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Moderator :
Dr. Agung
Presenters:
L 12.1
INTRODUCTION
ANATOMY
ANATOMY
WALDEYERS RING
VASCULARISATI
ON
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
-
SCHEMATIC DIAGRAM OF
PALATINE TONSIL & THE CELL
COMPOSITION
DEFINITION
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
Parainfluenza
Other
Mycobacterium (atypical nontuberculous)
Candida albicans
Predisposing Factors
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 of
antigen transport and presentation is altered due to shedding
of the M cells from the tonsil epitheliumThe direct influx of
antigens disproportionately expands the population of mature
B-cell clones and, as a result, fewer early memory B cells go
on to become J-chainpositive IgA immunocytespersistent
antigenic stimulation leads to ianability to respond to other
Antigenstonsil is no longer able to function adequately
in local protection, nor can it appropriately reinforce the secretory immune system of the upper respiratory tract (Reginald et
al , 2011).
PATHOGENESIS
THERAPY
Acute 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
American Academy of
Otolaryngology
indications
for tonsillectomy
Absolute Indication
Relative Indication
OTOLARYNGOLOGY- HEAD
AND NECK SURGERY
1.
2.
3.
4.
5.
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.
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.
A single, intraoperative dose of intravenous dexamethasone should be given
to children undergoing tonsillectomy (statement 7; strong recommendation).
Clinicians should not routinely administer or prescribe perioperative
antibiotics to children undergoing tonsillectomy (statement 8; strong
recommendation).
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.
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
C. DIFFERENTIAL DIAGNOSIS:
- Chronic tonsillitis
- Peritonsillar abscess
- Infectious mononucleosis (glandular fever)
- Diphtheria
Chronic
Tonsilitis
History
Chronic sore
throat
- Halitosis
- Tonsillitis
- Persistently
tender cervical
nodes
-
PTA
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
-
Infectious
Mononucleosi
s
Mostly
asymptomatic
- Sore throat
- Fatigue and
malaise
- Low grade fever
- Nausea and
anorexia
- Cough, ocular
muscle pain,
chest pain,
photophobia may
be present
-
Dipththeria
Early: sore
throat, loss of
appetite, slight
fever
- Bleeding from
mouth
- Severe:
swollen neck,
obstructed
airway (WHO)
-
(medscape)
(nhs.uk)
Age
Predilexio
n
Children above 2
y.o (American
Teenagers and
young adults
Academy of
Otolaryngology Head
and Neck Surgery)
(nhs.uk)
Primarily a
disease of young
adults (medscape)
Mostly occur in
unimmunized
children (WHO)
Chronic
Tonsilitis
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.
-
PTA
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
-
Infectious
Mononucleosi
s
Early signs:
fever,
lymphadenopathy,
pharyngitis, rash,
and/or periorbital
edema
- Late:
hepatomegaly,
palatal petechiae,
jaundice, uvular
edema,
splenomegaly,
splenic
tenderness
-
Dipththeria
Within 2 or 3
days a bluishwhite 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)
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
CONCLUSION