Acute & chronic tonsillitis and their management
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Acute & chronic tonsillitis and their management Presentation Transcript

  • 1. Acute & ChronicAcute & Chronic TonsillitisTonsillitisPresented ByPresented By MAJID NAWAZMAJID NAWAZ && TEHSINA NAWAZTEHSINA NAWAZ BANNU Medical CollegeBANNU Medical College Bannu k.p.k Pakistan.Bannu k.p.k Pakistan.
  • 2. IntroductionIntroduction The palatine tonsil is an ovoidThe palatine tonsil is an ovoid mass of lymphoid tissuemass of lymphoid tissue located in the oropharynxlocated in the oropharynx between thebetween the anterior and posterior pillarsanterior and posterior pillars It has 2 surfaces –It has 2 surfaces – 1. medial surface1. medial surface 2. lateral surface2. lateral surface It ha 2 poles –It ha 2 poles – 1. upper pole1. upper pole 2. lower pole2. lower pole
  • 3. Medial surfaceMedial surface It is lined by stratified squamous nonIt is lined by stratified squamous non keratinising epithelium which dipskeratinising epithelium which dips into the cryptsinto the crypts The crypts are 12-15 in numberThe crypts are 12-15 in number Secondary crypts arise from theSecondary crypts arise from the primary crypts and extend into theprimary crypts and extend into the substance of the tonsilsubstance of the tonsil One of the crypts located in the upperOne of the crypts located in the upper part is larger than the rest – cryptapart is larger than the rest – crypta magnamagna The crypts serve to increase theThe crypts serve to increase the surface area of the tonsilsurface area of the tonsil The crypts may be filled with cheesyThe crypts may be filled with cheesy material – epithelial debris, foodmaterial – epithelial debris, food particles and bacteriaparticles and bacteria
  • 4. Lateral surfaceLateral surface  It is covered by the fibrous capsule of the tonsilIt is covered by the fibrous capsule of the tonsil   The tonsillar bed is separated from the capsule byThe tonsillar bed is separated from the capsule by loose areolar tissueloose areolar tissue   This makes it is easy to dissect the tonsil from its bedThis makes it is easy to dissect the tonsil from its bed during tonsillectomyduring tonsillectomy  It is the site of collection of pus in peritonsillar abscessIt is the site of collection of pus in peritonsillar abscess (quinsy)(quinsy)  Some fibers of palatoglossus and palatopharyngeusSome fibers of palatoglossus and palatopharyngeus muscles get attached to the capsule of tonsilmuscles get attached to the capsule of tonsil
  • 5. Upper poleUpper pole It extends into the soft palateIt extends into the soft palate There is a semilunar fold of mucous membraneThere is a semilunar fold of mucous membrane which covers the medial part of the upper polewhich covers the medial part of the upper pole It extends from anterior pillar to posterior pillarIt extends from anterior pillar to posterior pillar It encloses a potential space – supratonsillarIt encloses a potential space – supratonsillar fossafossa
  • 6. Lower poleLower pole It is attached to the tongueIt is attached to the tongue A triangular fold of mucous membrane extends from theA triangular fold of mucous membrane extends from the anterior tonsillar pillar to the lower poleanterior tonsillar pillar to the lower pole It encloses a space – anterior tonsillar spaceIt encloses a space – anterior tonsillar space The lower pole is separated from the tongue by theThe lower pole is separated from the tongue by the tonsillo-lingual sulcustonsillo-lingual sulcus This sulcus may harbour carcinomaThis sulcus may harbour carcinoma
  • 7. Bed of tonsilBed of tonsil It is formed by the 2It is formed by the 2 musclesmuscles 1.Superior constrictor1.Superior constrictor 2.Styloglossus2.Styloglossus
  • 8. Structures related to theStructures related to the bed of tonsilsbed of tonsils
  • 9. Blood supplyBlood supply Blood supply is from the branches of 4 majorBlood supply is from the branches of 4 major arteries all of them are the braches of a mainarteries all of them are the braches of a main artery i.e external carotid artery . These areartery i.e external carotid artery . These are 1.Maxillary artery descending palatine1.Maxillary artery descending palatine arteryartery 2.Ascending pharyngeal artery Tonsillar2.Ascending pharyngeal artery Tonsillar branchesbranches 3.Facial artery tonsillar artery(main3.Facial artery tonsillar artery(main artery) & ascending palatine arteryartery) & ascending palatine artery 4.Lingual artery dorsal lingual branches.4.Lingual artery dorsal lingual branches.
