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PROBLEM BASED LEARNING
E.N.T
SAROSH UL HASSAN
CASE
SCENERIO• A 10year old boy comes to OPD with high
grade fever, sore throat and dysphagia to
solids for past 4 days.
• Mother informs that he had multiple similar
episodes in the past 2 years, always
alleviated by taking antibiotics.
• On examination tonsils were
inflamed, hypertrophied with whitish
membrane. Child looks toxic
though.
WHAT ARE
YOUR
DIFFERENTIAL
DIAGNOSIS???
DIFFERENTIAL DIAGNOSIS
ANATOMY OF PALATINE
TONSILS
• Palatine Tonsil is an
ovoid mass of lymphoid
tissue situated in the
lateral wall of
oropharynx between
anterior and posterior
pillars
• It has Two surfaces –
Medial and Lateral, and
Two poles – Upper and
Lower
MEDIAL SURFACE
• Medial Surface is
covered by
nonkeratinizing stratified
squamous epithellium
which dips into the
substance of tonsils in
the form of crypts
• One of the crypts, situated near the
upper part of tonsils is very large and
deep and is called CRYPT OF MAGNA
LATERAL SURFACE
• It is covered by the
fibrous capsule of the
tonsil
• The tonsillar bed is
separated from the
capsule by loose
areolar tissue
• This makes it is easy to
dissect the tonsil from its
bed during tonsillectomy
• It is the site of collection
of pus in peritonsillar
abscess (quinsy)
POLES OF TONSILS
• UPPER POLE
– It extends into the soft
palate
– There is a semilunar
fold of mucous
membrane which
covers the medial part
of the upper pole
• LOWER POLE
– It is attached to the
tongue
– The lower pole is
separated from the
tongue by the
tonsillolingual sulcus
• This sulcus may
harbour carcinoma
BLOOD SUPPLY
VENOUS AND LYMPHATIC
DRAINAGE
Enlarged non tender jugulodigastric lymph
node is a sign of chronic tonsillitis
Nerve supply
- Lesser palatine branch of sphenopalatine ganglion
- Glossopharyngeal nerve
FUNCTIONS OF TONSIL
• It has a protective function in that it
prevents entry of pathogens through the
nasal and oral route
• The crypts on the surface of the tonsil
serve to increase the surface area and
increase the efficiency of protection
against pathogens
• It forms a part of Waldeyer’s
lymphatic ring
COMING BACK TO
THE DIFFERENTIAL
DIAGNOSIS……
ACUTE TONSILLITIS
CATARRHAL TONSILLITIS
MEMBRANOUS TONSILLITISPARENCHYMATOUS TONSILLITIS
FOLLICULAR TONSILLITIS
MEMBRANE OVER TONSILS
MEMBRANOUS TONSILLITIS
DIPTHERIA
VINCENT ANGINA
INFECTIOUS MONONUCLEOSIS
AGRANULOCYTOSIS
LEUKEMIA
APHTHOUS ULCERS
MALIGNANCY TONSILS
TRAUMATIC ULCERS
CANDIDAL INFECTION OF TONSIL
MEMBRANOUS TONSILLITIS
• Occur due to pyogenic
organisms
• An exudative membrane
forms over the medial
surface of the tonsils
• Features of acute tonsillitis
DIPTHERIA
• Acute infection caused by
Corynebacterium
Diptheriae
• Formation of false
membrane which extends
beyond the tonsils on to the
soft palate and posterior
pharyngeal wall.
• Dirty gray in color, firmly attached to
mucosa.
• Cause bleeding when membrane is
removed
• Diphtheria is slower in onset with less
local discomfort
VINCENT ANGINA
• Insidious in onset with less fever and less
discomfort in throat
• Gray membrane forms usually over one
tonsils can be easily removed revealing an
irregular ulcer on the tonsil.
• Throat swab will show both
organisms typical of this disease, that
are:
• Fusiform Bacilli
• Spirochetes
INFECTIOUS
MONONUCLEOSIS
• Also called as glandular fever,
caused by epstein barr virus.
• Both tonsils are enlarged,
congested and covered with
mombrane.
• Lymph Node enlarged in the
posterior triangle of neck
along with speenomegaly
• Blood smear show more than 50%
lymphocytes, out of which 10% are atypical.
• White cell count is normal in first week but
rises in the second week
LEUKEMIA
• In children, 75% of leukemias
are acute lymphoblastic and
25% acute myelogenous or
chronic
• Peripheral blood shows
TLC>100,000/CU MM.
• It may be normal or less than
normal.
AGRANULOCYTOSIS
• Ulcerative necrotic lesions
not only on the tonsils but
also in the oropharynx.
• Patient is severely ill.
• In acute form, total
leucocytic count is dec. to
<2000/cu mm
APHTHOUS ULCERS
• They may involve any part of
oral cavity or oropharynx
• Very painfull
• It is solitary & may involve
the tonsil and pillars
• May be small or large
MALIGNANCY TONSILS
• Oral or pharyngeal tumors
are the excessive growth
of cells in these regions.
• They may be benign or
malignant.
