Tonsillitis

Anatomy

Histology
Specialized squamous epithelium (E) hemi-capsule (Cap) 10-30 Crypts Lymphoid follicles (F)

Grade of Tonsil Size

Grade % 0 in fossa 1 <25 2 25-50 3 51-75 4 >75

Clinical classification
1. Acute Tonsillitis 2. Chronic Tonsillitis (Recurrent Acute Tonsillitis) 3. Obstructive Tonsillar Hyperplasia

Acute tonsillitis

Etiology ()
BLPO (beta-lactamase-producing ) Anaerobic BLPO GABHS (GroupA beta-hemolytic streptococcus): most important pathogen because of potential sequelae

signs and symptoms

High fever, malaise, headache, and vomiting Sore throat and Odynophagia Dysphagia Tender cervical lymphadenopathy Erythematous/exudative tonsils Purulent exudate from the crypts A white membrane

Clinical Evaluation
Viral Lower grade fever Lower WBC, Lymphocytic shift Less tonsillar exudate Bacterial Higher WBC, Granulocytic shift More exudative

Acute Tonsillitis

Diagnosis
Evidence of inflammation of the tonsils
PLUS

pyrexia of at least 38.50C, measured orally. enlarged, tender, anterior cervical lymph nodes. documentation of GABHS infection by throat swab (antigen detection or culture).

Differential diagnosis (AT

Infectious mononucleosis Vincent's angina Malignancy: lymphoma, leukemia, carcinoma Diphtheria Scarlet fever Agranulocytosis

Complications
Peritonsillar abscess Cervical adenitis Acute myocarditis Acute glomerulonephritis Rheumatic fever

Peritonsillar Cellulitis And Abscess

aspiration or incision

Medical Management
Bed rest. PCN is first line, even if throat culture is negative for GABHS. Local treatment:Gargle, spray.

Recurrent Acute Tonsillitis

Seven episodes in a single year Five or more episodes in 2 years Three or more episodes in 3 years

Recurrent Acute Tonsillitis

Treatment: 1. PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes. 2. Tonsillectomy

Chronic Tonsillitis
DEFINITIONS:

No true consensus on the definition. Symptoms greater than 4 weeks

Microbiology(CT)
Most common organisms cultured from patients with chronic tonsillar disease

Streptococcus pyogenes (GABHS) H. influenza S. aureus Streptococcus pneumoniae

Symptoms
Low grade intermittent sore throat Halitosis

Signs
Enlarged, mildly red tonsils that are scarred with large pits Crypts tend to become impacted with white foul-smelling (especially to the owner) debris. Slightly enlarged lymph nodes that are not usually tender

Diagnosis
Histories of recurrent throat infections is
the most important.

Examinations
The size of tonsil is not correlative with the degree of inflammation.

Differential Diagnosis
Infectious Mononucleosis EBV Scarlet Fever Corynebacterium diptheriae Malignancy

ICA Aneurysm

Pleomorphic Adenoma

Other Tonsillar Pathology

Hyperkeratosis ()

Candidiasis
()

Syphilis

Retention Cysts

Supratonsillar Cleft

Complications of CT
Myocarditis Glomerulonephritis Rheumatic fever Fever

Medical Therapy
First Line
Penicillin/Cephalosporin for 10 days Injectable forms for noncompliance BLPO, co pathogens

Macrolides
Penicillin allergy Erythromycin/Clarithromycin 10 days Azithromycin (12mg/kg/day) 5 days

Medical Therapy
Patients with recurrent otitis media history have higher bacterial concentrations with BLPO.
Initial treatment with anti-BLP antibiotic.

Adenotonsillar size may respond to a one month course of antibiotic therapy. Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid.

Surgical Indications
Absolute
Obstructive airway with cor pulmonale Severe dysphagia Failure to thrive

Surgical Indications
Relative
Recurrent acute tonsillitis
episodes/year for 2 years or 3 episodes/year for 3 years

Chronic tonsillitis Obstructive Sleep Apnea Peritonsillar Abscess Halitosis Suspected Neoplasia/ Tonsillar hyperplasia

Innovative Surgical Techniques

Cold Dissection Electrosurgery Intracapsular partial tonsillectomy Harmonic Scalpel Radiofrequency tonsillar ablation and coblation.

Complications
Mortality rate is 1 in 16000-35000

Postoperative Bleeding Anesthetic complications Eustachian tube injury Nasopharyngeal stenosis Pulmonary Edema Atlantoaxial subluxation