2. HISTORY
In the first century AD, Celsus described
tonsillectomy performed with sharp tools
and followed by rinses with vinegar and
other medicinals.
Tonsillitis gained additional attention as a
medical concern in the late 19th century.
Quinsy was considered in the differential
diagnoses of George Washington's death.
3. NORMAL BACTERILOGY
(FLORA) OF TONSIL
Different in health and disease
Polymicrobial
Difference in flora retrived from suface and core samples
Surface: GABHS (disease)
40% of asymptomatic people also have culture positive for
GABHS
Other surface organisms: Haemophilus, Staphylococcus
aureus, Alpha haemolytic streptococci, Branhamella sp.,
Mycoplasma, Chlamydia, various anarobes , viruses like
adenovirus, myxovirus, picorna virus, coronavirus.
Core Samples (F.N.A.): normal tonsils – no growth of
pathogenic organisms.
Disease (recurrent tonsillitis): Haemophilus influenza, S.
Aureus, mixed flora more common, GABHS less common.
4.
Establishment of normal flora in URT begins at birth
6-8 months: Actinomyces, Fusobacterium, Nocardia
Later, Bacteroides, Leptotrichia, Propionibacterium,
Candida
At dentition & 1 year: Fusobacterium increase
Anaerobic : Aerobic = 10:1 (Saliva), due variation in
oxygen concentrations in the oral cavity.
Healthy children upto 5 years can harbour known
aerobic pathogens.
Frequency of pathogens decreases with age, because
of greater immunity.
Changes in bacterial flora is noted in viral illnesses
due to increased adherence of S. Aureus and other
gram negative enteric pathogens (secondary
infection).
6.
Self limiting infection of one or both tonsils.
Isolated episode.
Associated with viral upper respiratory illness
(catarrhal).
Part of systemic infection (eg. Infectious
mononucleosis)
8. Predisposing Factors
Fatigue, exposure to extremes of
temperature, pre existing URTI, known
metabolic and immune diseases.
Epidemic forms: institution settings like
recruit camps, daycare facilities.
9. Epidemiology
Both sexes equally affected.
All age groups
More common in children: 5-15 years of
age.
Peak incidence: 5-6 years of age.
Season: autumn and winter months.
10. Clinical Features
Self limited (4-6 days).
Diagnosis is clinical.
Sudden onset, pyrexial illness (fever and chills), sore throat, pain
on swallowing (due to involvement of the pharyngeal muscles),
dry throat, fullness in throat, otalgia
Systemic upsets: headache, malaise, joint pains.
Examination: pharyngeal erythema, enlarged congested tonsils,
patches of whitish exudate, painful cervical lymphadenopathy
(Jugulodigastric).
Exudate limited to tonsillar fossa, particularly over the crypts, soft
and friable, not adherent to the underlying tissue.
Follicular: multiple small patches.
Membranous/pseudomembranous: coalesce occurs.
Pharyngitis, tongue: coated, thick tenacious mucus within the
oral cavity.
Viral tonsilllitis = Bacterial tonsillitis (severity, duration).
11. Laboratory Evaluation
Leucocytosis
Throat Culture: GABHS, not conclusive to be causative,
results not immediate (24-48 hours), antibiotics,
refractory cases
Rapid Antigen Testing (RTA)
Group A streptococcal antigen
Latex agglutination / ELISA
Results 10 minutes.
Less Sensitive
More Specific
Differntiating between viral and bacterial infection
cost
12. Management
Supportive: proper oral hygiene (lavages with diluted 3%
hydrogen peroxide, warm saline solution), analgesics, hydration,
rest.
Specific: Systemic antibiotics
Penicillin (D.O.C.), erythromycin, tetracycline.
Penicillin + beta lactamase inhibitor (amoxycillin +
clavulanic acid).
Clindamycin
Erthyomycin + metronidazole
Effective when administered with in 24-48 hours of
symptom onset.
Decreases symptoms 12-24 hours sooner.
Prevents suppurative complications.
Diminishes likelyhood of Rheumatic Fever.
Ten full days of therapy (genesis of resistant organisms,
allergym anaphylaxis).
Single dose of dexamethasone (adjuvant therapy).
