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  • CHRONIC TONSILITISModerator : Dr. Agung

    Presenters: L 12.1

  • INTRODUCTIONHealth 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.

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

  • ANATOMY

  • WALDEYERS RING

  • VASCULARISATION

  • The tonsils vascularisation : Ascending pharyngealAscending palatineDescending palatineLingual & Facial arteries

  • LYMPHATIC DRAINAGEThe lymphatic drainage lymph node tonsillar (behind mandibula), superior deep cervical & jugular lymph nodes inflammatory cervical adenitis/abscess in children.

  • INNERVATIONThe 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

  • DEFINITIONTonsilitis: 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)

  • ETIOLOGIBacteria 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 Parainfluenza Other Mycobacterium (atypical nontuberculous) Candida albicans

  • Predisposing FactorsBad hygiene & overcrowdingDiminished resistanceSudden change of weatherOral & nasal infections

  • GRADING

  • PATHOGENESISInflammation and loss of integrity of the cryptepithelium chronic cryptitis and crypt obstruction, leading to stasis of crypt debris and persistence of antigen. Bacteria eveninfrequently found in normal tonsil crypts may multiply and establish chronic infection.

  • PATHOGENESISWith 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-chainpositive 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).

  • PATHOGENESISRecurrent 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 & SYMPTOMChronic sore throat, malodorous breath, excessive tonsillar debris (tonsilloliths),peritonsillar erythemapersistent, 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 515 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 TonsillitisBacterial : 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. Swollentonsilsthat causesairwayobstruction,severe dysphagia, sleep disorders andcardiopulmonarycomplicationsb. Peritonsilabscessesthatdo not improve with medical treatment anddrainagec. Tonsillitisthat causesfebrile seizuresd. Tonsillitisthat requirea biopsytodetermine theanatomicpathology

    Relative Indication

    a. Tonsil infections occurred 3ormore episodes per year withadequateantibiotic therapyb. Halitosisdue to chronic tonsillitisthatdoes not improve withmedicaltherapyc. Chronicorrecurrenttonsillitis causes by streptococcal career thatdoes not improve with antibiotic-resistant-lactamase treatment.

  • OTOLARYNGOLOGY- HEAD AND NECK SURGERYClinicians 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 >38.3C, 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 REPORTIDENTITYName : FAge : 14 years oldGender : FemaleReligion : IslamEducation : SMPAdress: KlatenMedical record no: 773385Date of visit : Friday , 29 March 2013

  • B.ANAMNESIS.Main Complaint: Discomfort in the throatHistory 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 (+) nume