CHRONIC TONSILITISModerator :

Dr. Agung

Presenters:

L 12.1

INTRODUCTION Health problems from disease in the tonsils are among

the most commonly encountered in the general population.

Complaints of sore throat, upper respiratory infection (URI), and associated ear disease account for the greatest number of patient visits in most primary care settings dealing with children.

Tonsillitis most often occurs in children, rarely, children younger than 2 years. Tonsillitis caused by streptococcus species typically occurs in children aged 5-15 years, while viral tonsillitis is more common in younger children.

ANATOMY

TONSIL (Tonsila Palatina)A paired, in general ovoid shaped masses located on the lateral walls of the oropharynx. (Bailey, 1998)

ANATOMY

WALDEYER’S RING

VASCULARISATION

The tonsils vascularisation : Ascending pharyngeal Ascending palatine Descending palatine Lingual & Facial arteries

LYMPHATIC DRAINAGE• The lymphatic drainage lymph node tonsillar

(behind mandibula), superior deep cervical & jugular lymph nodes inflammatory cervical adenitis/abscess in children.

INNERVATION

- The tonsillar nerves are derived from the tonsilla plexus of nerve from by branch of glossopharyngeal and vagus nerve.

- Other branches are derived from the pharyngeal plexus of nerves.

SCHEMATIC DIAGRAM OF PALATINE TONSIL & THE CELL COMPOSITION

DEFINITION Tonsilitis: defined as inflammation of the tonsils. Acute tonsillitis- present with fever, sore throat, foul breath,

dysphagia, odynophagia and tender cervical lymph nodes. Airway obstruction may manifest as mouth breath, snoring, sleep-disordered breathing or sleep apnea. Symptoms usually resolved in 3-4 days but may last up to 2 weeks despite adequate therapy.

Chronic tonsillitis- present with chronic sore throat, halitosis, tonsillitis, and persistent tender cervical nodes.

Recurrent streptococcal tonsillitis- 7 culture-proven episodes in 1 year, 5 infections in 2 consecutive years, or 3 infections each year for 3 consecutive years. (medscape)

ETIOLOGI Bacteria

   Aerobic     Group A beta-hemolytic streptococci (GABHS)     Groups B, C, F, streptococcus     Haemophilus influenza (type b and nontypeable)     Streptococcus pneumoniae     Streptococcus epidermidis     Moraxella catarrhalis     Staphylococcus aureus     Hemophilus parainfluenza     Neisseria sp.     Mycobacteria sp.     Lactobacillus sp.     Diphtheroids sp.     Eikenella corrodens     Pseudomonas aeruginosa     Escherichia coli     Helicobacter pylori     Chlamydia pneumoniae

 Anaerobic     Bacteroides sp.     Peptococcus sp.     Peptostreptococcus sp.     Actinomycosis sp.     Microaerophilic streptococci     Veillonella parvula     Bifidobacterium adolescences     Eubacterium sp     Lactobacillus sp.     Fusobacterium sp.     Bacteroides sp.     Porphyromonas asaccharolytica     Prevotella sp.Viruses   Epstein-Barr   Adenovirus   Influenza A and B   Herpes simplex   Respiratory syncytial   ParainfluenzaOther   Mycobacterium (atypical nontuberculous)   Candida albicans

Predisposing Factors

Bad hygiene & overcrowding Diminished resistance Sudden change of weather Oral & nasal infections

GRADING

PATHOGENESIS

Inflammation and loss of integrity of the crypt

epithelium chronic cryptitis and crypt

obstruction, leading to stasis of crypt debris and

persistence of antigen. Bacteria even

infrequently found in normal tonsil crypts may

multiply and establish chronic infection.

PATHOGENESIS

With chronic or recurrent tonsillitis, the controlled process ofantigen transport and presentation is altered due to sheddingof the M cells from the tonsil epitheliumThe direct influx ofantigens disproportionately expands the population of matureB-cell clones and, as a result, fewer early memory B cells goon to become J-chain–positive IgA immunocytespersistentantigenic stimulation leads to ianability to respond to otherAntigenstonsil is no longer able to function adequatelyin local protection, nor can it appropriately reinforce the secre-tory immune system of the upper respiratory tract (Reginald etal , 2011).

PATHOGENESIS

Recurrent inflammation causes the mucosal epithelium of the tonsil and lymphoid tissues to eroded and as a result during the healing process the the lymphoid tissues is replaced by the scar tissues enlargment of the crypt.

Contuinity of this process causes invasion to the tonsil capsule and finally causes adhesion to the tissue adhert of the tonsilaris fossa.

