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CHRONIC TONSILITIS

Moderator :
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

WALDEYERS RING

VASCULARISATI
ON

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
Parainfluenza
Other
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 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

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 is
between 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 use
in children under three years.
(CPG tonsillectomy for children, 2011)

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

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 or
Benzathine penicillin G 1.2 million U IM once or
Amoxicillin 500-875 mg PO q12h or 250-500 mg PO q8h for 10d or
Pediatric dosage:
Penicillin V 25-50 mg/kg/day divided q6h for 10d or
Benzathine penicillin G 25,000 U/kg IM once (maximum 1.2 million U) or
Amoxicillin 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 or
Clarithromycin 250 mg PO q12h for 10d or
Erythromycin base 500 mg PO QID for 10d or
Clindamycin 20 mg/kg/day in 3 divided doses (maximum 1.8 g/d) for 10d
Levofloxacin 500 mg PO once daily for 7d
Pediatric dosage if penicillin allergic:
Azithromycin 12 mg/kg PO once daily for 5d or
Clarithromycin 250 mg PO q12h for 10d or
Erythromycin succinate 20 mg/kg PO BID for 10d or
Clindamycin 20 mg/kg/day PO in 3 divided doses (maximum 1.8 g/d) for 10d

American Academy of
Otolaryngology
indications
for tonsillectomy
Absolute Indication
Relative Indication

a. Swollen tonsils that


causes airway obstruction, severe
dysphagia, sleep disorders
and cardiopulmonary complication
s
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

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 -lactamase
treatment.

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.

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
T3
T3
Hyperemis (+), enlargement (+), detritus (+),
Enlargement of the crypt (+), uneven surface of the tonsil.
Cervical lymph node enlargement (+)

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)

D. DIAGNOSIS: Chronic Tonsillitis


E. 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 patients 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.

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