Tonsillitis by Rama Maleakhi and R. Yusa Herwanto

1. TONSILLITIS
Rama Maleakhi Saragih
R. Yusa Herwanto

2. Preface
• Sore Health  Problem in Indonesia  Many people aren’t familiar with
Tonsillitis
• Tonsilitis  Inflammation of the palatine tonsil that is a part of waldeyer’s ring
• Infection  Bacteria or virus enter the body via Aerogen atau Foodborn 
Tonsil become red and enlargment of lymphoid tissue
• WHO  87.000 children below 15 years old have undergo tonsillectomy
• Tonsillitis Patient’s Habit Consume food like junk food, spicy food, and also cold
food
• This disease could be found with  High fever, sore throat, low apetite
• SNPPDI 2019  Kompetensi 4  Diagnose the patient and Treat the patient
completely  lowering the incidence of complication  Need to know tonsilitis
spesifically

3. Definition
• Tonsillitis is the inflammation of the tonsil as a part of waldeyer’s ring
• Tonsillitis can spread from air, hand-to-hand, and kissing/ saliva
• Tonsillitis can be found in all age, but spesifically in yonug age
• Acute tonsillits  Inflammation of the tonsil that is caused by bacterial or viral
infection  that occur in 2 weeks
• Acute tonsillitis  acute sore throat  odinophagia, red and swollen tonsil that
can be accompanied by tonsil’s exudate, cervical lymphadenopathy
• Chronic tonsillits  not clear  terminology: sore throat that occur in 3 weeks
that is accompanied by inflamation of the tonsil
• Chronis tonsillitis  the disease could be as a progressive disease from acute
tonsillits that didn’t get adequate treatment
• Etiological agent of acute and chronic tonsillits are usually same

4. Epidemiology
• Tonsillitis is the inflammation of the tonsil as a part of waldeyer’s ring  could be
found in 1,3% of outpatient
• This disease usually found in winter and spring  that could be induced by
headache, cold temperature, tobacco, smoking, humidity, and malnutrition
• Virus etiologic  Child below 5 year
• Acute tonsillitis  patient 10-30 years old, infant, elderly
• Chronic tonsillitis  7-14 years old, followed by teenager, and elderly patient is
seldom to find
• In H. Adam Malik General Hospital  4 case of acute tonsillitis (4,8%) and the
other 80 case were chronic tonsillitis (95,2%)
• Based of that research  the common age for tonsillitis was people 12-25 years old

5. Classification
Acute tonsillitis
Membranous
tonsillitis
Chronic
tonsillitis
Viral tonsillitis
Bacterial
tonsillitis
Tonsilitis
Diphteria
Tonsilitis
Fungal
Tonsilitis Plaut
Vincent
Caused by Corynebacterium diphteriae
Caused by Candida spp
Caused by Spirochaeta bacteria atau Treponema that could be
found from people with low hygiene level
sore throat that occur in 3 weeks that is accompanied by inflamation of the tonsil;
the disease could be as a progressive disease from acute tonsillits that didn’t get
adequate treatment

6. Acute tonsillits divided into:
• Acute Cattarhal Tonsillitis
• Acute Folicullar Tonsillitis
• Acute Parenchymatous Tonsillitis
• Acute Lacunar Tonsillitis
Tonsillitis Classification
Chronic tonsillits divided into:
• Chronic Folicullar Tonsillitis
• Chronic Parenchymatous
Tonsillitis
• Chronic Fibroid Tonsillitis

7. • This disease cause by Corynebacterium diphteriae.
• Clinical manifestation of this disease could be divided
into 3 type:
• Common Symptom (fever, headache, low apetite, slow
pulse, sore throat)
• Local Symptom (Swollen tonsil that is covered by white
plaque that will wider and form an membrane. This
pseudomembrane is easy to bleed. Bull neck could be
found
• Symptom because Exotoxin (miokarditis, paralysis of
palatum muscle, albuminuria)
Diphteria Tonsillitis

8. • This disease caused by spirochaeta (bacteria) or
triponema that could be found in people with low
hygiene level and vitamin c deficiency.
• Clinical manifestation are High fever, headache,
gastrointestinal problem, pain sensation in oral cavity,
hipersalivation, teeth dan gum are easy to bleed
• Physical exam oral cavity and faring mucose are
hyperemic, white membrane above tonsil, uvula,
faring wall, gum, smelly mouth (foetor ex ore) and
enlargment of submandibula lymph node
Angina Plaut Vincent

