Acute Pharyngitis, Acute

Tonsillitis, White Patch

Over Tonsil
DR. KANISHKA S RAO
MS ( ENT )
ACUTE PHARYNGITIS

 NON SPECIFIC

 SPECIFIC
NON SPECIFIC PHARYNGITIS

 Due to viral infection followed by secondary bacterial infection

 Results from URTI

 Etiology – Viruses and bacteria

NON SPECIFIC PHARYNGITIS -
ETIOLOGY

VIRUSES BACTERIA FUNGAL

Adenovirus Group A beta hemolytic Candida albicans

streptococi
Rhinovirus Non hemolytic Chlamydia trachomatis
streptococcus
Respiratory syncytial Pneumococcus
virus
Influenza & H.influenzae
Parainfluenza
Herpes simplex,
Coxsackie virus
 ETIOLOGY – Continued…….

 Climatic conditions like cold and damp weather

 Local trauma corrosive injury

 Pollutants like smoke, dust, chemicals

CLINICAL FEATURES

 Sore throat
 Fever
 Tender cervical nodes
 Rigor
 Congested oropharunx structures
 Uvula soft palate oedematous
DIFFERENTIAL DIAGNOSIS

 Acute tonsillitis
 Diphtheria
 Vincent’s angina
 Exanthematous condition
 Blood dyscrasias
COMPLICATIONS

 Otitis media
 Laryngitis
 Bronchitis
 Edema of glottis ( airway )
 Ludwig’s angina in submandibular space
 Septicemia , pericarditis , meningitis
INVESTIGATIONS

 CBC – TC , DC

 Peripheral smear

 Throat swab - Culture and sensitivity in secondary bacterial infections

TREATMENT

 Bed rest , Plenty of fluids

 Systemic broad spectrum antibiotics – Penicillin G group of drugs

 Anti-inflammatory antipyretics – Paracetamol , Ibuprofen Acelofenac

 Antiseptic gargles

 Throat lozenges
SPECIFIC ACUTE PHARYNGITIS

 Diphtheric

 Vincents’s Angina
DIPHTHERIC PHARYNGITIS

 Faucial diphtheria

 Severe contagious and life threatening

infection of pharynx and faucial area

 Caused by Corynebacterium diphtehriae

DIPHTHERIC PHARYNGITIS-ETIOLOGY

 Corynebacterium diphtheria produces endotoxins

 Absorbed from the membrane into blood stream

 Neurological and cardiac complications

DIPHTHERIC PHARYNGITIS-ETIOLOGY

 Incubation period – 2 to 4 days

 3 types – Gravis , Iniermedius and Mitis

 Staining by Albert’s stain shows – CHINESE LETTER PATTERN

DIPHTHERIC PHARYNGITIS-PATHOLOGY

 Formation of greyish white membrane

 Over tonsils,pillars and posterior pharyngeal wall

 Membrane adherent to underlying structures

 Bleeds easily on removal

SYMPTOMS

 Sore throat
 Odynophagia
 Stridor ( If spreads to larynx )
 Fever
 Toxic look
 Malaise
 Joint pain
SIGNS

 Greyish white patch covering tonsils and adjacent

structures

 Palatal paralysis , peripheral nerve paralysis

 Myocarditis 2 – 3 weeks after infection

 Cervical lymph nodes enlargement – BULL NECK

APPEARANCE
INVESTIGATIONS

 CBC

 ESR
 THROAT SWAB

 CULTURE AND STAINING – ALBERT’S STAIN -

CHINESE LETTER PATTERN
 CULTURE MEDIA – LOFFLER’S SERUM SLOPE OR
BLOOD AGAR
 TREATMENT

 Hospitilization and isolation

 Anti-Diphtheric serum 40,000 to 1 lac units started immediately

 Drug of choice - Inj crystalline penicillin – Benzyl penicillin 600mg

QID for 7 days

 Intubation / Tracheostomy - If airway obstructed / respiratory

paralysis

 PREVENTION – Routine vaccination of children and adults

VINCENT’S ANGINA

 Acute ulcerative lesion of pharynx

 Involves tonsil , soft palate and gums

 Caused by fusiform bacillus and spirochaete – Borrelia vincenti

 Affects young adults

CLINICAL FEATURES

 Sudden onset
 Sore throat
 Halitosis
 High grade fever
 Cervical adenitis
CLINICAL FEATURES

 Area covered with greyish membranous slough

 Starts at interdental papillae and spreads to free margin

of gingivae

 Gingivae red and oedematous

 Base of ulcer usually bleeds

 Syymptoms subside in 4 to 7 days

INVESTIGATIONS

 Throat swab

 Gentian violet stained smear of pharyngeal exudate

TREATMENT

 Systemic antibiotics

 Metronidazole , Penicillin / clindamycin

 Antiseptic mouth wash

 Antiseptic paint over tonsils and gums

ACUTE TONSILLITIS

 Inflammatory condition of the Palatine tonsils

 Involves mucosa, crypts , tonsillar parenchyma

 Non specific

 Specific – Diphtheria, Infectious mononucleosis, Vincents angina

CAUSATIVE AGENTS

 Viral : Influenza , Parainfulenza , Adenovirus , rhinovirus

 Bacterial: Group A Beta Haemolytic Streptococcus , H influenza,

Pneumococcus , M.catarrahalis
Types

 Acute Catarrhal
 Acute Follicular
 Acute Parenchymatous
 Acute Membranous
Acute Catarrhal