• Most oral/pharyngeal
tumors are malignant
CHRONIC TONSILLITIS
QUINSY
• Also called as peritonsillar
abscess.
• It the collection of pus in the
peritonsillar space.
FEATURES:
• Dysphagia
• High grade fever
• Muffled and thick speech also
called HOT POTATO VOICE
• Trismus
• Swollen soft palate
• Uvula swollen and edematous.
Tonsillitis case

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Tonsillitis case

  • 2. CASE SCENERIO• A 10year old boy comes to OPD with high grade fever, sore throat and dysphagia to solids for past 4 days. • Mother informs that he had multiple similar episodes in the past 2 years, always alleviated by taking antibiotics. • On examination tonsils were inflamed, hypertrophied with whitish membrane. Child looks toxic though.
  • 5. ANATOMY OF PALATINE TONSILS • Palatine Tonsil is an ovoid mass of lymphoid tissue situated in the lateral wall of oropharynx between anterior and posterior pillars • It has Two surfaces – Medial and Lateral, and Two poles – Upper and Lower
  • 6. MEDIAL SURFACE • Medial Surface is covered by nonkeratinizing stratified squamous epithellium which dips into the substance of tonsils in the form of crypts • One of the crypts, situated near the upper part of tonsils is very large and deep and is called CRYPT OF MAGNA
  • 7. LATERAL SURFACE • It is covered by the fibrous capsule of the tonsil • The tonsillar bed is separated from the capsule by loose areolar tissue • This makes it is easy to dissect the tonsil from its bed during tonsillectomy • It is the site of collection of pus in peritonsillar abscess (quinsy)
  • 8. POLES OF TONSILS • UPPER POLE – It extends into the soft palate – There is a semilunar fold of mucous membrane which covers the medial part of the upper pole • LOWER POLE – It is attached to the tongue – The lower pole is separated from the tongue by the tonsillolingual sulcus • This sulcus may harbour carcinoma
  • 10. VENOUS AND LYMPHATIC DRAINAGE Enlarged non tender jugulodigastric lymph node is a sign of chronic tonsillitis
  • 11. Nerve supply - Lesser palatine branch of sphenopalatine ganglion - Glossopharyngeal nerve
  • 12. FUNCTIONS OF TONSIL • It has a protective function in that it prevents entry of pathogens through the nasal and oral route • The crypts on the surface of the tonsil serve to increase the surface area and increase the efficiency of protection against pathogens • It forms a part of Waldeyer’s lymphatic ring
  • 13. COMING BACK TO THE DIFFERENTIAL DIAGNOSIS……
  • 14.
  • 17. MEMBRANE OVER TONSILS MEMBRANOUS TONSILLITIS DIPTHERIA VINCENT ANGINA INFECTIOUS MONONUCLEOSIS AGRANULOCYTOSIS LEUKEMIA APHTHOUS ULCERS MALIGNANCY TONSILS TRAUMATIC ULCERS CANDIDAL INFECTION OF TONSIL
  • 18. MEMBRANOUS TONSILLITIS • Occur due to pyogenic organisms • An exudative membrane forms over the medial surface of the tonsils • Features of acute tonsillitis
  • 19. DIPTHERIA • Acute infection caused by Corynebacterium Diptheriae • Formation of false membrane which extends beyond the tonsils on to the soft palate and posterior pharyngeal wall. • Dirty gray in color, firmly attached to mucosa. • Cause bleeding when membrane is removed • Diphtheria is slower in onset with less local discomfort
  • 20. VINCENT ANGINA • Insidious in onset with less fever and less discomfort in throat • Gray membrane forms usually over one tonsils can be easily removed revealing an irregular ulcer on the tonsil. • Throat swab will show both organisms typical of this disease, that are: • Fusiform Bacilli • Spirochetes
  • 21. INFECTIOUS MONONUCLEOSIS • Also called as glandular fever, caused by epstein barr virus. • Both tonsils are enlarged, congested and covered with mombrane. • Lymph Node enlarged in the posterior triangle of neck along with speenomegaly • Blood smear show more than 50% lymphocytes, out of which 10% are atypical. • White cell count is normal in first week but rises in the second week
  • 22. LEUKEMIA • In children, 75% of leukemias are acute lymphoblastic and 25% acute myelogenous or chronic • Peripheral blood shows TLC>100,000/CU MM. • It may be normal or less than normal. AGRANULOCYTOSIS • Ulcerative necrotic lesions not only on the tonsils but also in the oropharynx. • Patient is severely ill. • In acute form, total leucocytic count is dec. to <2000/cu mm APHTHOUS ULCERS • They may involve any part of oral cavity or oropharynx • Very painfull • It is solitary & may involve the tonsil and pillars • May be small or large MALIGNANCY TONSILS • Oral or pharyngeal tumors are the excessive growth of cells in these regions. • They may be benign or malignant. • Most oral/pharyngeal tumors are malignant
  • 24. QUINSY • Also called as peritonsillar abscess. • It the collection of pus in the peritonsillar space. FEATURES: • Dysphagia • High grade fever • Muffled and thick speech also called HOT POTATO VOICE • Trismus • Swollen soft palate • Uvula swollen and edematous.