Acute & Chronic tonsillitis

1. By Dr. Subhash Chandra Mahaseth

7.  Paired structures situated in lateral wall of oropharynx
between anterior and posterior pillars
 Consists of two surfaces (medial and lateral) and
Poles (upper and lower)
 Medial surface is covered by non keratinizing
stratified squamous epithelium
 There are 12-15 crypts on the medial surface
 Largest crypt is called crypta magna or intratonsillar
cleft

9.  BLOOD SUPPLY
The tonsil is supplied by
five arteries
1. Facial Artery.
2. Ascending pharyngeal
artery
3. Internal Maxillary
Artery.
4. Lingual Artery

10.  Venous drainage: Para tonsillar vein of Denni’s brown
 Lymphatic drainage: jugulo-digastric lymph node
 Nerve supply: Glossopharyngeal nerve
& Lesser palatine nerve

11.  TONSIL
1. Sub-epithelial
2. Partly encapsulated
3. Efferent only
4. Crypts present
5. No cortex and medulla
6. Growth curve present
 LYMPH NODE
1. Connective tissue
2. Fully encapsulated
3. Afferent + Efferent
4. Absent
5. Present
6. Absent

12. 1. Ciliated columnar 1. Non-keratinizing
epithelium squamous epithelium
2. No capsule 2. Partly encapsulated
3. Has furrows/clefts 3. Has crypts
4. Peak growth: 6 yr 4. Peak growth: 8 yr
5. Growth stops: 12 yr 5. Growth stops: 15 yr
6. Disappears: 20 yr 6. Partial regression:18 yr

13.  Brodsky grading scale (5 grades) in 1989
 Grade 0 - (tonsils within the tonsillar fossa),
 Grade 1 - (tonsils just outside of the tonsillar fossa and occupy
25% of the oropharyngeal width),
 Grade 2 - (tonsils occupy 26%-50% of the oropharyngeal
width)
 Grade 3 - (tonsils occupy 51%-75% of the oropharyngeal
width)
 Grade 4 - (tonsils occupy >75% of the oropharyngeal width).

19. 1. Acute catarrhal/superficial
2. Acute parenchymatous
3. Acute follicular
4. Acute membranous
1. Acute catarrhal/superficial - here tonsillitis is
a part of generalized pharyngitis, mostly seen in
viral infections

20. 2. Acute
parenchymatous -
tonsil in uniformly
enlarged and
congested

21. 3. Acute follicular -
infection spread into
the crypts with
purulent material,
presenting at the
opening of crypts as
yellow spots

22. 4. Acute membranous - follows stage of acute
follicular tonsillitis where exudates coalesces to form
membrane on the surface

23.  Mostly affects children in the age group of
5-15 years, may also affect adults
 Organisms beta-hemolytic streptococci
(most common), staphylococci, pneumococci,
H.influenzae

24. SYMPTOMS
 Sore throat.
 Difficulty and painful swallowing
 Fever - may be associated with chills and rigors.
Sometimes, a child presents with an unexplained
fever and it is only on examination that an acute
tonsillitis is discovered.
 Earache
 Constitutional symptoms- headache, general body
aches, malaise

25. SIGNS
 Tonsils are congested and enlarged depending on type
of acute tonsillitis
 Congestion of pillars, soft palate and uvula.
 Halotosis and coated tongue
 Enlarged and tender Jugulo-digastric nodes

27.  Clinical history
 Examination
 Investigation:
1. Complete blood count: Leucocytosis
2. Elevated ESR and CRP
3. Throat swab
4. Rapid Immunoassay : GABH

28.  TREATMENT
1. Bed rest
2. Plenty of oral fluids
3. Analgesics
4. Antimicrobial therapy- penicillin
5. In case of penicillin sensitivity macrolides are given

29. LOCAL
 Recurrent tonsillitis
 Intratonsillar abscess
 Peritonsillar abscess
 Parapharyngeal abscess
 Retropharyngeal abscess
 Chronic tonsillitis
 Cervical abscess
 Acute otitis media
 Rheumatic fever
 Acute glomerulo nephritis
 Sub acute bacterial
endocarditis-
GENERAL

30.  Gr.+ve diptheria bacillus (cornybacterium diptheriae;
 Rare disease, Spread=by droplet of infection.
 Common in children=2-5yrs age.
 Mortality in underdeveloped country=10%.
 Secretes powerful exotoxin (local & distant effect).
 Locally at the site of invasion-coagulation necrosis.
 Distant: 3 tissues:
 Heart muscle (myocarditis)
 Kidney (tubular necrosis),
 Peripheral nerves (eye, soft
palate, diaphragm; GB synd)

31. CLINICAL FEATURE
 Primary site of infection- Nasal cavities, pharynx, larynx.
 Onset-insidious, toxic, low gr.fever
 Ant. nasal dipth: mucopurulent hemorrhagic discharge, nasal
obstruction due to memb. in nasal cavity or nasopharynx.
 Oropharynx: sev. sorethroat with dirty greyish greenish memb. on
one side of tonsil extends beyond (pillars, soft palate, uvula, post
pharyngeal wall).
 Memb. difficult to remove and bleeds on removable.
 Massive BL cervical lympadenopathy`BULL NECK`

