Acute & chronic tonsillitis and their management
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Transcript of Acute & chronic tonsillitis and their management
Acute & Chronic Acute & Chronic TonsillitisTonsillitis
Presented By Presented By MAJID NAWAZ MAJID NAWAZ & & TEHSINA NAWAZTEHSINA NAWAZ
BANNU Medical College BANNU Medical College Bannu k.p.k Pakistan.Bannu k.p.k Pakistan.
IntroductionIntroductionThe palatine tonsil is an ovoid The palatine tonsil is an ovoid
mass of lymphoid tissue mass of lymphoid tissue located in the oropharynx located in the oropharynx between the between the
anterior and posterior pillarsanterior and posterior pillars
It has 2 surfaces –It has 2 surfaces – 1. medial surface1. medial surface 2. lateral surface 2. lateral surface It ha 2 poles –It ha 2 poles – 1. upper pole 1. upper pole 2. lower pole2. lower pole
Medial surfaceMedial surfaceIt is lined by stratified squamous non It is lined by stratified squamous non
keratinising epithelium which dips keratinising epithelium which dips into the crypts into the crypts
The crypts are 12-15 in number The crypts are 12-15 in number Secondary crypts arise from the Secondary crypts arise from the
primary crypts and extend into the primary crypts and extend into the substance of the tonsil substance of the tonsil
One of the crypts located in the upper One of the crypts located in the upper part is larger than the rest – crypta part is larger than the rest – crypta magna magna
The crypts serve to increase the The crypts serve to increase the surface area of the tonsil surface area of the tonsil
The crypts may be filled with cheesy The crypts may be filled with cheesy material – epithelial debris, food material – epithelial debris, food particles and bacteriaparticles and bacteria
Lateral surfaceLateral surface It is covered by the fibrous capsule of the tonsilIt is covered by the fibrous capsule of the tonsil The tonsillar bed is separated from the capsule by loose The tonsillar bed is separated from the capsule by loose
areolar tissueareolar tissue This makes it is easy to dissect the tonsil from its bed during This makes it is easy to dissect the tonsil from its bed during
tonsillectomy tonsillectomy
It is the site of collection of pus in peritonsillar abscess It is the site of collection of pus in peritonsillar abscess (quinsy) (quinsy)
Some fibers of palatoglossus and palatopharyngeus Some fibers of palatoglossus and palatopharyngeus muscles get attached to the capsule of tonsil muscles get attached to the capsule of tonsil
Upper poleUpper pole
It extends into the soft palate It extends into the soft palate
There is a semilunar fold of mucous membrane There is a semilunar fold of mucous membrane which covers the medial part of the upper pole which covers the medial part of the upper pole
It extends from anterior pillar to posterior pillar It extends from anterior pillar to posterior pillar
It encloses a potential space – supratonsillar fossa It encloses a potential space – supratonsillar fossa
Lower poleLower poleIt is attached to the tongueIt is attached to the tongue A triangular fold of mucous membrane extends from the A triangular fold of mucous membrane extends from the anterior tonsillar pillar to the lower pole anterior tonsillar pillar to the lower pole
It encloses a space – anterior tonsillar spaceIt encloses a space – anterior tonsillar space The lower pole is separated from the tongue by the tonsillo-The lower pole is separated from the tongue by the tonsillo-
lingual sulcuslingual sulcus This sulcus may harbour carcinoma This sulcus may harbour carcinoma
Bed of tonsilBed of tonsil
It is formed by the 2 It is formed by the 2 musclesmuscles
1.Superior constrictor1.Superior constrictor 2.Styloglossus 2.Styloglossus
Structures related to the Structures related to the bed of tonsilsbed of tonsils
Blood supplyBlood supplyBlood supply is from the branches of 4 major Blood supply is from the branches of 4 major
arteries all of them are the braches of a main arteries all of them are the braches of a main artery i.e external carotid artery . These are artery i.e external carotid artery . These are
1.Maxillary artery descending palatine 1.Maxillary artery descending palatine arteryartery
2.Ascending pharyngeal artery Tonsillar 2.Ascending pharyngeal artery Tonsillar branchesbranches
3.Facial artery tonsillar artery(main 3.Facial artery tonsillar artery(main artery) & ascending palatine arteryartery) & ascending palatine artery
4.Lingual artery dorsal lingual branches.4.Lingual artery dorsal lingual branches.
Veins, lymphatics & Veins, lymphatics & nervesnerves
LymphaticsLymphatics pierce the superior pierce the superior constrictor and drain into upper deep constrictor and drain into upper deep cervical (jugulo-digastric) nodes cervical (jugulo-digastric) nodes located below the angle of mandible.located below the angle of mandible.
VeinsVeins from the tonsils drain into from the tonsils drain into paratonsillar vein which then joins the paratonsillar vein which then joins the common facial vein and pharyngeal common facial vein and pharyngeal venous plexusvenous plexus
NervesNervesLesser palatine branches of Lesser palatine branches of
sphenopalatine ganglion and sphenopalatine ganglion and glossopharyngeal nerve provide glossopharyngeal nerve provide sensory nerve supply.sensory nerve supply.