 Mostly part of generalized pharyngitis

 Seen in viral infection of upper respiratory tract

Acute Follicular

 Severe form of infection caused by virulent strains

 Streptococcus hemolyticus, H influenza

 Spread of infection from tonsillar crypts to tonsillar

follicles
 Follicles inflamed and swollen

 Irregular crypts filled with yellowish white exudates

Acute Parenchymatous

 Seen more in children

 Secondary bacterial infection following viral infection

 Infection invades the crypts and spread to tonsillar

parenchyma

 Appear swollen and uniformly enlarged

Acute Membranous

 Follows acute follicular tonsillitis

 Exudation from crypts coalesces to form a

membrane on the surface of tonsil

 Clinically mainly Acute follicular and

Prenchymatous types of tonsil are
encountered
CLINICAL FEATURES - SYMPTOMS

 Sore throat
 Odynophagia
 Fever
 Ear ache
 General bodyache,malaise, constipation
 Abdominal pain
CLINICAL FEATURES - SIGNS

 Halitosis
 Congested pillars, soft palate, uvula
 Tonsils diffusely swollen
 Crypts filled with pus
 Membrane over surface of tonsil
 Various grades of tonsil enlargement
 Jugulodigastric lymph node enlargement
GRADES OF TONSILLAR HYPERTROPHY
DIFFERENTIAL DIAGNOSIS

 Scarlet fever
 Diphtheria
 Infectious mononucleosis
 Vincents angina
 Glandular fever
 Agranulocytosis
 Leukaemia
INVESTIGATIONS

 CBC – TC,DC – Leukocytosis and Neutrophiliais noted

 Peripheral Smear – Rule out agranulocytosis and leukaemia
 Throat swab
 ASO titre – Elevated antistreptolysin antigen
 Monospot test , Paul Bunnel test
 X-ray PNS
TREATMENT

 Bed rest
 Drink Plenty of fluids
 Liquid diet
 IV fluids
 Mouth gargles – Mandls paint application
 Antibiotics
 Analgesics and anti-inflammatory drugs - Paracetamol
Antibiotics – In children

 Oral – First choice – Amoxicillin 20 -40 mg /kg/day TID

 Second choice – Cefuroxime 125 -250mg BD
Clarithromycin – 7.5 – 15mg/kg BD

 Parenteral – First choice - Amoxy-clavulanic acid 30- 40mg/kg/day TID

Second choice - Ceftriaxone +/- Clindamycin
 Antibiotics - Adults

 Oral – First choice – Amoxicillin 500mg – I g TID , Amoxy – clavulanic acid

1g BD
Second choice – Cefpodoxime proxetil – 200 – 400mg BD
Clarithromycin – 500 mg BD
Azithromycin – 500mg OD for 5 days

 Parenteral – First choice – Augmentin 1.2 g IV TID

Second choice – Ceftraxone 1- 2 g BD
+/- Clindamycin
COMPLICATIONS

 Chronic tonsillitis
 Peritonsillar abscess
 Parapharyngeal abscess
 Acute otitis media
 Rheumatic fever
 Acute glomerulonephritis
 Subacute bacterial endocarditis
WHITE PATCH OVER TONSIL

 Viral – Infectious mononucleosis, HIV

 Bacterial – Follicular tonsillitis, Diphtheria , Vincent’s angina
 Fungal – Candidiasis
 Autoimmune – Lichen planus, Wegener’s granulomatosis
 Trauma
 Systemic – Leukemia,agranulocytosis
 Malignancy
Membranous tonsillitis
Diphtheria

 Slow onset , less local discomfort

 Membrane extends beyond tonsils on to soft palate

 Dirty grey colour

 Adherent

 Removal leaves bleeding surface

 Throat swab – Corynebacterium diphtheriae

Vincent’s Angina

 Insidious onset

 Fever

 Membrane over tonsil can be easily removed

 Throat swab – Fusiform bacilli and spirochaetes

Infectious Mononucleosis

 Seen in young adults

 Tonsils enlarged , congested covered with membrane

 Post Triangle lymph nodes, Splenomegaly

 Blood smear – Lymphocytes , Atypical lymphocytes

 Second week – Increase in WBC

 Paul Bunnell test – High titre heterophil antibody

Agranulocytosis

 Ulcerative necrotic lesions in oropharynx

 Severely ill patient

 Acute Fulminant form – TLC dcreased to < 2000 cu mm

 Chronic / recurrent form

Leukaemia

 Peripheral blood – TLC > 100,000 / cu mm

 Anaemia

 Bone marrow aspiration – Blast cells ++

Aphthous ulcers

 Involve any part of oral cavity or oropharynx

 Solitary

 Very painful
 Malignancy Tonsil

 Unilateral tonsil enlargement

 SCC most common present as ulcerated lesion with necrotic

base

 Lymphomas +++

 Odynophagia, Ear pain , Neck swelling , Bleeding , Trismus ,

Halitosis

 Confirm by taking biopsy

Traumatic ulcer

 Injury to oropharynx heals by formation of membrane

 Occurs accidently with toothbrush , pencil in mouth , finger trauma

Candidiasis

 Seen in immunocompromised patients

 HIV , Patients of long term immunosuppressants

and steroids, Diabetics

 Fluconazole drug of choice

Other causes

 Autoimmume – Lichen planus , Wegeners granulomatosis

 Premalignant lesions – Leukoplakia , Submucous fibrosis

 Tumour like conditions – Fibroma , Tonsillar cyst , Tonsillolith ,Papilloma

Next class…………

 Chronic pharyngitis
 Chronic tonsillitis
 Keratosis Pharyngitis
THANK YOU