  • 10. Veins, lymphatics &Veins, lymphatics & nervesnerves  LymphaticsLymphatics pierce the superiorpierce the superior constrictor and drain into upper deepconstrictor and drain into upper deep cervical (jugulo-digastric) nodescervical (jugulo-digastric) nodes located below the angle of mandible.located below the angle of mandible.  VeinsVeins from the tonsils drain intofrom the tonsils drain into paratonsillar vein which then joins theparatonsillar vein which then joins the common facial vein and pharyngealcommon facial vein and pharyngeal venous plexusvenous plexus NervesNerves Lesser palatine branches ofLesser palatine branches of sphenopalatine ganglion andsphenopalatine ganglion and glossopharyngeal nerve provideglossopharyngeal nerve provide sensory nerve supply.sensory nerve supply.
  • 11. Function on tonsilsFunction on tonsils It has a protectiveIt has a protective function in that it preventsfunction in that it prevents entry of pathogensentry of pathogens through the nasal andthrough the nasal and oral routeoral route  The crypts on the surfaceThe crypts on the surface of the tonsil serve toof the tonsil serve to increase the surface areaincrease the surface area and increase theand increase the efficiency of protectionefficiency of protection against pathogensagainst pathogens  It forms a part ofIt forms a part of Waldeyer’s lymphaticWaldeyer’s lymphatic ring.ring.
  • 12. TonsillitisTonsillitis Inflammation 0f tonsils due toInflammation 0f tonsils due to bacterial or viral infectionbacterial or viral infection causing a sore throat , fever,causing a sore throat , fever, and difficulty in swallowing isand difficulty in swallowing is called tonsillitis.called tonsillitis. There are 3 types of itThere are 3 types of it 1.Acute tonsillitis1.Acute tonsillitis 2. chronic tonsillitis2. chronic tonsillitis 3. Compensated3. Compensated tonsillitistonsillitis
  • 13. Local signs of tonsillitisLocal signs of tonsillitis Unpleasant mouth odor Unpleasant mouth odor Unpleasant feeling in the throat Unpleasant feeling in the throat Pus or tonsil stones in lacunae Pus or tonsil stones in lacunae
  • 14. Local signs of tonsillitis -Local signs of tonsillitis - changes in the palatinechanges in the palatine archesarches HyperemiaHyperemia Cicatricles formation Cicatricles formation Slight swelling Slight swelling
  • 15. Acute tonsillitisAcute tonsillitis  Mostly affects children in the age group of 5-15Mostly affects children in the age group of 5-15 years, may also affect adultsyears, may also affect adults  OrganismsOrganisms  beta-hemolytic streptococcibeta-hemolytic streptococci (most common), staphylococci, pneumococci,(most common), staphylococci, pneumococci, H.influenzaeH.influenzae  Symptoms: sore throat, difficulty in swallowing,Symptoms: sore throat, difficulty in swallowing, fever, ear ache, constitutional symptomsfever, ear ache, constitutional symptoms
  • 16. Types of acuteTypes of acute tonsillitistonsillitis 1).1).Acute catarrhal/superfficial  here tonsillitis is ahere tonsillitis is a part of generalized pharyngitis, mostly seen inpart of generalized pharyngitis, mostly seen in viral infectionsviral infections
  • 17. Types of acuteTypes of acute tonsillitistonsillitis 2).Acute follicular2).Acute follicular  infection spread into theinfection spread into the crypts with purulent material, presenting atcrypts with purulent material, presenting at the opening of crypts as yellow spots.the opening of crypts as yellow spots.
