tonsilitis : it's causes, sign and symptoms, nursing management

1. Prepared by:
RN Arpana Bhusal
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3. CONTENTS
Anatomy
Introduction
Causes
Pathophysiology
Classification
Sign and symptoms
Diagnostic evaluation
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4. CONTENTS cnt…
Management
Medical
Supportive
Surgical
Nursing
Complication
Prevention
References
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6. ANATOMY
The tonsils are 3 masses of tissue:
 Lingual tonsil
 Pharyngeal (adenoid) tonsil
 Palatine or fascial tonsil
Together they form Waldeyer's ring
 Are lymphoid tissue
 Covered by respiratory epithelium
 Pseudostratified ciliated
 Columnar epithelium
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7. Anatomy of tonsil
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8. Waldeyer's ring
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9. Anatomy cnt…
Produce lymphocytes
Are active in the synthesis of
immunoglobulins.
Generally, the palatine tonsils referred to as
“the tonsils”.
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10. Introduction
Tonsillitis is inflammation of the tonsils most
commonly caused by a viral or bacterial
infection.
 That can be acute, sub-acute, and chronic due
to causative factors affecting it.
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12. CAUSES
Bacterial and viral infections can cause tonsillitis
through droplet infection.
A common cause is Streptococcus bacteria.
Other common causes include:
Adenoviruses
Influenza virus
Epstein-Barr virus
Parainfluenza viruses
Enteroviruses
Herpes simplex virus
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14. Predisposing factors
Endogenous
URTI
Postnasal discharge due to sinusitis
Residual tonsillar tissue after tonsillectomy
Exanthemata
Blood dyscrasias
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15. Predisposing factors cnt…
Exogenous
Cold drinks and foods
Contact with infected persons
Crowded and ill-ventilated environment
Imbedded foreign body
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16. PATHOPHYSIOLOGY
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17. Classification
Acute tonsillitis
Sub-acute tonsillitis
Chronic tonsillitis
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18. Acute tonsillitis
 Acute tonsillitis tends to be bacterial or viral in
nature.
 Acute infection of the tonsils involving the surface
epithelium, crypts and lymphoid tissue
 This is the commonest URTI in children.
 Occurs up to the age of 15; common in all sexes
 Incubation period ; is 72 hours.
 Viral: HSV, EBV,CMV, Adenovirus, Measles.
 Bacteral: anaerobes, group A beta hemolytic strepto
pyogens, mycoplasma, chlamydia, N.gonorrhea
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19. Acute Tonsillitis subtype
I. Acute superficial/catarrhal tonsillitis
II. Acute membranous tonsillitis
III. Acute follicular tonsillitis
IV.Acute parenchymatous tonsillitis
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20. i. Acute catarrhal/superficial
Here tonsillitis is a part of generalized
pharyngitis, mostly seen in viral infections
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21. ii. Acute membranous
Follows stage of acute follicular tonsillitis
where exudates coalesce to form membrane on
the surface
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22. iii. Acute follicular
Infection spread into the crypts with purulent
material, presenting at the opening of crypts as
yellow spots.
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23. iv. Acute parenchymatous
Tonsil in uniformly enlarged and congested
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25. Symptoms and Signs
Symptoms:
Sore throat – raw sensation in the throat
Refusal to eat due to odynophagia
Earache – either referred pain from the tonsil
or due to acute otitis media
Voice becomes thick and muffled
Fever, may be associated with chills and rigor.
Headache
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26. Signs cnt…
Signs:
1. Tonsils appear congested and swollen
Yellowish spots – follicular
Whitish membrane – membranous
Red and enlarged – parenchymatous
2. Hyperemia of pillars, uvula, soft palate
3.Halitosis, impeded movements of palate and
increased secretions
4.Enlarged and tender jugulodigastric
nodes
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27. Chronic Tonsillitis
Characterized by recurrent acute attacks.
It lasts between 3 weeks to 3 month in
duration.
Incubation period ; is 4-6 days .
Etiology:
1. Recurrent acute tonsillitis
2. Subclinical infection of tonsils
3. Chronic infection in sinuses or teeth.
4. Complication of acute tonsillitis
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28. Symptoms and Signs
Symptoms:
Recurrent throat pain
Cough
Halitosis and bad taste in the mouth
Quiescent phase: discomfort, irritation, pain;
asymptomatic
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29. Signs:
Chronic parenchymatous :- Appearance:
hypertrophied, congested
chronic follicular; small, fibrotic with cheesy
debris.
Squeezing: pus oozes out – should be
distinguished from lymphatic fluid of normal
tonsils
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30. Retention cysts: yellowish swellings filled
with yellow liquid and debris
Enlarged jugulodigastric nodes
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31. Diagnostic evaluation
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32. Diagnostic evaluation
Clinical presentation
1.HISTORY
Individuals with acute tonsillitis present with
fever, sore throat, foul breath, dysphagia,
odynophagia and tender cervical lymph nodes.
