Diseases of palatine tonsil


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Diseases of palatine tonsil

  2. 2. 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.
  3. 3. 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.
  4. 4.  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).
  6. 6.  Self limiting infection of one or both tonsils. Isolated episode. Associated with viral upper respiratory illness (catarrhal). Part of systemic infection (eg. Infectious mononucleosis)
  7. 7. 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.
  8. 8. 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.
  9. 9. 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.
  10. 10. 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).
  11. 11. 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
  12. 12. 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).
  13. 13. 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.
  14. 14.  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.
  15. 15.  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.
  16. 16.  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.
  17. 17. Complications Suppurative  Peritonsillar abscess  Parapharyngeal abscess  Retropharyngeal abscess  Le Mieres syndrome Non suppurative  Scarlet fever  Acute Rhuematic Fever  Post Streptococcal glomerulonephritis  Tonsillitis and Psoriasis
  18. 18. 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.
  19. 19.  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
  20. 20.  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.
  21. 21. 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.
  22. 22. 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.
  23. 23. 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
  24. 24. 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
  25. 25.  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
  26. 26. CHRONIC TONSILLITIS Chronic low grade symptoms Tonsillar enlargement  Parenchymal hyperplasia  Fibrinoid degeneration (by obstruction of crypts), chronic scarification. Pathogens Recurrent sore throats, febrile episodes, systemic complaints, halitosis, cervical adenopathy, increased URTI Variable tonsillar enlargement, tonsillar crypts, tonsillar pillars Acute inflammation – rest, fluidsm analgesics, antibiotics Definative therapy – tonsillectomy Differential Diagnosis  Pharyngeal Tuberculosis, Leprosy, Syphillis, Lupus, Actinomycosis  Candida, Blastomycosis, Coccioidomycosis