  • 18. Types of acuteTypes of acute tonsillitistonsillitis 3).Acute membranous3).Acute membranous  follows stage of acutefollows stage of acute follicular tonsillitis where exudates coalesce tofollicular tonsillitis where exudates coalesce to form membrane on the surfaceform membrane on the surface
  • 19. Types of acuteTypes of acute tonsillitistonsillitis4).Acute parenchymatous4).Acute parenchymatous  tonsil is uniformlytonsil is uniformly enlarged and congestedenlarged and congested
  • 20. SymptomsSymptoms::  Sore throatSore throat  Difficulty inDifficulty in swallowingswallowing  Generalised bodyGeneralised body acheache  FeverFever  Earache and ThickEarache and Thick speechspeech SignsSigns::  Swollen congestedSwollen congested tonsils withtonsils with exudatesexudates  Enlarged tenderEnlarged tender Jugulo-diagastricJugulo-diagastric lymph nodeslymph nodes  Coasted tongueCoasted tongue  Foetid breathFoetid breath  Hyperaemia ofHyperaemia of pillars soft palate &pillars soft palate & uvula.uvula.
  • 21. TREATMENTTREATMENT  Bed restBed rest  Plenty of oral fluidsPlenty of oral fluids  AnalgesicsAnalgesics  Antimicrobial therapyAntimicrobial therapy penicillinpenicillin  In case of penicillin sensitivityIn case of penicillin sensitivity erythromycin are given.erythromycin are given.  Antibiotics should be continued for 7_10Antibiotics should be continued for 7_10 daysdays
  • 22. COMPLICATIONSCOMPLICATIONS  chronic tonsillitischronic tonsillitis  peritonsillar abscessperitonsillar abscess  parapharyngeal abscessparapharyngeal abscess  cervical abscesscervical abscess  acute otitis mediaacute otitis media  rheumatic feverrheumatic fever  acute glomerulo nephritisacute glomerulo nephritis  sub acute bacterial endocarditissub acute bacterial endocarditis
  • 23. DIFFERENTIALDIFFERENTIAL DIAGNOSIS OFDIAGNOSIS OF MEMBRANE OVER THEMEMBRANE OVER THE TONSILTONSIL Membranous tonsillitisMembranous tonsillitis  DiphtheriaDiphtheria  Vincents anginaVincents angina  Infectious mononucleosisInfectious mononucleosis  AgranulocytosisAgranulocytosis  LeukaemiaLeukaemia  Traumatic ulcerTraumatic ulcer  Aphthous ulcerAphthous ulcer  malignancymalignancy
  • 24. CHRONIC TONSILLITISCHRONIC TONSILLITIS  Aetiology:Aetiology: Complication of acute tonsillitisComplication of acute tonsillitis Sub clinical infection of tonsilSub clinical infection of tonsil Chronic sinusitis or dental sepsisChronic sinusitis or dental sepsis Mostly affects children and young adultsMostly affects children and young adults
  • 25. TYPES OF CHRONICTYPES OF CHRONIC TONSILLITISTONSILLITIS  1). Chronic follicular tonsillitis1). Chronic follicular tonsillitis tonsillar crypts are full of cheesytonsillar crypts are full of cheesy material resulting in yellow spotsmaterial resulting in yellow spots on the surface.on the surface.  2). Chronic parenchymatous2). Chronic parenchymatous tonsillitistonsillitis  tonsils are very much enlargedtonsils are very much enlarged almost touching each other andalmost touching each other and may interfere with speech,may interfere with speech, deglutition and respiration, longdeglutition and respiration, long standing cases may developstanding cases may develop pulmonary hypertensionpulmonary hypertension
  • 26. types of Chronictypes of Chronic tonsillitistonsillitis 3).Chronic fibroid tonsillitis3).Chronic fibroid tonsillitis Tonsils are small but infected , withTonsils are small but infected , with history of repeated sore throat.history of repeated sore throat.
