1.

1 Concept of Disease
1.1.1 Anatomy and Physiology
1.1.1.1 Mouth

The mouth is the first organ from the digestive tract that extends from the
lips to the istmus fausium, the border between the mouth and the pharynx.
The mouth consists of:
a. Oris vestibulum: the part between the lips and cheeks on the outside, the
gums and inner teeth. The top and bottom of the vestibule are limited by
the folds of the mucous membranes of the lips, cheeks and gums. The
cheeks form the lateral vestibule, arranged by M. buksinator, lined with
mucous membranes. The outer side of M. buccinator is covered by the
bucopharyngeal fascia, facing the second molar tooth. The upper part is a
small papilla where the parotid gland duct emerges.
b. Kavitasoris propia: the part between the alveolar arch, gums, dangigi, has a
roof formed by the hard palate (palate) in the front, the soft palate (soft
palate), the back.
Digestion in the mouth is divided into:
a. Mechanical Digestion, is a process of chewing and peristaltic motion.
b. Chemical digestion, is a process that is aided by digestive enzymes released
in the mouth, stomach, usushalus, gallbladder, etc.
Mouth parts:

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1.1.1.2 Teeth

Teeth and molars are located in the dental alveoli of the maxillary and
mandibular casts. Teeth have one root, while molars have 2 to 3 roots. At the
end of the root of the tooth there is an apical foramen into the root canal of
the tooth leading to the pulpitis cavity. The root of the tooth is covered with
cement which is associated with the dentist alveolus through the membrane
periodental. Dentine is the largest part of teeth coated with email.
The function of the teeth is to chew food, breaking large particles into
small particles that can be swallowed without causing choking. This process
is the first mechanical process experienced by food at the time through the
digestive tract with the aim of destroying food, smoothing and moistening dry
food with saliva and stirring the food until even.
Based on the shape and function of the teeth can be divided into:
a. Incisors (I) which have the function of cutting and biting.
b. Canines or Caninus (C) which have the function to tear.
c. Molar teeth can be differentiated into small molars or Premolar (P) and
large molars or Molar (M) which have the function of chewing and
pulverizing food.

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1.1.1.3 Tongue

It is present in the oral cavity, which is a rough arrangement of muscle

fibers equipped with mucosa. The tongue plays a role in the process of
digestive mechanism in the mouth by moving food in all directions.
The parts of the tongue are:
a. Base of tongue (radik lingua)
At the base of the back of the tongue there is a tongue (epiglotis) which
functions to close the airway at the time of swallowing, so that the food
does not enter the airway.
b. Tongue tongue (dorsum lingua)
There are taste buds to determine the taste of food. On the lingual dorsum
there are small bumps as the taste nipple consists of:
1) Filiform papilla which is spread over the entire surface of the tongue
2) The fungiform papilla is located on the edge of the tongue in the apex
3) Circumvalate papilla in front of the sulcus terminal
4) Foliata papilla posterior side edge
c. Tip of the tongue (lingua apex)
Helps reverse food, the process of talking, feel the food eaten, and
helps the process of swallowing.
The tongue helps regulate the placement of food so that it can be
chewed by the upper teeth and lower teeth. In addition, the tongue also
helps mix food and swallow food. On the tongue there are many receptors

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 that function as taste or taste so that the tongue can taste sweet, salty, bitter
and sour.

1.1.1.4 Salivary Glands

Salivary
gland (saliva) is
a gland that
secretes mucus
solution into the
mouth, moistens
and lubricates
food particles before being swallowed. This gland contains two digestive
enzymes, the lingua lipase to digest fat and the enzyme ptyalin / amylase to
digest flour. Salivary gland consists of:
a. Salivary gland below the jaw (submaxillary gland): located below the
middle of the upper jaw. The channel is called the wartoni duct which
empties into the oral cavity near the lingua frenulum.
b. The salivary gland under the tongue (sublingual gland): is located under
the mucous membrane of the base of the oral cavity and empties into the
base of the oral cavity.
c. Parotid gland: located below the front of the ear between the left and right
mastoid processes near the mandibular os. The channel is called stencil
ductus coming out from the parotid grandula to the oral cavity through
the cheek (m buksinator). normal salivary secretions every day from
1000 to 1500 ml.
Salivary secretion is controlled through unconditional reflexes of the
tongue, esophagus, stomach, and upper small intestine and the reflex
requirements of the cerebral cortex by means of seeing, hearing, and