9. • This disease caused by Candida. The common type was
C. albicans followed by C. glabrata, C. krusei, C.
Parapsilosis
• Symptom  white membrane in the surface of the
mucose; erythematous plaque in soft and hard palate;
Angular cheilitis; dysphagia; odynophagia; sense of
burnt in oral cavity and tongue
• Microscopic examination  Smear with Periodic Acid
Schiff’s or KOH  to search for Candida’s yeast dan
blastospora
• Biopsy  Hyperplastic candidiasis Epithelial
parakeratosis with PMN leukocyte in superficial area.
Fungal Tonsillitis

10. Viral Tonsillitis
• Caused by virus DNA double strand (adenovirus, Epstein Barr Virus), virus DNA single
strand(Human Boca Virus), virus RNA single strand (virus influenza dan para-influenza; entero-
virus termasuk virus Coxsackie; virus corona; respiratory syncytial virus/RSV; human meta-
pneumo-virus, dan retro-virus termasuk human immunodeficiency virus/HIV.
• In Children , Adenovirus 1-7, 7a, 9, 14, dan 15; Influenza-Virus A dan B; Parainfluenza-Virus 1-4;
Epstein-Barr-Virus (EBV), Human-Herpes-Virus 4 (HHV4), dan Enterovirus termasuk Coxsackie-
Virus are common pathogen, seldom could be found rhinovirus atau virus pernapasan syncytial
(RSV).
• In Adult  Rhinovirus atau Coronavirus.
Etiologic Agent

11. Etiologic Agent
Bacterial Tonsillitis
• Dominant Pathogen was Grup A beta-hemolitic
Streptococcus (GABHS) including Streptococcus
pyogenes that could make inflammation of the
tonsil.
• Other pathogen that could be found:
Staphylococcus aureus (termasuk MRSA/methicillin
resistant Staphylococcus aureus), Streptococcus
pneumoniae, Mycoplasma pneumoniae, Chlamydia
pneumoniae, Bordetella pertussis, Fusobacterium
sp., Treponema pallidum, dan Neisseria
gonorrhoeae.
• Bacterial tonsillits could be found with viral
infection.

12. Etiologic Agent
Non Infectious Etiologic Agent
• Extra-oesphageal disease or laryngopharyngeal reflux disease
• Physical or chemical trauma (Nasogastric tube, Chronic irritation caused by
smoking)
• Other disease: sindroma stevens-johnson, kawasaki disease
• Hematologic disease (Aplastic anaemia and leukemia)
• Side effect’s of medication
• Tonsillar cancer

13. • Risk Factor for tonsillitisyoung age, residential area, cold weather, non
sterile water
• Research Tonsilitis with age, low hygiene level, diet, stress level, and
habit of consume spicy food
• Tonsilitis  more common in women then men, and children with <5 years old
• Children <6 years old bigger tonsil compared to adult tonsil  more susceptible
to tonsillitis
• Unhygiene lifestyle and envinronment
Risk Factor

14. Patophysiology
• Pathologic phase of inflammation of the tonsil:
1. Inflammation of the tonsil
2. Exudte formation
3. Selulitis tonsil
4. Peritonsillar abcess formation
5. Tissue Necrosis

16. • Tonsillitis diagnosis adequate History taking, adequate physical
examination
• Choice of Treatment need more examination to give best
treatment
Diagnosis

17. History taking, identification of Sign and Symptom
Common History taking:
• Sore Throat
• Odynophagia
• Fever
• Swollen neck or submandibula area
• Pain in ear
• Hallitosis
• Constitutional symptom, including headache, pain across the body, malaise

18. History taking, identification of Sign and Symptom
• Common sign and symptom in acute bacterial tonsillitis were inflamation of the
tonsil with exudate to be found, disfagia, odinofagia, dan cervical
lymphadenopathy.
• On Acute viral tonsillitis were, dysphagia, fever, odinofagia, and eritema tonsil
without exudate

19. Sign and Symptom of Chronic Tonsillitis
• Symptom:
• Sore throat (Reccurent attack) that is occur 3 or 4 times in a year
• Cough
• Halitosis
• Low taste sensation because there are pus in tonsill crypt
• Lower intonation of speech, Odinophagya

20. Sign and Symptom of Chronic Tonsillitis
• Four Cardinal Sign:
• Persistent Congestion of Anterior
Pillar
• Tonsillar Squeeze (Ervin Moore
Sign) Positive  Place tongue
depressor at anterior pillar and
press the tonsil  ther is exudate
green-yellowish came from the
crypt  Positive result
• Bilateral enlargment of
Jugulodigastic Lymph Node
• Chronic Parenchymatous Tonsillitis
 tonsil enlargment