  • 27. CLINICAL FEATURESCLINICAL FEATURES  recurrent attacks of sore throatrecurrent attacks of sore throat  chronic irritation in throat with coughchronic irritation in throat with cough  halitosishalitosis  dysphagiadysphagia  odynophagiaodynophagia  thick speechthick speech
  • 28. ExaminationExamination  Tonsil may show varying degree of enlargementTonsil may show varying degree of enlargement depending on the typedepending on the type  Irwin-moore signIrwin-moore sign tonsils are small but pressure on thetonsils are small but pressure on the anterior pillar expresses pus or cheesy materialanterior pillar expresses pus or cheesy material mainly seen in fibroid typemainly seen in fibroid type  There bmay be yellowish beads of pus on the medialThere bmay be yellowish beads of pus on the medial surface of tonsils chronic follicular tonsillitissurface of tonsils chronic follicular tonsillitis  Flushing of the anterior pillar compared to rest of theFlushing of the anterior pillar compared to rest of the pharyngeal mucosapharyngeal mucosa  Enlargement of the jugulo-digastric node soft nonEnlargement of the jugulo-digastric node soft non tendertender
  • 29. TREATMENTTREATMENT Conservative managementConservative management Pay attention to the generalPay attention to the general health ,diet,and treatmenthealth ,diet,and treatment of co- existent infections ofof co- existent infections of teeth , nose , andteeth , nose , and sinuses.sinuses. TonsillectomyTonsillectomy when recurrent attackswhen recurrent attacks ,interference with speech ,,interference with speech , deglutination & respiration.deglutination & respiration.
  • 30. COMPLICATIONSCOMPLICATIONS  Peritonsillar abscessPeritonsillar abscess  Parapharyngeal abscessParapharyngeal abscess  Retro pharyngealRetro pharyngeal abscessabscess  Intra tonsillar abscessIntra tonsillar abscess  Tonsillar cystTonsillar cyst  TonsillolithTonsillolith  Focus of infection forFocus of infection for RF, AGNRF, AGN Peritonsillar abscess
  • 31. Compensated tonsillitisCompensated tonsillitis  Compensated tonsillitisCompensated tonsillitis it isit is usually a type of chronicusually a type of chronic tonsillitis. clinically manifeststonsillitis. clinically manifests itself withitself with absence of anyabsence of any complaintscomplaints andand presencepresence of only local signsof only local signs of aof a chronic inflammation of thechronic inflammation of the tonsils. It is usually revealedtonsils. It is usually revealed during prophylacticduring prophylactic examinations.examinations.
  • 32. TonsillectomyTonsillectomy It’s the surgical removal of tonsils , done inIt’s the surgical removal of tonsils , done in the treatment of chronic infection ofthe treatment of chronic infection of tonsils ,obstructive sleep apnea ,tonsils ,obstructive sleep apnea , supporative ottits media etc.supporative ottits media etc.
  • 33. IndicationsIndications A. AbsoluteA. Absolute 1.1. Recurrent infections of throatRecurrent infections of throat 2.2. Peritonsillar abscessPeritonsillar abscess 3.3. Tonsillitis causing febrile seizuresTonsillitis causing febrile seizures 4.4. Hypertrophy of tonsils causing obstructionHypertrophy of tonsils causing obstruction 5.5. Suspicion of malignancySuspicion of malignancy B. RelativeB. Relative 1.1. Diphtheria carriers,Diphtheria carriers, 2.2. Streptococcal carriersStreptococcal carriers 3.3. Chronic tonsillitis with bad taste or halitosisChronic tonsillitis with bad taste or halitosis 4.4. Recurrent streptococcal tonsillitis in a patient with valvularRecurrent streptococcal tonsillitis in a patient with valvular heart diseaseheart disease C. As a Part of Another OperationC. As a Part of Another Operation 1.1. PalatopharyngoplastyPalatopharyngoplasty 2.2. Glossopharyngeal neurectomy.Glossopharyngeal neurectomy. 3.3. Removal of styloid process.Removal of styloid process.