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 thinking about food. With stimulation of the sympathetic nerves salivary
secretion becomes runny, the volume becomes large, and the content of
organic matter is little accompanied by vasodilation in the gland.
Saliva function:
a. Mechanical function: mixing saliva with food to make it soft or half liquid
called bolus to be easily swallowed and cool the food.
b. Kemis function: dissolve dry food to be felt. For example, sugar in the
mouth is dissolved by saliva. Saliva also monitors teeth that become
rotten by changing the acidic atmosphere caused by decomposing
bacteria into an alkaline atmosphere.
If there is food in the mouth there is a reflex stimulation of the muscles
to move the mandible. The muscles that function are:
a. M.Evator who lifts the jaw: the projector is M. masseter and M.
pterygoid, the retractor is M. temporalis
b. M. depressor which lowers the jaw: the projector M. external pterigoideus
and M. digastricus, retractors: M. milohioideus and M. geniohioideus
Chewing muscle cooperation with the tongue and cheek muscles is very
important in the process of chewing efficiently to form a bolus (half liquid
food) that is swallowed. Rhythmic movements chew are controlled by
somatic nerves to the mouth and jaw muscles. The movement of reflexes is
activated by pressure on food against the gums, teeth, hard palate, and
tongue. Most chewing muscles are innervated by the brain nerve branch V
(trigeminal nerve) and are controlled by the back muscles.

1.1.1.5 Tonsils

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 Tonsils form 2-5 cm long ovals, each tonsil has 10-30 crystals
extending inwards that extend to the tonsillar tissue. Tonsils do not fill the
entire tonsil fossa, the empty area above is known as supratonsillary fossa.
The outside of the tonsils are loosely attached to the mushulus of the
superior pharyngeal contour, so that it is stressed every meal. Although the
tonsils are located in the oropharynx because excessive development of
tonsils can spread towards the nasopharynx so that it can cause
velopharyngeal insufficiency or nasal obstruction, although rarely found.
The most common direction of tonsillar development is towards the
hypopharynx, so that it often causes disruption during sleep due to airway
disorders. Microscopically contains 2 main elements:
1. Connective / trabecular tissue as a framework for supporting nerve
vessels.
2. Interpholular tissue that occurs lymphoid tissue in various stages.
Peri tonsil abscess occurs after an acute attack of tonsillitis. About a
week after the onset of illness, the patient begins to feel unwell and fever,
and dysphagia reappears. The characteristic symptom of a peri tonsillary
abscess is the presence of trimus, without these symptoms the diagnosis of
tonsillary peri abscess may be wrong. Tonsils (tonsils) and adenoids are
lymphoid tissues found in the pharynx or throat region. Both have existed
since birth and began to function as part of the body's immune system after

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 "inherited" immunity from the mother began to disappear from the body.
Tonsils and adenoids are the main immune organs. The immune system has
2 types, namely cellular and humoral immunity. Cellular immunity works
by making cells (lymphoid T) that can "eat" germs and viruses and kill
them.
While humoral immunity works because of the presence of cells
(lymphoid B) that can produce immunoglobulin substances that can kill
germs and viruses. Germs that are "eaten" by tonsil and adenoid cellular
immunity sometimes do not die and remain lodged there and cause chronic
and recurrent tonsil infections (chronic tonsillitis). These infectious
infections will cause tonsils and adenoids to "work continuously" by
producing large numbers of immune cells so that the size of the tonsils and
adenoids will enlarge to quickly exceed normal size. Such tonsils and
adenoids are often known as tonsils which can be a source of infection
(focal infection).

1.1.2 Definition
Tonsillitis is an inflammation of the palatine tonsils which are part of the
Waldeyer ring. Waldeyer ring consists of the arrangement of lymph glands contained
in the oral cavity, namely: pharyngeal tonsils, tonsillar palatina, lingual tonsils (tongue
base tonsil), Eustachian tube tonsils, (Soepardi, Effiaty Arsyad, et al. 2007).
Tonsillitis is inflammation caused by bacterial infection of group A beta
hemolytic streptococcus, but can also be caused by other types of bacteria or by viral
infections, (Hembing, 2004).
Acute tonsillitis is an acute inflammation caused by beta hemolytic streptococcus
germs, streptococcus viridons and streptococcus pygenes, can also be caused by
viruses, (Mansjoer, A. 2000)
Conclusions based on some of the above meanings, tonsillitis is an inflammation
of the tonsils caused by bacteria or viruses, the process can be acute or chronic and
usually occurs in children.

