INFLAMMATORYDISEASES OF THE PALATINE TONSIL By Dr. Syed Salman
HISTORY In the first century AD, Celsus described tonsillectomy performed with sharp tools and followed by rinses with vinegar and other medicinals. Tonsillitis gained additional attention as a medical concern in the late 19th century. Quinsy was considered in the differential diagnoses of George Washingtons death.
NORMAL BACTERILOGY (FLORA) OF TONSIL Different in health and disease Polymicrobial Difference in flora retrived from suface and core samples Surface: GABHS (disease) 40% of asymptomatic people also have culture positive for GABHS Other surface organisms: Haemophilus, Staphylococcus aureus, Alpha haemolytic streptococci, Branhamella sp., Mycoplasma, Chlamydia, various anarobes , viruses like adenovirus, myxovirus, picorna virus, coronavirus. Core Samples (F.N.A.): normal tonsils – no growth of pathogenic organisms. Disease (recurrent tonsillitis): Haemophilus influenza, S. Aureus, mixed flora more common, GABHS less common.
Establishment of normal flora in URT begins at birth 6-8 months: Actinomyces, Fusobacterium, Nocardia Later, Bacteroides, Leptotrichia, Propionibacterium, Candida At dentition & 1 year: Fusobacterium increase Anaerobic : Aerobic = 10:1 (Saliva), due variation in oxygen concentrations in the oral cavity. Healthy children upto 5 years can harbour known aerobic pathogens. Frequency of pathogens decreases with age, because of greater immunity. Changes in bacterial flora is noted in viral illnesses due to increased adherence of S. Aureus and other gram negative enteric pathogens (secondary infection).
Self limiting infection of one or both tonsils. Isolated episode. Associated with viral upper respiratory illness (catarrhal). Part of systemic infection (eg. Infectious mononucleosis)
Bacteriology Aerobic/anaerobic bacteria, viruses, yeasts, parasites. Normal flora/exogenous pathogenic organism Polymicrobial (synergistically) Most frequently cultured – GABHS Other: Staphylococci, pneumococci, haemophilus, other anaerobic bacteria Viral pathogens: influenza, parainfluenza, herpes simplex, coxsackievirus, echovirus, rhinovirus, RSV. Pre-school children: viral causes more likely. Older children: bacterial causes more likely.
Predisposing Factors Fatigue, exposure to extremes of temperature, pre existing URTI, known metabolic and immune diseases. Epidemic forms: institution settings like recruit camps, daycare facilities.
Epidemiology Both sexes equally affected. All age groups More common in children: 5-15 years of age. Peak incidence: 5-6 years of age. Season: autumn and winter months.
Clinical Features Self limited (4-6 days). Diagnosis is clinical. Sudden onset, pyrexial illness (fever and chills), sore throat, pain on swallowing (due to involvement of the pharyngeal muscles), dry throat, fullness in throat, otalgia Systemic upsets: headache, malaise, joint pains. Examination: pharyngeal erythema, enlarged congested tonsils, patches of whitish exudate, painful cervical lymphadenopathy (Jugulodigastric). Exudate limited to tonsillar fossa, particularly over the crypts, soft and friable, not adherent to the underlying tissue. Follicular: multiple small patches. Membranous/pseudomembranous: coalesce occurs. Pharyngitis, tongue: coated, thick tenacious mucus within the oral cavity. Viral tonsilllitis = Bacterial tonsillitis (severity, duration).
Laboratory Evaluation Leucocytosis Throat Culture: GABHS, not conclusive to be causative, results not immediate (24-48 hours), antibiotics, refractory cases Rapid Antigen Testing (RTA) Group A streptococcal antigen Latex agglutination / ELISA Results 10 minutes. Less Sensitive More Specific Differntiating between viral and bacterial infection cost
Management Supportive: proper oral hygiene (lavages with diluted 3% hydrogen peroxide, warm saline solution), analgesics, hydration, rest. Specific: Systemic antibiotics Penicillin (D.O.C.), erythromycin, tetracycline. Penicillin + beta lactamase inhibitor (amoxycillin + clavulanic acid). Clindamycin Erthyomycin + metronidazole Effective when administered with in 24-48 hours of symptom onset. Decreases symptoms 12-24 hours sooner. Prevents suppurative complications. Diminishes likelyhood of Rheumatic Fever. Ten full days of therapy (genesis of resistant organisms, allergym anaphylaxis). Single dose of dexamethasone (adjuvant therapy).