21. • T0 : Post Tonsillectomy
• T1 : <25% tonsil volume compared to half the volume of the
oropharynx, or the medial border of the tonsils crosses the anterior
pillar to the distance of the anterior pillar of the uvula.
• T2 : 25-50% of the tonsil volume compared to half the volume of the
oropharynx, or the medial border of the tonsil extends from the
distance of the anterior-uvular pillar to of the distance of the
anterior uvula pillar.
• T3 : 50-75% of tonsil volume compared to half the volume of the
oropharynx, or the medial border of the tonsils extends from the
distance of the anterior-uvular pillar to of the distance of the
anterior uvula pillar.
• T4 : >75% of the tonsil volume compared to half the volume of the
oropharynx, or the medial border of the tonsil extends the distance
from the anterior-uvula pillar to the uvula or more.
Degree of Tonsil Enlargment

22. 1. Tonsil Enlargment with Degree of Enlargment >T2
2. Hyperemic of the tonsil. Form the acute tonsillitis with detritus called Follicular
tonsillitis. If this detritus become on, form an way inside the crypt  Lacunar
Tonsillitis.
3. Soft Palate, arkus anterior and arkus posterior juga biasanya Oedem and
hyperemic.
4. Enlargment of Neck Lymph node, accompanied by pain
5. Could be found with coated tongue
Physical Examination (Acute Tonsillitis)

23. Physical Examination (Acute Tonsillitis)

24. Scoring System in Tonsillitis
• Modification Centor Score, presented by McIsaac  acute tonsillitis in all age
• Only patient with score 3 or more (Centor or McIsaac), rapid test or culture must be considered until
treatment with antibiotic
Criteria Point
Fever (>38o C) 1
There isn’t any symptom of Upper Respiratory Infection
(Conjunctivitis, rinorea, or cough).
1
Painful Cervical Lymphadenopathy 1
Tonsil Erythema, swollen with exudate 1
Age
3-14 years old 1
15-44 years old 0
≥45 years old -1

25. 1. Tonsil enlargment with unflat surface, wider
crypt with detritus
2. Submandibula lymph node enlargment
3. Yellowish spot with pus on the surface of
tonsil  Tonsilitis Folikular Kronis
4. Enlargment of tonsil with various degree.
Sometime tonsil could met in midline
5. Small tonsil, but pressure on anterior pillar
will make yellowish pus come out (on
tonsilitis kronis fibroid)
Physical Examination (Chronic Tonsillitis)

26. Further Investigation
• Culture Throat Swab
• Other Workup:
• Blood smear eliminate hematologic disorder as leukemia, agranulositosis
• Paul-Bunnel Test  Infectif Mononucleosis
• Xray Paranasal Sinus  nasosinus septic focus
• Xray nasopharynx  Hipertrofi Adenoid
• CT Scan sinus and neck  complication of acute tonsillitis
• Complete Blood Count

27. Differential Diagnose
• Infectious Mononucleosis (Pfeiffer’s disease)
• Scarlett Fever
• Tonsil Carcinoma

28. Tonsillitis Treatment
• Pharmacologic Treatment
• Etiological based Treament
• Supportive Treatment
• Nonpharmacologic Treatment, Education

29. Pharmacologic Treatment
• Antibiotic
Sign and symptom in acute tonsillitis patient that indicate bacterial infection (skor
Centor modifikasi/McIsaac atleast 3).
1. Age ≤ 14 years old
• Some antibiotic:
• Penisilin V (100.000 IU/kg/day in three dose for 7 days).
• Phenoxymethylpenicillin-Benzathin (50.000 IU/kg/days in two dose for 7 days).
• In special case where alergic penicilin:
• Eritromisin-estolat (40 mg/kg/days in three dose for 5 days).
• First generation Cephalosphorin (Cefadroxil 50 mg/kg/days in two dose for 5 days).

30. Pharmacologic Treatment
2. Age > 15 years old
• Penisilin V (3 × 0,8–1,0 Mio IU/days for 7 days).
In special case where alergic penicilin:
• Eritromisin-estolat (3 × 500 mg/days for 5 days).
• First generation Cephalosphorin (Cefadroksil 2 × 1000 mg/days for 5 days).

31. Pharmacologic Treatment
• Antivirus
• Severe Viral Tonsillitis
• Metisoprinol with dose 60- 100mg/kgBB divided into 4-6 times/ day for adults and children
• Diphteria Tonsillitis
• Aim  Neutralize Toxin and Kill the Organism
• Dose  20.000-40.000 unit for diphteriae below 48 hours, or when the membrane only
found in tonsil; and 80.000-120.000 unit if the diphteri occur more than 48 hour, or wider
membrane
• Antibiotic  benzyl penisilin dose 600mg per 6 hours for 7 days or Eritromycin 500mg per 6
hour per oral
• Corticosteroid 1,2mg/ kgBB/ days; Antipiretic for symptomatic treatmen
• Patient must be isolated. Bed time rest for 2-3 week

