Chronic Tonsillitis & Pharyngitis

By Adnan AL-Maaitah

Chronic Tonsillitis

Chronic Tonsillitis

• Halitosis – due to crushing of tonsilloliths• More resistant to antibiotics• Obstruction to breathing – snoring, sleep apnea• Blockage of Eustachian Canal• Dysphagia• Constants feeling of fullness and pain in the throat• Accompany multiple infections• May be with peritonsilar abscess• Persistent tender cervical nodes

Tonsillolith

Enlarged tonsils in child with obstructive sleep apnea.

Tonsillectomy

Tonsillectomy

• Surgical removal of tonsils or a tonsil• One of the most common surgical procedures among

children• Controversy regarding indications for surgery

Tonsillectomy / Indications

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures:

• Absolute indications• Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep

disorders, or cardiopulmonary complications• Peritonsillar abscess that is unresponsive to medical management and drainage

documented by surgeon, unless surgery is performed during acute stage• Tonsillitis resulting in febrile convulsions• Tonsils requiring biopsy to define tissue pathology

• Relative indications• Three or more tonsil infections per year despite adequate medical therapy• Persistent foul taste or breath due to chronic tonsillitis that is not responsive to

medical therapy• Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-

lactamase-resistant antibiotics• Unilateral tonsil hypertrophy that is presumed to be neoplastic

Tonsillectomy/Contraindications

• Bleeding diathesis• Poor anesthetic risk or uncontrolled medical illness• Anemia• Acute infection (tonsillitis: wait 3 weeks)• Peritonsillar abscess

Tonsillectomy/Procedure

• Patient lying flat on their backs, with the shoulders elevated on a small pillow so that the neck is hyperextended – the so-called 'Rose' position.

• Tonsil is held by forceps and removed by blunt scalpel or electrocautery

• Bleeding is stopped with electrocautery

Tonsillectomy/Postop.

• Painful – give adequate analgesia• Hydration• Tonsil beds maybe covered with white or yellowish

exudate (up to 2 weeks) – normal, not pus

• Complications:• Bleeding: primary, reactionary (first 24Hr), secondary (3-7 days)• Sepsis• Chest complications• Otitis media• Peritonsillar abcess

Normal appearance after tonsillectomy

Pharyngitis

Pharynx/Anatomy

• The musculomembranous cavity behind the nasal cavities, mouth and larynx communicating with them and with the esophagus.

• Composed of skeletal muscles lined by mucous membrane.

• Respiratory and digestive function• Divided into:

• Nasopharynx• Oropharynx• Hypopharynx (Laryngopharynx)

Pharynx/Anatomy

Pharyngitis

• Inflammation of the mucous membrane and underlying part of the pharynx

• One of the most common causes of absence from school or work

• Vast majority due to viruses• More common in children (peak 4 – 7 yrs)• Affects all races and both sexes equally• Usually associated with URTI

Pharyngitis

• Causes:• Viral: rhinovirus, adenovirus, EBV, HSV, influenza virus• Bacterial: GABHS• Other: allergy, trauma, toxins, neoplasia

• Predisposing factors:• Smoking (including passive)• Mouth breathing• Rhinosinusitis• Periodontal disease

Pharyngitis

Pathophysiology:• Viral and bacterial

directly invades the mucosa causing local inflammatory response.

• Some viruses causes inflammation to the mucosa secondary to nasal secretion

Pharyngitis

• Symptoms:• Sore throat is the main CCx• Fever, headache• Acute: rapid onset, short duration, with dysphagia and malaise• Chronic: persistent, mild soreness, dryness. Eliminate underlying

cause.

• Signs:• Edema and erythema of the pharynx• Exudate can be present

Pharyngitis

Bacterial

• Exposure to known carrier

• High fever, chills, headache, abdominal pain

• Painful cervical adenopathy

• Rare pathogen < 2 yrs

Viral

• Involvement of other mucous membrane

• With sneezing, rhinorrhea and cough

An acute inflammation of the part of the throat between the tonsils and the larynx (the pharynx)

 Beefy redness of posterior pharynx, which is the result of infection.

Phryngitis/Complications

• Usually self limiting• Primary concern in children (3 – 18 yrs) is that untreated

GABHS may cause rheumatic fever• Adjacent organs: otitis media, sinusitis, peritonsillar

abscess• Acute respiratory inflammation• Acute glomerulonephritis• Toxic shock syndrome• Mortality due to airway obstruction (rare)

Streptococcus pyogenes at 100X magnification.

Pharyngitis/DDx

• Streptococcal pharyngitis• Non-infectious pharyngitis• Peritonsilar abscess• Pharyngeal candidia• Diphtheria

Pharyngitis/RRx

• Symptomatic• Rest, oral-fluids, and salt-water gargling are the main

supportive measures• Paracetamol (Acetaminophen) is the DOC in high pain and

fever• Antibiotics are indicated for clinically suspected and culture

or antigen verified GAS infection. Prevent rheumatic fever if given 9 days from onset