Download - 9 - Chronic Tonsillitis & Pharyngitis
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Chronic Tonsillitis & Pharyngitis
By Adnan AL-Maaitah
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Chronic Tonsillitis
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Chronic Tonsillitis
• Halitosis – due to crushing of tonsilloliths• More resistant to antibiotics• Obstruction to breathing – snoring, sleep apnea• Blockage of Eustachian Canal• Dysphagia• Constants feeling of fullness and pain in the throat• Accompany multiple infections• May be with peritonsilar abscess• Persistent tender cervical nodes
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Tonsillolith
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Enlarged tonsils in child with obstructive sleep apnea.
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Tonsillectomy
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Tonsillectomy
• Surgical removal of tonsils or a tonsil• One of the most common surgical procedures among
children• Controversy regarding indications for surgery
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Tonsillectomy / Indications
The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures:
• Absolute indications• Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep
disorders, or cardiopulmonary complications• Peritonsillar abscess that is unresponsive to medical management and drainage
documented by surgeon, unless surgery is performed during acute stage• Tonsillitis resulting in febrile convulsions• Tonsils requiring biopsy to define tissue pathology
• Relative indications• Three or more tonsil infections per year despite adequate medical therapy• Persistent foul taste or breath due to chronic tonsillitis that is not responsive to
medical therapy• Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-
lactamase-resistant antibiotics• Unilateral tonsil hypertrophy that is presumed to be neoplastic
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Tonsillectomy/Contraindications
• Bleeding diathesis• Poor anesthetic risk or uncontrolled medical illness• Anemia• Acute infection (tonsillitis: wait 3 weeks)• Peritonsillar abscess
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Tonsillectomy/Procedure
• Patient lying flat on their backs, with the shoulders elevated on a small pillow so that the neck is hyperextended – the so-called 'Rose' position.
• Tonsil is held by forceps and removed by blunt scalpel or electrocautery
• Bleeding is stopped with electrocautery
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Tonsillectomy/Postop.
• Painful – give adequate analgesia• Hydration• Tonsil beds maybe covered with white or yellowish
exudate (up to 2 weeks) – normal, not pus
• Complications:• Bleeding: primary, reactionary (first 24Hr), secondary (3-7 days)• Sepsis• Chest complications• Otitis media• Peritonsillar abcess
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Normal appearance after tonsillectomy
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Pharyngitis
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Pharynx/Anatomy
• The musculomembranous cavity behind the nasal cavities, mouth and larynx communicating with them and with the esophagus.
• Composed of skeletal muscles lined by mucous membrane.
• Respiratory and digestive function• Divided into:
• Nasopharynx• Oropharynx• Hypopharynx (Laryngopharynx)
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Pharynx/Anatomy
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Pharyngitis
• Inflammation of the mucous membrane and underlying part of the pharynx
• One of the most common causes of absence from school or work
• Vast majority due to viruses• More common in children (peak 4 – 7 yrs)• Affects all races and both sexes equally• Usually associated with URTI
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Pharyngitis
• Causes:• Viral: rhinovirus, adenovirus, EBV, HSV, influenza virus• Bacterial: GABHS• Other: allergy, trauma, toxins, neoplasia
• Predisposing factors:• Smoking (including passive)• Mouth breathing• Rhinosinusitis• Periodontal disease
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Pharyngitis
Pathophysiology:• Viral and bacterial
directly invades the mucosa causing local inflammatory response.
• Some viruses causes inflammation to the mucosa secondary to nasal secretion
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Pharyngitis
• Symptoms:• Sore throat is the main CCx• Fever, headache• Acute: rapid onset, short duration, with dysphagia and malaise• Chronic: persistent, mild soreness, dryness. Eliminate underlying
cause.
• Signs:• Edema and erythema of the pharynx• Exudate can be present
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Pharyngitis
Bacterial• Exposure to known
carrier• High fever, chills,
headache, abdominal pain
• Painful cervical adenopathy
• Rare pathogen < 2 yrs
Viral• Involvement of other
mucous membrane• With sneezing, rhinorrhea
and cough
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An acute inflammation of the part of the throat between the tonsils and the larynx (the pharynx)
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Beefy redness of posterior pharynx, which is the result of infection.
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Phryngitis/Complications
• Usually self limiting• Primary concern in children (3 – 18 yrs) is that untreated
GABHS may cause rheumatic fever• Adjacent organs: otitis media, sinusitis, peritonsillar
abscess• Acute respiratory inflammation• Acute glomerulonephritis• Toxic shock syndrome• Mortality due to airway obstruction (rare)
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Streptococcus pyogenes at 100X magnification.
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Pharyngitis/DDx
• Streptococcal pharyngitis• Non-infectious pharyngitis• Peritonsilar abscess• Pharyngeal candidia• Diphtheria
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Pharyngitis/RRx
• Symptomatic• Rest, oral-fluids, and salt-water gargling are the main
supportive measures• Paracetamol (Acetaminophen) is the DOC in high pain and
fever• Antibiotics are indicated for clinically suspected and culture
or antigen verified GAS infection. Prevent rheumatic fever if given 9 days from onset
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