DIFFERENTIAL DIAGNOSISDiphtheria Corynebacterium diphtheria, gram positive, pleomorphic aerobic bacillus, lethal exotoxin. Only toxigenic strains infected with bacteriophage can cause diphtheria. Gradual onset, less pronounced systemic infection, hoarseness stridor croupy cough. Exudative tonsillopharyngitis, thick pharyngeal membrane. Infection can spread to the tonsils, palatate and larynx. Laryngeal inflammation combined with firm leathery exudative necrotic gray pharyngeal membrane may result in airway obstrucion. Removal of this membrane causes bleeding. Early diagnosis is critical, goal of therapy to neutralize unbound toxin with antitoxin. Antitoxin must be given in the first 48 hours to be effective, Myocarditis, Neurological sequlae resembling poliomyelitis & Gullian Barre syndrome may result. Organism identified by Flourescent antibody studies, prisence of Klebs- Loffler bacillus in membrane can be diagnosed with gram staining. Airway obstruction – tracheostomy. Penicillin high doses.
Vincents angina Ulcerative gingivitis and stomatitis Simultaneous infection of Spirocheta denticulata and Vincents fusiform bacillus (Borrelia vincenti or Treponema vincentii) Gradual onset, mild local and systemic symptoms. Poor orodental hygiene, overcrowded conditions. High fever headache sore throat. Cervical lymohadenopathy, gray necrotic membrane on the tonsil, when removed reveals ulcer confined to surrounding tissue, heals in 7-10 days. Necrosis of the surface mucosa, contains the infecting organism. Sloughing to the membrane produces bleeding. Penicillin therapy, oral hygeine. Trench mouth – ulcers include the gums and oral mucus membrane.
NEISSERIA Neisseria gonorrhoea. Common in homosexual men Acute exudative tonsillitis, gonococcal pharyngitis. Asymptomatic to exudative pharyngitis, disseminated gonococcemia. Penicillin and tertracycline. Herpangia Coxsackievirus Small vescicles with erythematous base that become ulcers. Spread over the anterior pillar, tonsils, palate and posterior pharynx.
Infectious Mononucleosis Ebstein Barr Virus, B lymphocytic Human Herpes Virus, oral contact, young adults. Acute Phanyngotonsillitis, large swollwn dirty gray tonsils. Petechiae located at the junction of hard and soft palate. High fever, general malaise, haematological and liver function disturbance, spleenomegaly, posterior cervical lymphadenopathy, generalized lymphadenapathy. DLC – 50% lymphocytosis, 10% atypical lymphocytes. Serology – Monospot blood test, Serum heterophill antibody titer (Paul Bunnel Davidsohn or Ox-cell haemolysis). Confirmation – specific EBV anibody tests (serological assays). 30% - seconday bacterial infection. Beta haemolytic streptococci, antibiotics – penicillin high dose Ampicillin avoided, severe allergic rash. Airway compromise – short course of high dose conrticosteroids.
Complications Suppurative Peritonsillar abscess Parapharyngeal abscess Retropharyngeal abscess Le Mieres syndrome Non suppurative Scarlet fever Acute Rhuematic Fever Post Streptococcal glomerulonephritis Tonsillitis and Psoriasis
Peritonsillar Abscess Principal compication, recurrent tonsillitis, chronic tonsillitis inadequately treated. Unilateral. Collection of pus between the tonsillar capsule and tonsillar bed, spread of infection from superior pole of tonsil. Severe pain referred otalgia, drooling of saliva (due to odynophagia, dysphagia), trismus (pterygoid muscles), breath becomes rancid, speech – nasal or thickened (hot potato), dehydration. Examination is difficult (trismus), oral topical anaesthetic solution. Gross unilateral swelling of palate and anterior pillar with displacement of tonsil medially with reflection if uvula to the opposite side. Marked associated lymphadenopathy. Cultures – polymicrobial infection. Needle aspiration – test aspirate, identify the site of abscess. Ct scan with contrast– extension of infection. Inferior extension of pus – supraglottic edema, airway obstruction. Spontaneous drainage – into oral cavity. Adequate hydration, parenteral antibiotics.