SIGN & SYMPTOM

Chronic sore throat, malodorous breath, excessive tonsillar debris (tonsilloliths), peritonsillar erythema persistent, tender cervical adenopathy are

consistent with a diagnosis of chronic tonsillitis when no other source (such as the sinuses or lingual tonsils) can be identified.

The Centor score gives one point each for:

-tonsillar exudate-tender anterior cervical lymph nodes-history of fever-absence of cough.

The likelihood of GAbHS infection increases with increasing score, and isbetween 25-86% with a score of 4 and 2-23% with a score of 1, depending upon age, local prevalence and seasonal variation. Streptococcal infection is most likely in the 5–15 year old age group and gets progressively less likely in younger or older patients.13 The score is not validated for usein children under three years.

(CPG tonsillectomy for children, 2011)

THERAPYAcute Tonsillitis- Bacterial : broad spectrum antibiotic penicillin V 500 mg PO BID for 10d

or 250mg PO QID for 10d, erythromycin base 500 mg PO QID for 10d. Antipyritic such as paracetamol. Mouth wash contain desinfectant.

- Viral: Patient is put to bed and encouraged to take plenty of fluids, analgesic and antiviral.

Chronic tonsilitis :

-Amoxicillin-clavulanate 15-25 mg/kg q8hr PO or

-Clindamycin 20mg/kg/day in three devided doses (max. 1,8 g/d) for 10d

-Another study used cefadroxil 15-25 mg/kg q12hr PO for this case because it work as the same as penicillin.

-tonsillectomy

If results are not available for rapid strep test, culture, or Monospot

Adult dosage:Penicillin V 500 mg PO BID for 10d or 250 mg PO QID for 10d orBenzathine penicillin G 1.2 million U IM once orAmoxicillin 500-875 mg PO q12h or 250-500 mg PO q8h for 10d orPediatric dosage:Penicillin V 25-50 mg/kg/day divided q6h for 10d orBenzathine penicillin G 25,000 U/kg IM once (maximum 1.2 million U) orAmoxicillin 50 mg/kg/day PO in 2 or 3 divided doses for 10d or

Adult dosage if penicillin allergic:Azithromycin 500 mg PO daily for 5d orClarithromycin 250 mg PO q12h for 10d orErythromycin base 500 mg PO QID for 10d orClindamycin 20 mg/kg/day in 3 divided doses (maximum 1.8 g/d) for 10dLevofloxacin 500 mg PO once daily for 7d

Pediatric dosage if penicillin allergic:Azithromycin 12 mg/kg PO once daily for 5d orClarithromycin 250 mg PO q12h for 10d orErythromycin succinate 20 mg/kg PO BID for 10d orClindamycin 20 mg/kg/day PO in 3 divided doses (maximum 1.8 g/d) for 10d  

American Academy of Otolaryngologyindications for tonsillectomyAbsolute Indication

a. Swollen tonsils that causes airway obstruction, severe 

dysphagia, sleep disorders and cardiopulmonary complications

b. Peritonsil abscesses that do not improve with medical treatment  and drainage

c. Tonsillitis that causes febrile seizures

d. Tonsillitis that require a biopsy to determine the anatomic pathology

Relative Indication

a. Tonsil infections occurred 3 or more episodes per year with adequate antibiotic therapy

b. Halitosis due to chronic tonsillitis that does not improve with medical therapy

c. Chronic or recurrent tonsillitis causes by streptococcal career that does not improve with antibiotic-resistant β-lactamase treatment.

OTOLARYNGOLOGY- HEAD AND NECK SURGERY1. Clinicians should watchful waiting for recurrent throat infection if there have

been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.

2. RECURRENT THROAT INFECTION WITH DOCUMENTATION: Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for GABHS.

3. A single, intraoperative dose of intravenous dexamethasone should be given to children undergoing tonsillectomy (statement 7; strong recommendation).

4. Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy (statement 8; strong recommendation).

5. Clinicians should advocate for pain management after tonsillectomy and should educate caregivers about the need to manage and reevaluate pain (statement 9)

CASE REPORT

A. IDENTITY Name : F Age : 14 years old Gender : Female Religion : Islam Education : SMP Adress: Klaten Medical record no: 773385 Date of visit : Friday , 29 March 2013

B.ANAMNESIS. Main Complaint: - Discomfort in the throat History of present illness:- Patient came to the clinic with complain of having enlarged tonsil

since 5 years ago. 3 years ago, she was advised to undergo tonsil surgery but was mentally not prepared to do so. In the beginning, the tonsils would become bigger whenever she had fever, tired, cough or running nose. Whenever the tonsils became enlarged, she felt pain around the throat, hard to swallow and snored when she sleeps. However, as time goes by, she got used to the pain and now she only feel minimal discomfort. She felt very disturbed with the enlarged tonsil because it happens very often even she had adequate treatment for her sickness.

