Chronic Tonsillitis & Pharyngitis

By Adnan AL-Maaitah

Chronic Tonsillitis

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

Tonsillolith

Enlarged tonsils in child with obstructive sleep apnea.

Tonsillectomy

Tonsillectomy
Surgical removal of tonsils or a tonsil One of the most common surgical procedures among children Controversy regarding indications for surgery

Tonsillectomy / Indications
The American Academy of OtolaryngologyHead 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 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 betalactamase-resistant antibiotics Unilateral tonsil hypertrophy that is presumed to be neoplastic

Relative indications

Tonsillectomy/Contraindications
Bleeding diathesis Poor anesthetic risk or uncontrolled medical illness Anemia Acute infection (tonsillitis: wait 3 weeks) Peritonsillar abscess

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

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

Normal appearance after tonsillectomy

Pharyngitis

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)

Pharynx/Anatomy

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

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

Pharyngitis
Pathophysiology: Viral and bacterial directly invades the mucosa causing local inflammatory response. Some viruses causes inflammation to the mucosa secondary to nasal secretion

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

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

An acute inflammation of the part of the throat between the tonsils and the larynx (the pharynx)

Beefy redness of posterior pharynx, which is the result of infection.

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)

Streptococcus pyogenes at 100X magnification.

Pharyngitis/DDx

Streptococcal pharyngitis Non-infectious pharyngitis Peritonsilar abscess Pharyngeal candidia Diphtheria

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