  • 34. ContraindicationsContraindications 1.1. Haemoglobin level less than 10 g%.Haemoglobin level less than 10 g%. 2.2. Acute upper respiratory tract infection, acuteAcute upper respiratory tract infection, acute tonsillitis.tonsillitis. 3.3. Children under 3 years of age.Children under 3 years of age. 4.4. Overt or submucous cleft palate.Overt or submucous cleft palate. 5.5. Bleeding disorders, e.g. leukaemia, purpura,Bleeding disorders, e.g. leukaemia, purpura, aplastic anaemia, haemophilia.aplastic anaemia, haemophilia. 6.6. At the time of epidemic of polio.At the time of epidemic of polio. 7.7. Uncontrolled systemic disease, e.g. diabetes,Uncontrolled systemic disease, e.g. diabetes, cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma. 8.8. Tonsillectomy is avoided during the period ofTonsillectomy is avoided during the period of menses.menses.
  • 35. ContraindicationsContraindications 1.1. Haemoglobin level less than 10 g%.Haemoglobin level less than 10 g%. 2.2. Acute infection in upper respiratory tract, acuteAcute infection in upper respiratory tract, acute tonsillitis. Bleeding is more in the presence oftonsillitis. Bleeding is more in the presence of acute infection.acute infection. 3.3. Children under 3 years of age.Children under 3 years of age. 4.4. submucous cleft palate.submucous cleft palate. 5.5. Bleeding disorders, e.g. leukaemia,Bleeding disorders, e.g. leukaemia, haemophilia.haemophilia. 6.6. At the time of epidemic of polio.At the time of epidemic of polio. 7.7. Uncontrolled systemic disease, e.g. diabetes,Uncontrolled systemic disease, e.g. diabetes, cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma. 8.8. Tonsillectomy is avoided during the period ofTonsillectomy is avoided during the period of menses.menses.
  • 36. AnaesthesiaAnaesthesia  Usually done underUsually done under generalgeneral anaesthesiaanaesthesia with endotracheal intubation.with endotracheal intubation.  In adults, it may be done underIn adults, it may be done under locallocal anaesthesia.anaesthesia.
  • 37. PositionPosition  Rose's positionRose's position, i.e. patient lies supine, i.e. patient lies supine with head extended by placing a pillowwith head extended by placing a pillow under the shoulders and a rubber padunder the shoulders and a rubber pad under the head. In this position both theunder the head. In this position both the head and neck are extended.head and neck are extended.
  • 38. Advantages of RoseAdvantages of Rose position:position:  1. There is virtually no aspiration of blood or1. There is virtually no aspiration of blood or secretions into the airway.secretions into the airway.  2. Both hands of the surgeon are free. This2. Both hands of the surgeon are free. This position helps in proper application of theposition helps in proper application of the Boyles Davis mouth gag.Boyles Davis mouth gag.  3. The surgeon can be comfortably seated at3. The surgeon can be comfortably seated at the head end of the patientthe head end of the patient
  • 39. Boyle-Davis mouth gagBoyle-Davis mouth gag
  • 40. Boyles Davis mouthBoyles Davis mouth gaggag Davis mouth gagDavis mouth gag Boyles tongue bladeBoyles tongue blade
  • 41. Boyle-Davis mouth gagBoyle-Davis mouth gag
  • 42. Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs, (15) Nasopharyngeal pack, (16) Towel clips.Downloaded from: StudentConsult (on 6 December 2012 06:54 PM) © 2005 Elsevier
  • 43. Steps of OperationSteps of Operation (Dissection and Snare(Dissection and Snare Method)Method)1.1. Boyle-Davis mouth gag is introduced andBoyle-Davis mouth gag is introduced and opened. It is held in place by Draffin'sopened. It is held in place by Draffin's bipods .bipods . 2.2. Tonsil is grasped with tonsil-holdingTonsil is grasped with tonsil-holding forceps and pulled medially.forceps and pulled medially. 3.3. Incision is made in the mucousIncision is made in the mucous membrane where it reflects from the tonsilmembrane where it reflects from the tonsil to anterior pillar. It may be extended alongto anterior pillar. It may be extended along the upper pole to mucous membranethe upper pole to mucous membrane between the tonsil and posterior pillar.between the tonsil and posterior pillar.