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 1.1.2.1 Classification of Tonsillitis
a. Tonsilitis akut - terjadi ketika tonsilitis disebabkan oleh salah satu
bakteri atau virus.Infeksi ini biasanya sembuh sendiri (Eunice, 2014).
b. Tonsilitis kronis - terjadi ketika tonsilitis disebabkan oleh infeksi
bakteri yang dapat bertahan jika tidak diobati (Eunice, 2014).

1.1.3 Etiology
The main causes of tonsillitis are streptococcal bacteria (streptococcus, hemolycitus
streptococci, viridians and pyogeneses), other causes are viral infections (influenza,
and herpes). (Nic & Noc, 2008). The cause is streptococcal bacterial infection or viral
infection. Tonsils function to help attack bacteria and other microorganisms as a
preventive measure against infection. Tonsils can be defeated by bacteria or viruses, so
they swell and become inflamed, causing tonsillitis (Soepardi, Effiaty Arsyad, et al.,
2007).

1.1.4 Clinical Manifestations

1.1.4.1 According to Smeltzer, Suzanne (2000).
Symptoms that arise are sore throat, fever, snoring, and difficulty swallowing.
1.1.4.2 According to Effiaty Arsyad Soepardi, et al (2007).
a. Sore throat
b. No appetite
c. Pain swallowing
d. Sometimes accompanied by otalgia
e. High fever
f. Submandibular gland enlargement and tenderness

1.1.5 Pathophysiology
Initially infiltrating the epithelial lining. When the epithelium is eroded, the
superficial limpofid tissue signifies a reaction, there is an inflammatory dam with
infiltration of polymorphonukuler leukocytes. This process is clinically visible in the

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 tonsillar crypts containing yellow patches called detritus. Detritus is a collection of
leukocytes, bacteria and epithelium that are released. As a result of this process
tonsillar swelling or enlargement will occur, pain swallowing, dysfalgia. Sometimes if
an enlargement exceeds the uvula it can cause difficulty breathing.
The membrane mucosa of the oropharynx becomes dry and irritated, the adenoid
approaching the tube eustachus can block the channel resulting in the development of
otitis media, (Reeves, J Charlene, 2001).

1.1.6 Pathway

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1.1.7 Supporting Examination
1.1.7.1 Tonsillary swabs are cultured to determine bacterial infection. Wipe bias
throat, nose.
1.1.7.2 Biopsy is performed in all cases with unuilateral tonsillar enlargement.
1.1.7.3 Complete blood examination.
a. Leukocytes: 11.20H
b. Hemoglobin: 11.90 g / dl
c. Platelets: 314
1.1.7.4 Radiology.
1.1.7.5 Thoracic.

1.1.8 Management
1.1.8.1 Management of tonsillitis patients, (Mansjoer, A 2000):
a. Management of acute tonsillitis
1) Antibiotics for penicillin or sulfanamid for 5 days and mouthwash or
suction drugs with disinfectants, if allergic to erythromycin or
clindomycin.
2) Adequate antibiotics to prevent secondary infections, corticosteroids to
reduce edema of the larynx and symptomatic drugs.
3) Give bed rest to avoid complications of the bag for 2-3 weeks or until
the results of the throat swab are 3x negative.
4) Giving antipyretics.
b. Management of chronic tonsillitis
1) Local therapy for oral hygiene with mouthwash / suction.
2) Radical therapy with tonsillectomy if medical therapy or conservative
therapy is unsuccessful.
1.1.8.2 Tonsillectomy (Sandra M. Nettina. 2006):
a. Preoperative Care:
1) Carefully examine the ears, nose and throat and get the culture needed
to determine whether there is no source of infection.

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2) Take blood specimens for preoperative examination to determine the
risk of bleeding: clotting time, platelet discharge, prothrombin period,
partial thromboplastin period.
3) Perform a preoperative assessment:
4) Bleeding in children or families, assessing hydration status, prepare
children specifically to face what is expected in the postoperative
period, use techniques that are appropriate to the level of child
development (books, puppets, pictures), talk to children about things
only to be seen in the operating room, and explain if there are wrong
concepts, help parents prepare their child by discussing general terms
first about surgery and developing to more specific information,
reassuring parents that the complication rate is low and recovery is
usually fast, encourage parents to stay with the child and help provide
care.
b. Postoperative care:
1) Assess pain frequently and give analgesics as indicated.
2) Assess frequently for signs of postoperative bleeding
3) Prepare a suction device and nasal packing devices in case of an
emergency.
4) When the child is still under the influence of anesthesia, position
him face down or semi facedown in the child with the head tilted to
the side to prevent aspiration
5) Let the child get a comfortable position on his own after he is aware
(parents may hold a child)
6) At first the child can experience old blood vomiting. If suction is
needed, avoid trauma to the oropharynx.
7) Remind children not to cough or clean the throat unless necessary.
8) Provide adequate fluid intake; give ice cubes 1 to 2 hours after
being aware of anesthesia. When vomiting is difficult to stop, give
clear water carefully.