History of past illness:

- History of the same complaints (+) numerous times since 5 years ago

- History of allergy denied History of illness in family members:- History of the same complaints (+) her sister

had tonsillectomy - History of allergy denied

B. PHYSICAL EXAMINATION General status: well conscious, adequately

nourished Vital Sign :-Blood pressure: 110/70mmHg-Pulse: 84x/min-Respiration: 20x/min-Temperature: 37degree

Otorhinolaryngology Examination

AD AS

Normal

AD AS Normal

Rhinoscopy anterior: within normal limits. Mouth:-lip, palatum, uvula and tongue is in normal limits Oropharynx:- Hyperemis (-), - Granulation(-),Tumor(-) Tonsil- Hyperemis (+), enlargement (+), detritus (+),- Enlargement of the crypt (+), uneven surface of the tonsil. Cervical lymph node enlargement (+)

T3 T3

C. DIFFERENTIAL DIAGNOSIS:- Chronic tonsillitis- Peritonsillar abscess- Infectious mononucleosis (glandular fever)- Diphtheria

Chronic Tonsilitis

PTA Infectious Mononucleosi

s

Dipththeria

History - Chronic sore throat- Halitosis- Tonsillitis- Persistently tender cervical nodes

- Worsening sore throat, usually unilateral- T > 38C- Difficulty opening your mouth- Odinophagia- Dysphagia, which may lead to drooling saliva- Changes to your voice or difficulty speaking - Halitosis, earache on the affected side (nhs.uk)

- Mostly asymptomatic- Sore throat- Fatigue and malaise- Low grade fever- Nausea and anorexia- Cough, ocular muscle pain, chest pain, photophobia may be present (medscape)

- Early: sore throat, loss of appetite, slight fever- Bleeding from mouth- Severe: swollen neck, obstructed airway (WHO)

Age Predilexion

Children above 2 y.o (American Academy of Otolaryngology – Head and Neck Surgery)

Teenagers and young adults (nhs.uk)

Primarily a disease of young adults (medscape)

Mostly occur in unimmunized children (WHO)

Chronic Tonsilitis

PTA Infectious Mononucleosi

s

Dipththeria

Physical Exam

- Enlargement of tonsils-Excessive detritus- Tonsil and peritonsillar erythema- Persistent, tender cervical adenopathy are consistent with a diagnosis of chronic tonsillitis when no other source (such as the sinuses or lingual tonsils) can be identified.

- Erythema and exudates of the tonsil- Fever- Asymmetric tonsillar hypertrophy- Inf. and medial displacement tonsil- Contralateral deviation of uvula- Drooling, salivation, trouble handling oral secretion- Trismus- Cervical lymphadenitis- ‘Hot potato’ voice

- Early signs: fever, lymphadenopathy, pharyngitis, rash, and/or periorbital edema- Late: hepatomegaly, palatal petechiae, jaundice, uvular edema, splenomegaly, splenic tenderness

- Within 2 or 3 days a bluish-white or grey membrane forms in the throat, on the tonsils, soft palate of the throat and may bleed- Bleeding happened: membrane become greyish-green or black- Severe: swollen neck (WHO)

D. DIAGNOSIS: Chronic TonsillitisE. TREATMENT- Tonsillectomy F. PROBLEM

Pain (sore throat,othalgia) Dehydration (do not eat d/t pain) Weight loss (d/t decrease meal intake) Fevel (local infection) Hemorrhage

Primary Intraoperative (within first 24 hours) Secondary (between 24 hours to 10 days)

G. PLANNING

1. Use liquid acetaminophen with or without codeine for pain control. For pain control, ketorolac use should be avoided due to high rates of posttonsillectomy hemorrhage.2. Maintain good hydration.3. The patient should eat an adequate diet. No evidence suggests that a special diet is required; however, soft foods are more easily swallowed than hard foods.4. Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children. 5. Instruct the patient to avoid smoking.6. Instruct the patient to avoid heavy lifting and exertion for 10 days.

DISCUSSION

In this case of chronic tonsilitis, main complaints is mild discomfort around the throat.

The patient’s mother stated that the patient snored during sleep since 3 years ago. She also said that sometimes her daughter has bad mouth breathe.

Physical examinations of the patient revealed hyperemic tonsils, detritus, enlargement of the crypt, and uneven surface of the tonsil.

For this patient, no medication is indicated and preparation should be done for subsequent surgery.

CONCLUSION

A female patient aged 14 years old being diagnosed with chronic tonsillitis has been reported. This patient requested for tonsillectomy. If the condition of her health is good, we should plan for the surgery.