  • 44. Steps of OperationSteps of Operation cont..cont.. 4.4. A blunt curved scissor may be used toA blunt curved scissor may be used to dissect the tonsil from the peritonsillardissect the tonsil from the peritonsillar tissue and separate its upper pole.tissue and separate its upper pole. 5.5. Now the tonsil is held at its upper poleNow the tonsil is held at its upper pole and traction applied downwards andand traction applied downwards and medially. Dissection is continued withmedially. Dissection is continued with tonsillar dissector or scissors until lowertonsillar dissector or scissors until lower pole is reachedpole is reached
  • 45. Steps of OperationSteps of Operation cont..cont.. 6.6. Now wire loop of tonsillar snare isNow wire loop of tonsillar snare is threaded over the tonsil on to its pedicle,threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and thetightened, and the pedicle cut and the tonsil removed.tonsil removed. 7.7. A gauze sponge is placed in the fossaA gauze sponge is placed in the fossa and pressure applied for a few minutes.and pressure applied for a few minutes. 8.8. Bleeding points are tied with silk.Bleeding points are tied with silk. Procedure is repeated on the other side.Procedure is repeated on the other side.
  • 46. Post-operative CarePost-operative Care 1. Immediate general care1. Immediate general care (a)(a) Keep the patient in coma position untilKeep the patient in coma position until fully recovered from anaesthesia.fully recovered from anaesthesia. (b)(b) Keep a watch on bleeding from theKeep a watch on bleeding from the nose and mouth.nose and mouth. (c)(c) Keep check on vital signs, e.g. pulse,Keep check on vital signs, e.g. pulse, respiration and blood pressure.respiration and blood pressure.
  • 47. Post-operative CarePost-operative Care cont..cont.. 2. Diet2. Diet a.a.When patient is fully recovered he is to takeWhen patient is fully recovered he is to take liquids, e.g. cold milk or ice cream.liquids, e.g. cold milk or ice cream. b.b.Sucking of ice cubes gives relief from pain.Sucking of ice cubes gives relief from pain. c.c.Diet is gradually built from soft to solid food.Diet is gradually built from soft to solid food. They may take custard, jelly, soft boiled eggsThey may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2ndor slice of bread soaked in milk on the 2nd day.day. d.d. Plenty of fluids should be encouraged.Plenty of fluids should be encouraged.
  • 48. ComplicationsComplications A. ImmediateA. Immediate  11 immediate haemorrhage.immediate haemorrhage. Occurs at theOccurs at the time of operation. It can be controlled bytime of operation. It can be controlled by pressure, ligation or electrocoagulation ofpressure, ligation or electrocoagulation of the bleeding vessels.the bleeding vessels.  2.2. Reactionary haemorrhage.Reactionary haemorrhage. Occurs withinOccurs within a period of 24 hours and can be controlleda period of 24 hours and can be controlled by simple measures such as removal of theby simple measures such as removal of the clot, application of pressure orclot, application of pressure or vasoconstrictor.vasoconstrictor.  3.3. Injury to tonsillar pillars, uvula, softInjury to tonsillar pillars, uvula, soft palatepalate, tongue or superior constrictor, tongue or superior constrictor muscle due to bad surgical technique.muscle due to bad surgical technique.
  • 49. ImmediateImmediate Complications cont..Complications cont.. 4.4. Injury to teeth.Injury to teeth. 5.5. Aspiration of blood.Aspiration of blood. 6.6. Facial oedema.Facial oedema. Some patients get oedemaSome patients get oedema of the face particularly of the eyelids.of the face particularly of the eyelids. 7.7. Surgical emphysema.Surgical emphysema. Rarely occurs due toRarely occurs due to injury to superior constrictor muscle.injury to superior constrictor muscle.
  • 50. Delayed ComplicationsDelayed Complications cont..cont..  1.1. Infection.Infection. Infection of tonsillar fossa mayInfection of tonsillar fossa may lead to parapharyngeal abscess or otitislead to parapharyngeal abscess or otitis media.media.  2.2. Lung complications.Lung complications. Aspiration of blood,Aspiration of blood, mucus or tissue fragments may causemucus or tissue fragments may cause atelectasis or lung abscess.atelectasis or lung abscess.  3.3. Scarring in soft palate and pillarsScarring in soft palate and pillars..
  • 51. Thank YouThank You