32.  DX= Throat swab cs.
 TREATMENT
1. Isolation + bed rest
2. I.V. benzyl penicillin 600 mg q6h
3. Diphtheritic anti - toxin infusion in saline
 20,000 – 40,000 U:  48 hrs duration, tonsillar
 40,000 – 80,000 U: nasopharynx / larynx
 80,000 – 120,000 U:  48 hrs, neck edema
4. Emergency tracheostomy required for stridor

33. Membranous Diphtheria
Age > 5 yr 2-5 yr
Onset Acute Insidious
General
Symptoms
More Less
Odynophagia More Less
Temperature High Low
Tachycardia Proportionate Disproportionate
Tonsils Enlarged, congested Normal

34. Membranous Diphtheria
Membrane Bilateral May be unilateral
Whitish yellow Gray
Thin Thick
Limited to tonsil May go beyond
Easily removed Bleeds on removal
Culture  Hemolytic streptococci Corynebacterium
diphtheriae
Lymph node Jugulo-digastric only Generalized (Bull neck)

35.  AKA glandular fever, caused by Epstein - Barr virus, common in young
adult.
 Spread by oral contact with exchange of saliva.
 SYMPTOMS= headache, fever, tiredness, exudative tonsillitis, painfull
lymphadenopathy, petechial rash on palate, splenomegaly,
maculopapular rash over body.
 Rash on use of Ampiciilin
 Lymphocyte predominant leucocytosis
 Heterophile antibody: Paul Bunnel test
 RX : symptomatic, IV antibiotic
(penicillin ) to prevent sec. infect,
steroid in sev. cases.

36.  Spirochete Borellia vincenti, anaerobic organism bacillus fusiformis.
 Poor dental and oral hygiene.
 Grey necrotic pseudo membrane cover either tonsil or pharyngeal
mucosa, easily removed revealing irregular ulcer.
 DX=clinical (oral ulceration) scarpings from the ulcer or gingiva in
gentian blue (spirochete fusiform bacillus)

37.  Chronic tonsillitis is a persistent long term
subclinical infection of the tonsils.
 Mostly affects children and young adults
 Complication of acute tonsillitis , Chronic sinusitis or
dental sepsis
 Repeated infections may cause the formation of small
pockets (crypts) in the tonsils, which harbor bacteria.

38.  Chronic parenchymatous tonsillitis : tonsils are very
much enlarged uniformly and may interfere with speech,
deglutition and respiration, long standing cases may develop
pulmonary hypertension
 Chronic follicular tonsillitis: Here tonsillar crypts are full
of infected cheesy material which shows on the surface as
yellowish spots
 Chronic fibroid tonsillitis: Tonsils are small but infected

39. SYMPTOMS :
1. Recurrent attack of sore throat or acute tonsillitis.
2. Chronic irritation in throat with cough
3. Halitosis
4. Mild dysphagia , Mild odynophagia
5. Thick speech

40. SIGNS
1. Tonsil may show varying degree of enlargement
depending on the type
2. Flushing of the anterior pillar compared to rest of the
pharyngeal mucosa
3. Enlarged but non tender Jugulo-digastric nodes
4. Irwin-moore sign- pressure on the anterior pillar
expresses frank pus or cheesy material mainly seen in
fibroid type

41.  TREATMENT
1. Conservative treatment :
Attention to general health, diet, treatment of
coexistent infection of teeth,nose and sinuses.
2. Tonsillectomy :
It is indicated when tonsils interfere with speech,
deglutition and respiration or cause recurrent
attacks

42. COMPLICATIONS
1. Peritonsillar abscess
2. Parapharyngeal abscess
3. Retro pharyngeal abscess
4. Intra tonsillar abscess
5. Tonsillar cyst
6. Tonsillolith

43.  Infectious :
 Auto-immune:
 Trauma:
 Pre malgnant lesion :
 Malignancy :
 Blood Disorder :

44.  INFECTIOUS:
1. Viral :
A. Infectious mononucleosis
B. HIV
C. Herpes Simplex
2. Bacterial:
A. Acute :
• Non specific :GABHS , S.aureus
• Specific : Diphtheria , Vincent angina
B. Chronic :
• Non Specific : Kaeratosis
• Specific : TB , Syphilis
3. Fungal : Candidiasis

45.  Autoimmune : Lichen planus , WG
 Trauma:
 Surgical trauma: that causing slough
 Chemical induced : Corrosive
 Thermal injury , Post radiation
 Pre malignant : Leucoplakia , Submucous fibrosis

46. 1. Acute lingual tonsillitis
2. Hypertrophy of lingual tonsils
3. Abscess of lingual tonsil

47.  Recurrent acute infections of tonsil
Paradise criteria
(a) Seven or more episodes in 1 year, or
(b) Five episodes per year for 2 years, or
(c) Three episodes per year for 3 years, or
(d) Two weeks or more of lost school or work in 1 year.

48. Tonsilar cause:
1. Tonsillar malignancy
2.Peri-tonsillar abscess
3.Tonsillolith
4.Tonsillar cyst
6.Tonsillar artery aneurysm
7. Vincent's angina

49. Extra-tonsillar causes:
 Parapharyngeal abscess
 Parapharyngeal tumours
 Tumours of deep parotid lobe