURGICAL CARE

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Indication

 Sever and refractory pain

 Hyperpyrexia

 Complications of AOM such as facial paralysis,

mastoiditis, labyrinthitis, or central nervous
system infection
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 Immunologic compromise from any source.
 COMPLICATIONS
 Intratemporal :

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 Dermatitis
 Chronic and recurrent OM
 Mastoiditis
 Petrositis
 Labyrinthitis
 Facial paralysis
 Hearing loss
Intracranial :
 Meningitis
 Subdural empyema
 Brain abscess
 Extradural abscess 47
 Lateral sinus thrombosis
 Otitic hydrcepohalus
THANK YOU