Airway obstruction may manifest as mouth
breathing, snoring, sleep-disordered breathing,
nocturnal breathing pauses, or sleep apnea.
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33. Diagnosis cnt…
Lethargy and malaise are common.
Symptoms usually resolve in 3-4 days but may
last up to 2 weeks despite adequate therapy.
Recurrent streptococcal tonsillitis is diagnosed
when an individual has
• 7 culture-proven episodes in 1 year,
• 5 infections in 2 consecutive years, or
• 3 infections each year for 3 years consecutively
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34. Diagnosis cnt…
Individuals with chronic tonsillitis may present
with chronic sore throat, halitosis, tonsillitis, and
persistent tender cervical nodes.
Children are most susceptible to infection by
those in the carrier state.
Individuals with peritonsillar abscess (PTA)
present with severe throat pain, fever, drooling,
foul breath, trismus (difficulty opening the
mouth), and altered voice quality (the hot-potato
voice).
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35. Diagnosis cnt…
2. PHYSICAL EXAM
 Should begin by determining the degree of distress
regarding airways and swallowing.
 Examination of pharynx may be facilitated by mouth
opening without tongue protrusion, followed by
gentle central depression of the tongue.
 Full assessment of oral mucosa, dentation, and
salivary ducts may then be performed by gently
“walking ”a tongue depressor about the lateral oral
cavity.
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36. Diagnosis cnt…
Acute tonsillitis reveals fever and enlarged
inflammed tonsil that may have exudates.
Open mouth breathing and voice changes
result from obstructive tonsillar enlargement.
Voice change in acute tonsillitis is not as
severe as that with peritonsillar abscess
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37. Physical examination
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39. Diagnosis cnt…
3. INVESTIGATIONS
 Testing is indicated when group A beta-hemolytic
Streptococcus pyogenes (GABHS) infection is suspected.
 Throat cultures (sensitivity 90-95%) are the criterion
standard for detecting GABHS.
Lab Studies
 Complete blood count for elevated white blood cells
& lymphocytes
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40. Diagnosis cnt…
Imaging
Peritonsillar abscess CT scan with contrast is
indicated in general for unusual presentation(e.g.
inferior pole abscess) and for pts at high risk of
drainage procedures.
For patients in whom acute tonsillitis is suspected
to have spread to deep neck structures radiologic
imaging using plain films of the lateral neck or
CT scans with contrast is warranted.
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41. MANAGEMENT
1. Medical management
Corticosteroids(shorten the duration of fever and
pharyngitis.
Antibiotics(oral penicillin and erythromycin; for 7
to 10days), IM for non compliant patient of oral
therapy.
Analgesics, Antipyretics
Symptomatic treatment
Treatment of co-existing infection of teeth, sinus
and nose.
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42. 2. Supportive care
Bed rest
Soft diet
Plenty of fluids
Warm saline gargles
Ice compression as PRN
Provide communication pads
Anticipate patient needs instead of asking
Maintain air humidification
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43. Surgical management
TONSILlECTOMY
INDICATIONS FOR TONSILLECTOMY
The American Academy of Otolaryngology– Head
and Neck Surgery (AAO-HNS):
Enlarged tonsils that cause upper airway
obstruction, severe dysphagia, sleep disorders
Recurrent peritonsillar abscess.
Recurrent acute tonsillitis: attack occurring 4-6
times per year or more despite adequate medical
therapy(i.e. antibiotics) and that is affecting
quality and lifestyle (work/school) of the patient.
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44. Indication cnt…
Obstructive sleep apnea: when large tonsils
physically block the passage of the airflow
causing snoring pauses in breathing during
sleep, lethargy, sleepiness and lack of
concentration during the day.
Unilateral tonsil hypertrophy that is presumed
to be neoplastic (tumour tonsillectomy)
Chronic or recurrent tonsillitis, Cor-pulmonale
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45. TONSILLCTOMY
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46. Mgmt cnt…
Contraindications
Bleeding disorders
Anemia
Acute infection
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47. COMPLICATION
1. Chronic tonsillitis – incomplete resolution of acute
tonsillitis
2. Peritonsillar abscess
3. Parapharyngeal abscess
4. Acute otitis media – recurrent attacks
5. Cervical abscess due to suppuration of
jugulodigastric nodes
6. Rheumatic fever – group A B-hemolytic streptococci
7. Subacute bacterial endocarditis (patients with
valvular heart disease) – streptococcus viridans.
8. Tonsilloliths (stones), tonsillar cysts, sleep apnoea
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48. Post-operative Complications
 Haemorrhage
- the most common complication
- intraoperative/primary (occurring within the first
24hrs)
- secondary (occurring between 24hrs and 10 days)
 Pain (sore throat, otalgia)
 Dehydration (children - do not eat because of pain)
 Fever (not common, usually related to local infection
 Postoperative airway obstruction (uvular oedema,
haematoma, aspirated material)
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49. Local trauma to oral tissues
Temporomandibular joint dislocation
Nasopharyngeal stenosis
Death
- uncommon
- bleeding
- or anaesthetic complications
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51. NURSING MANAGEMENT
NANDA nursing diagnosis for TONSILLECTOMY
1. Pain related to inflammatory process/surgical
operation.