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 9) There are several controversies relating to the supply of milk and
ice cream on the night of surgery: it can calm and reduce swelling,
but can increase mucus production which causes children to clean
their throat more often, increasing the risk of bleeding.
10) Give an ice collar to the neck, if cooled. (remove the ice collar, if
the child becomes restless).
11) Rinse the patient's mouth with cold water or an alkaline solution.
12) Keep children and the surrounding environment free from blood-
stained drainage to help reduce anxiety.
13) Encourage parents to stay with the child when the child is aware.

1.2 Nursing Care Plans

1.2.1 Focus on assessment (Firman S. 2006), namely:
1.2.1.1 Interview
a. Assess for a history of previous illness (tonsillitis)
b. Is treatment adequate
c. When the symptoms appear
d. How is the diet
e. Is it routine / diligent to clean the mouth
1.2.1.2 Physical examination of basic data assessment according to Doengoes, (2000),
namely:
a. Ego Integrity Symptoms: Fear, worry Sign: anxiety, depression, refuse.
b. Food/Fluid Symptoms: Difficulty swallowing Signs: Difficulty
swallowing, easy pressure, inflammation
c. Hygiene Signs: poor oral and dental hygiene
d. Pain/Safety Signs: Restlessness, cautious behavior Symptoms: Chronic
sore throat, spread of pain to the ear
e. Respiratory Symptoms: History of smoking cigarette smoke (there may be
family members who smoke), living in a dusty place.
1.2.1.3 Supporting Examination

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 a. Tonsillary swabs are cultured to determine bacterial infection. Wipe bias
throat, nose.
b. Biopsy is performed in all cases with unuilateral tonsillar enlargement.
c. Complete blood examination.
1. Leukocytes: 11.20H
2. Hemoglobin: 11.90 g / dl
3. Platelets: 314
a. Radiology.
b. Thoracic.
1.2.2 Diagnosis
1.2.2.1 Diagnosis 1: Acute pain associated with agent biology injury.
Objective: there are no problems with pain, pain can be lost or reduced
Criteria for results:
1) Reporting pain decreases
2) Facial expressions look relaxed
Intervention:
1) Perform a comprehensive pain assessment including location,
characteristics, duration, frequency, quality and precipitation factors.
Rational: as a basis for determining the next intervention
2) Teach non-pharmacological techniques with deep breath distractions.
Rational: deep distraction / breathing techniques can reduce pain
3) Increase patient rest
Rational: rest can forget from pain
1.2.2.2 Hypertemics associated with disease processes are characterized by body
temperature rising above the normal range.
Objective: After nursing action is expected normal body temperature.
Criteria results: The patient is not nervous, normal body temperature {36 °
-37 ° C}.
Intervention and rational:
1) Monitor ambient temperature.

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 Rational: The ambient temperature must be changed to keep the
temperature near normal.
2) Monitor the patient's temperature.
Rational: Indicates an infectious disease process.
3) Give warm compresses
Rational: Can reduce fever

1.2.2.3 The risk of changes in nutrition is less than the body's needs associated with
anorexia
Objective: nutritional needs are met.
Criteria results: Adequate client nutritional needs, no signs of malnutrition,
able to spend food according to the portion given.
Intervention:
1) Monitor input and weight as indicated
Rational: provide information regarding nutritional needs and
effectiveness of therapy
2) Auscultation of bowel sounds
Rational: food only starts after the bowel sounds improve
3) Start with snacks and increase according to tolerance.
Rational: food content can lead to intolerance, requiring changes in speed

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 BIBLIOGRAPHY

Ningsih MW. “Relationship between eating habits and the risk of chronic tonsillitis in patients
at the General Hospital ENT Polyclinic Zainoel Abidin Banda Aceh in 2015”
[thesis]. Aceh: Syiah Kuala University; 2015
World Health Organization. “Survailance of risk factors for non-communicable disease: the
WHO is stepping up to study”. Summary. Geneva: 2013.
Assyifa Amalia “Essay Relationship Between Knowledge With The Event Of Tonsilitic In Sd
Inpres Maccini Sombala Students In 2017” Doctor Education Study Program
Medical School Hasanuddin University Makassar 2017

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