Incision and drainage Topical anaesthesia (4% to 5% Xylocaine) placed against the tonsillar pillars, injectable avoided, Supplemental anaesthetic - intranasally into sphenopalatine ganglion. IV analgesics. Children – ET intubation and General anaesthesia. Position – awake (sitting, partially reclining, head supported), GA (head down, Trendelenburg position). Long handled scalpel, No.11 Blade (guarded), blunt tipped haemostatic forcep. Tonsillectomy Absess tonsillectomy – a chuad 3-4 days – a tiede 4-6 weeks – a froid
Complications Infection seeding (regional and distant sites). Supraglottic edema (emergency tracheostomy). Endocarditis, nephritis, peritonsillitis, brain abscess. Local venous thrombosis / phlebitis. Extension into the pharyngomaxillary space – external drainage, through the submandibular triangle, Necrotizing fascitis. Perichondritis of thyroid cartilage. Aspiration – pneumonitis, pulmonary abscess. Spontaneous haemorrhage – carotid / jugular vessels, vessels erosion.
Parapharyngeal Abscess Between superior constrictor muscle and deep cervical fascia. Pain, Fever, leucocytosis. Trismus (pterygoid), stiff neck (paraspinal muscles). Swelling of lateral pharyngeal wall especially behind the posterior pillar, Anteromedial displacement of tonsil on the lateral pharyngeal wall. Thickness of sternocleidomastoid (fluctuance). May spread down the carotid sheath into the mediastinum (mediastinitis), retroperitoneal sepsis. CT scan with contrast – to differentiate between peritonsillar abscess. Neorological deficit – Cr. N. IX, X, XII. Agressive antibiotic therapy, fluid replacement. Incision and Drainage – external approach, transverse submandibular incision, approx. 2 cm inferior to the mandibular margin.
Retropharyngeal Abscess Infants, young children below 5 years Retropharyngeal space, cranial base (superior limit), retroviseral space – into the mediastinum upto the level of bifurcation of trachea (inferior limit). Lymphoid tissue (nose, paranasal sinuses, pharynx, eustachian tube) Buccopharyngeal fascia is adhrent to prevertebral fascia in midline, infection is unilateral. Irritability, fever, dysphagia, muffled speech, noisy breathing, stiff neck, cervical lymphadenopathy, airway compromise. X – ray, USG, CT contrast. High dose antibiotics, Incision and Drainage under GA, ET tube, drained per orally, vertical incision on lateral aspect of posterior pharyngeal wall.
Le Mierres Syndrome Rare and fatal complication Septic thrombophlebitis of internal jugular vein. Fusiform bacillus. Severe neck pain, septicaemia, prolonged fulminant course, secondary to tympanomastoid infection. Imaging – thrombus in neck veins. Prolonged six weeks antibiotics. Anticoagulation – speading thrombophlebitis. Significant Mortality
Scarlet Fever Secondary to acute streptococcal tonsillitis/pharyngitis. Thick membranous tonsillitis. Due to production of endotoxin by bacteria. Marked erythema of pharyngeal mucosa, characteristic – strawberry tongue, prominent lingual papillae, diffuse erythematous skin rash, severe lymphadenopathy, memebrane more friable than that of diphtheria. Diagnosis – throat cultures, immune testing, Dicks test (intradermal injection of dilute streptococcal toxin), Schultz Charlt blanching phenomenon (convalescent serum causes the rash to fade). IV penicillin. Otologic complications – necrotizing otitis media
Tonsillitis and Psoriasis Exacerbation, guttate variety, immune phenomenon Acute Rheumatic Fever Post streptococcal glomerulonephritis Both after pharyngeal and skin infection, acute nephritic syndrome, 1-2 weeks, common antigen of glomerulus and streptococcus. Recurrent Tonsilltis Sub acute Tonsillitis Chronic Tonsillitis