2. Fluid volume deficit related to decreased fluid intake
secondary to pain on swallowing.
3. Imbalanced nutrition less than body requirement
related to reduced input secondary to pain on
swallowing.
4. Hyperthermia related to related to acute infection by
micro-organism.
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52. Diagnosis cnt…
5. Risk of ineffective airway clearance.
6. Impaired verbal communication.
7. Disturbed sleep pattern related to the pain in the
tonsil area.
8. Risk for infection related to the factors of surgery.
9. Risk to the ineffectiveness of therapeutic
management related to inadequate knowledge about
the complication, pain, positioning and management
activities.
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53. Implementation
1. Pain management
Assess the level of pain and change in facial
grimace.
Monitor vital signs.
Provide comfort measures e.g. changes in
position, music, and relaxation.
If prescribed analgesics, analgesics are
routinely set during the first 24 hours, not
waiting for patient to ask for it.
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54. Apply ice collar PRN to control pain and
postoperative bleeding.
To minimize nausea and vomiting, teach the
patient to spit out secretions as much as
possible.
Provide lozengs to reduce sore throat
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55. 2. Promoting fluid intake
Assess patient for effective swallowing.
Collaborate with surgery and anesthesiology staff
regarding need for administration of steroids to
control swelling of uvula, as needed.
Measure and record intake and output hourly.
Assess skin turgor and moisture of mucous
membranes.
Administer IV fluids via infusion pump as
ordered. Monitor IV site hourly.
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56. Once patient is conscious and reflex have
returned, offer ice chips or lukewarm fluids.
Do not offer straw, as this may precipitate
bleeding.
To minimize nausea and vomiting, teach the
patient to spit out secretions as much as possible.
Discourage excessive coughing, nose blowing or
clearing of throat. Administer anti-emetics as
prescribed to prevent vomiting.
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57. 3. Maintaining airway clearance.
Assess for signs and symptoms of inadequate
oxygenation.
Place in the prone or side-lying position.
Have a suction equipment available at the
bedside.
Teach and demonstrate breathing exercises.
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58. Observe for patent airway and possible
laryngospasm due to swelling of uvula, palate,
nasopharynx, retropharyngeal space, tongue and
nose.
Report any airway obstruction or laryngospasm to
anesthesiology immediately; have oxygen and
ambu bag available.
Apply cool, humidified air per order, to minimize
swelling, promote comfort and maintain
oxygenation status.
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59. 4. Enhancing Knowledge
Assess parents’ knowledge of the condition and
management.
Allow time for teaching, use a variety of methods
(written instructions, pictures, verbal instruction),
encourage questions and reassure about condition.
Instruct to refrain from performing strenuous
physical activity following surgery and may
return to work/school once comfortable.
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60. Provide information about the surgery
as needed. Teach that an important risk after a
tonsillectomy, discourage excessive coughing
and clearing the throat.
Instruct parents to encourage to drink clear
liquids during the first day, then shift to soft
foods as per physician’s preference. Teach
visitors how to evaluate for dehydration.
Provide medication teaching as needed.
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61. 5. Reducing infection
Monitor temp. every 4 hourly, the state of
injury when performing maintenance.
Give an antibiotics is prescribed, give at least
two liters of fluid every day while
implementing antibiotic therapy.
Give antipyretics are prescribed if there is
fever.
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62. Assess and observe surgical site for odor,
irritation, inflammation, pus.
Assess vital signs.
Assess laboratory value WBC/fever, chills,
blood culture.
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63. 6. Promoting communication
Assess patient ability to understand the spoken
word and expression.
Provide call light.
Paper pencil.
Keep patient near the nursing station.
Provide rest to the larynx or vocal cord to
minimize pain and bleeding.
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64. Prevention
Wash your hands often, especially before
touching your nose or mouth.
Avoid sharing food, drink, or utensils with
someone who is sick.
Replace toothbrush regularly.
Gargle with warm salt water.
Suck on lozenges with benzocaine or other
medications to numb throat.
Get lots of rest
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65. References
1. Mandal G.N (2016) “A Textbook of Medical
Surgical Nursing”. 5th editionKathmandu.Makalu
Publication House.2078/03/11 at 4:30 pm
2. Brunner and Suddarth, “Text Book of Medical
and Surgical Nursing”, 12th edition, Wolter
Kluwer India Private Limited
3. https://www.healthline.com/health/tonsillitis
4. https://www.slideshare.net/drangelosmith/tonsilli
tis-38166423
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66. References cnt…
5.https://www.slideshare.net/vandanavalluri/tons
illitis-48105665
6. https://www.mayoclinic.org/diseases-
conditions/tonsillitis/symptoms-causes/syc-
20378479
7. Pubmed…current articles 2013
8. Current diagnosis & treatment in
otolaryngology.
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