32. Pharmacologic Treatment
• Angina Plaut Vincent
• Antimicrobial Treatment
• Amoxicillin 500mg PO 3x1 for 10 days plus Metronidazole 250mg PO 3x1 for 10 days
• Amoxicillin-Clavulanate 500mg/ 125 mg PO 3x1
• Clindamycin 150-300mg PO 3x1 for 10 days
• Adjunctive Therapy
• Oral rinse  Hidrogen peroksida 3%
• Chlorhexidine 0,12% oral rinse 15mL BID
• Pasien HIV  Nystatin rinse 5 mL 4x1 atau Fluconazole 200mg PO 1x1 for 7-14 days
• Consume Vitamin C and B Complex, keep good level of hygiene on the mouth

33. Pharmacologic Treatment
• Fungal Tonsillitis usually caused by C. Albicans, C. Glabrata, C. dubliensis, C.
krusei
• Mild Symptom Clotrimazole troche 10 mg 5 times per day or miconazole
mucoadhesive buccal 50 mg tablet 1 times per day for 7-14 days
• Alternative for Mild Symtpom Suspensi nystatin (100.000 U/mL) 4-6mL 4X1
• Moderate to Severe Symptom Fluconazole oral 100-200mg 1x1 for 7-14
days
• Chronic Suppresive Therapy not required if required for reccurent attack
 Fluconazole 100mg 3 times per week

34. Pharmacologic Treatment
• Supportive Treatment
• Asses the patient, is the patient need oxygen (SpO2 <93%). Acute management follow the
airway, breathing, circulation.
• Asses the dehidration status (fluid theraphy) and hipoglycemia (oral glucose or bolus iv, KGD <
70mg/dL).
• Oral steroid or intramuscular in children and teen  significant theraphy and minimal side
effect
• Best result  Streptococcal tonsilitis  deksametason (10 mg), betametason (8 mg) and
prednisolon (60 mg)
• Analgetic, Antipiretic
• Mouthwash (Chlorhexidine, Glukonat, Benzihidamin Hydrochloride)

35. Nonpharmacologic Treatment
• Maintain good oral hygiene
• Use of mouthwash
• Educate the patient for pola good life style
• Educate the patient for stop smoking
• Avoid food that is sour and spicy
• Educate the patient for not in stress state for long timr
• Maintain a healthy diet
• Regular exercise, and adequate hydration or drinking

36. Absolute Indication for Tonsillectomy
1. Tonsils that are large enough to cause airway
obstruction, severe dysphagia associated with weight
loss, to sleep disturbances, even in chronic cases can
cause cardiopulmonary complications such as cor
pulmonale.
2. The presence of recurrent peritonsillar abscess or
abscess that extends to the surrounding tissue, which
does not improve with medical treatment and drainage
alone.
3. Excisional biopsy is suspected of malignancy (lymphoma
or tonsil cancer)
Tonsillectomy

37. Relative Indication for Tonsillectomy
1. There have been 3 or more episodes of tonsillitis in 1 year with adequate
antibiotic therapy.
2. Halitosis due to chronic tonsillitis that does not improve with medical therapy.
3. Chronic or recurrent tonsillitis in streptococcal carriers that does not improve
with antibiotics.
Tonsillectomy

38. Contraindication for tonsilectommy:
1. Bleeding diathesis (abnormal homeostasis and bleeding);
2. The risk of complications of anesthesia and surgery related to medical conditions
that are not well controlled (such as hypertension, diabetes mellitus, etc.);
3. Anemia (especially if <10 g/dL).
Tonsillectomy

39. 1. Peritonsillar Abscess
2. Parapharyngeal Abscess
3. Cervical Abscess
4. Acute Media Otitis
5. Rheumatic Fever
6. Glomerulonephritis
7. Endocarditis
8. Tonsilollith
9. Tonsillar Cyst
Complication

40. • Tonsillitis is an inflammation that occurs in the palatine tonsil which is part of the Waldeyer
ring which can be caused by a bacterial or viral infection.
• Tonsillitis can be classified into acute tonsillitis, chronic tonsillitis, and membranous
tonsillitis
• Establishing the diagnosis of tonsillitis includes: history taking regarding exposure to risk
factors, identification of signs and symptoms; physical examination in accordance with the
clinical manifestations of tonsillitis; and supporting examinations to support the
management plan
• Tonsillitis is generally managed by: adequate rest; gargle with warm water; drinking warm
water; eating soft foods rich in vitamins and other nutrients; Pharmacological management
based on microorganisms that cause tonsillitis, and tonsillectomy procedures according to
indications and the absence of contraindications.
Conclusion

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43. Thank You