Acute & chronic tonsillitis and their management

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.

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

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

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

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

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

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

Structures related to theStructures related to the
bed of tonsilsbed of tonsils

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.

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.

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.

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

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

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

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

Types of acuteTypes of acute
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

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.

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

tonsillitistonsillitis4).Acute parenchymatous4).Acute parenchymatous  tonsil is uniformlytonsil is uniformly
enlarged and congestedenlarged and congested

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.

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

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

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

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

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
 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

types of Chronictypes of Chronic
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.

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

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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

Boyle-Davis mouth gagBoyle-Davis mouth gag

Boyles Davis mouthBoyles Davis mouth
gaggag
Davis mouth gagDavis mouth gag
Boyles tongue bladeBoyles tongue blade

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

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.

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

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.

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.

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.

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.

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.

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..

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