13. DIFFERENTIAL DIAGNOSIS
Diphtheria
Corynebacterium diphtheria, gram positive, pleomorphic aerobic bacillus,
lethal exotoxin.
Only toxigenic strains infected with bacteriophage can cause diphtheria.
Gradual onset, less pronounced systemic infection, hoarseness stridor
croupy cough.
Exudative tonsillopharyngitis, thick pharyngeal membrane.
Infection can spread to the tonsils, palatate and larynx.
Laryngeal inflammation combined with firm leathery exudative necrotic
gray pharyngeal membrane may result in airway obstrucion.
Removal of this membrane causes bleeding.
Early diagnosis is critical, goal of therapy to neutralize unbound toxin
with antitoxin. Antitoxin must be given in the first 48 hours to be effective,
Myocarditis, Neurological sequlae resembling poliomyelitis & Gullian
Barre syndrome may result.
Organism identified by Flourescent antibody studies, prisence of Klebs-
Loffler bacillus in membrane can be diagnosed with gram staining.
Airway obstruction – tracheostomy. Penicillin high doses.
14.
Vincent's angina
Ulcerative gingivitis and stomatitis
Simultaneous infection of Spirocheta denticulata
and Vincent's fusiform bacillus (Borrelia vincenti or
Treponema vincentii)
Gradual onset, mild local and systemic symptoms.
Poor orodental hygiene, overcrowded conditions.
High fever headache sore throat.
Cervical lymohadenopathy, gray necrotic
membrane on the tonsil, when removed reveals
ulcer confined to surrounding tissue, heals in 7-10
days. Necrosis of the surface mucosa, contains
the infecting organism. Sloughing to the
membrane produces bleeding.
Penicillin therapy, oral hygeine.
Trench mouth – ulcers include the gums and oral
mucus membrane.
15.
NEISSERIA
Neisseria gonorrhoea.
Common in homosexual men
Acute exudative tonsillitis, gonococcal pharyngitis.
Asymptomatic to exudative pharyngitis, disseminated
gonococcemia.
Penicillin and tertracycline.
Herpangia
Coxsackievirus
Small vescicles with erythematous base that become
ulcers.
Spread over the anterior pillar, tonsils, palate and
posterior pharynx.
16.
Infectious Mononucleosis
Ebstein Barr Virus, B lymphocytic Human Herpes Virus,
oral contact, young adults.
Acute Phanyngotonsillitis, large swollwn dirty gray
tonsils. Petechiae located at the junction of hard and
soft palate.
High fever, general malaise, haematological and liver
function disturbance, spleenomegaly, posterior cervical
lymphadenopathy, generalized lymphadenapathy.
DLC – 50% lymphocytosis, 10% atypical lymphocytes.
Serology – Monospot blood test, Serum heterophill
antibody titer (Paul Bunnel Davidsohn or Ox-cell
haemolysis).
Confirmation – specific EBV anibody tests (serological
assays).
30% - seconday bacterial infection. Beta haemolytic
streptococci, antibiotics – penicillin high dose
Ampicillin avoided, severe allergic rash.
Airway compromise – short course of high dose
conrticosteroids.
17. Complications
Suppurative
Peritonsillar abscess
Parapharyngeal abscess
Retropharyngeal abscess
Le Miere's syndrome
Non suppurative
Scarlet fever
Acute Rhuematic Fever
Post Streptococcal glomerulonephritis
Tonsillitis and Psoriasis
18. Peritonsillar Abscess
Principal compication, recurrent tonsillitis, chronic tonsillitis inadequately
treated. Unilateral.
Collection of pus between the tonsillar capsule and tonsillar bed, spread
of infection from superior pole of tonsil.
Severe pain referred otalgia, drooling of saliva (due to odynophagia,
dysphagia), trismus (pterygoid muscles), breath becomes rancid, speech
– nasal or thickened (hot potato), dehydration.
Examination is difficult (trismus), oral topical anaesthetic solution.
Gross unilateral swelling of palate and anterior pillar with displacement of
tonsil medially with reflection if uvula to the opposite side. Marked
associated lymphadenopathy.
Cultures – polymicrobial infection.
Needle aspiration – test aspirate, identify the site of abscess.
Ct scan with contrast– extension of infection.
Inferior extension of pus – supraglottic edema, airway obstruction.
Spontaneous drainage – into oral cavity.
Adequate hydration, parenteral antibiotics.
19.
Incision and drainage
Topical anaesthesia (4% to 5% Xylocaine) placed
against the tonsillar pillars, injectable avoided,
Supplemental anaesthetic - intranasally into
sphenopalatine ganglion.
IV analgesics.
Children – ET intubation and General anaesthesia.
Position – awake (sitting, partially reclining, head
supported), GA (head down, Trendelenburg position).
Long handled scalpel, No.11 Blade (guarded), blunt
tipped haemostatic forcep.
Tonsillectomy
Absess tonsillectomy – a chuad
3-4 days – a tiede
4-6 weeks – a froid
20.
Complications
Infection seeding (regional and distant sites).
Supraglottic edema (emergency tracheostomy).
Endocarditis, nephritis, peritonsillitis, brain
abscess.
Local venous thrombosis / phlebitis.
Extension into the pharyngomaxillary space –
external drainage, through the submandibular
triangle,
Necrotizing fascitis.
Perichondritis of thyroid cartilage.
Aspiration – pneumonitis, pulmonary abscess.
Spontaneous haemorrhage – carotid / jugular
vessels, vessels erosion.
21. Parapharyngeal Abscess
Between superior constrictor muscle and deep cervical fascia.
Pain, Fever, leucocytosis. Trismus (pterygoid), stiff neck
(paraspinal muscles).
Swelling of lateral pharyngeal wall especially behind the posterior
pillar, Anteromedial displacement of tonsil on the lateral
pharyngeal wall.
Thickness of sternocleidomastoid (fluctuance).
May spread down the carotid sheath into the mediastinum
(mediastinitis), retroperitoneal sepsis.
CT scan with contrast – to differentiate between peritonsillar
abscess.
Neorological deficit – Cr. N. IX, X, XII.
Agressive antibiotic therapy, fluid replacement.
Incision and Drainage – external approach, transverse
submandibular incision, approx. 2 cm inferior to the mandibular
margin.
22. Retropharyngeal Abscess
Infants, young children below 5 years
Retropharyngeal space, cranial base (superior limit), retroviseral
space – into the mediastinum upto the level of bifurcation of
trachea (inferior limit). Lymphoid tissue (nose, paranasal sinuses,
pharynx, eustachian tube)
Buccopharyngeal fascia is adhrent to prevertebral fascia in
midline, infection is unilateral.
Irritability, fever, dysphagia, muffled speech, noisy breathing, stiff
neck, cervical lymphadenopathy, airway compromise.
X – ray, USG, CT contrast.
High dose antibiotics, Incision and Drainage under GA, ET tube,
drained per orally, vertical incision on lateral aspect of posterior
pharyngeal wall.
23. Le Mierre's Syndrome
Rare and fatal complication
Septic thrombophlebitis of internal jugular vein.
Fusiform bacillus.
Severe neck pain, septicaemia, prolonged fulminant
course, secondary to tympanomastoid infection.
Imaging – thrombus in neck veins.
Prolonged six weeks antibiotics.
Anticoagulation – speading thrombophlebitis.
Significant Mortality
24. Scarlet Fever
Secondary to acute streptococcal
tonsillitis/pharyngitis. Thick membranous tonsillitis.
Due to production of endotoxin by bacteria.
Marked erythema of pharyngeal mucosa,
characteristic – strawberry tongue, prominent lingual
papillae, diffuse erythematous skin rash, severe
lymphadenopathy, memebrane more friable than that
of diphtheria.
Diagnosis – throat cultures, immune testing, Dick's
test (intradermal injection of dilute streptococcal toxin),
Schultz Charlt blanching phenomenon (convalescent
serum causes the rash to fade).
IV penicillin.
Otologic complications – necrotizing otitis media
25.
Tonsillitis and Psoriasis
Exacerbation, guttate variety, immune
phenomenon
Acute Rheumatic Fever
Post streptococcal glomerulonephritis
Both after pharyngeal and skin
infection, acute nephritic syndrome, 1-2
weeks, common antigen of glomerulus
and streptococcus.
Recurrent Tonsilltis
Sub acute Tonsillitis
Chronic Tonsillitis