Function on tonsilsFunction on tonsils It has a protective It has a protective
function in that it prevents function in that it prevents entry of pathogens entry of pathogens through the nasal and through the nasal and oral route oral route
The crypts on the surface The crypts on the surface of the tonsil serve to of the tonsil serve to increase the surface area increase the surface area and increase the and increase the efficiency of protection efficiency of protection against pathogens against pathogens
It forms a part of It forms a part of Waldeyer’s lymphatic Waldeyer’s lymphatic ring.ring.
TonsillitisTonsillitis Inflammation 0f tonsils due to Inflammation 0f tonsils due to
bacterial or viral infection bacterial or viral infection causing a sore throat , fever, causing a sore throat , fever, and difficulty in swallowing is and difficulty in swallowing is called tonsillitis.called tonsillitis.
There are 3 types of itThere are 3 types of it
1.Acute tonsillitis1.Acute tonsillitis 2. chronic tonsillitis2. chronic tonsillitis 3. Compensated3. Compensated tonsillitis tonsillitis
Local signs of tonsillitisLocal signs of tonsillitisUnpleasant mouth odor
Unpleasant feeling in the throat
Pus or tonsil stones in lacunae
Local signs of tonsillitis - Local signs of tonsillitis - changes in the palatine changes in the palatine arches arches Hyperemia
Cicatricles formation
Slight swelling
Acute tonsillitisAcute tonsillitis Mostly affects children in the age group of 5-15 Mostly affects children in the age group of 5-15
years, may also affect adultsyears, may also affect adults Organisms Organisms beta-hemolytic streptococci beta-hemolytic streptococci
(most common), staphylococci, pneumococci, (most common), staphylococci, pneumococci, H.influenzaeH.influenzae
Symptoms: sore throat, difficulty in swallowing, Symptoms: sore throat, difficulty in swallowing, fever, ear ache, constitutional symptomsfever, ear ache, constitutional symptoms
Types of acute tonsillitisTypes of acute tonsillitis1).1).Acute catarrhal/superfficial here tonsillitis is a here tonsillitis is a
part of generalized pharyngitis, mostly seen in part of generalized pharyngitis, mostly seen in viral infectionsviral infections
Types of acute tonsillitisTypes of acute tonsillitis2).Acute follicular 2).Acute follicular infection spread into the infection spread into the
crypts with purulent material, presenting at crypts with purulent material, presenting at the opening of crypts as yellow spots.the opening of crypts as yellow spots.
Types of acute tonsillitisTypes of acute tonsillitis3).Acute membranous3).Acute membranous follows stage of acute follows stage of acute
follicular tonsillitis where exudates coalesce to follicular tonsillitis where exudates coalesce to form membrane on the surfaceform membrane on the surface
Types of acute tonsillitisTypes of acute tonsillitis4).Acute parenchymatous4).Acute parenchymatous tonsil is uniformly tonsil is uniformly
enlarged and congestedenlarged and congested
SymptomsSymptoms:: Sore throatSore throat Difficulty in Difficulty in
swallowingswallowing Generalised body Generalised body
acheache FeverFever Earache and Earache and
Thick speechThick speech
SignsSigns:: Swollen congested Swollen congested
tonsils with tonsils with exudatesexudates
Enlarged tender Enlarged tender Jugulo-diagastric Jugulo-diagastric lymph nodeslymph nodes
Coasted tongueCoasted tongue Foetid breathFoetid breath Hyperaemia of Hyperaemia of
pillars soft palate & pillars soft palate & uvula.uvula.
TREATMENTTREATMENT Bed restBed rest Plenty of oral fluidsPlenty of oral fluids AnalgesicsAnalgesics Antimicrobial therapyAntimicrobial therapy penicillin penicillin In case of penicillin sensitivity In case of penicillin sensitivity
erythromycin are given.erythromycin are given. Antibiotics should be continued for 7_10 Antibiotics should be continued for 7_10
daysdays
COMPLICATIONSCOMPLICATIONS chronic tonsillitischronic tonsillitis peritonsillar abscessperitonsillar abscess parapharyngeal abscessparapharyngeal abscess cervical abscesscervical abscess acute otitis mediaacute otitis media rheumatic feverrheumatic fever acute glomerulo nephritisacute glomerulo nephritis sub acute bacterial endocarditis sub acute bacterial endocarditis
DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS OF MEMBRANE OVER THE OF MEMBRANE OVER THE TONSILTONSIL Membranous tonsillitisMembranous tonsillitis DiphtheriaDiphtheria Vincents anginaVincents angina Infectious mononucleosisInfectious mononucleosis AgranulocytosisAgranulocytosis LeukaemiaLeukaemia Traumatic ulcerTraumatic ulcer Aphthous ulcerAphthous ulcer malignancymalignancy
CHRONIC TONSILLITISCHRONIC TONSILLITIS Aetiology: Aetiology: Complication of acute tonsillitisComplication of acute tonsillitisSub clinical infection of tonsilSub clinical infection of tonsilChronic sinusitis or dental sepsisChronic sinusitis or dental sepsis
Mostly affects children and young adultsMostly affects children and young adults
TYPES OF CHRONIC TYPES OF CHRONIC TONSILLITISTONSILLITIS
1). Chronic follicular tonsillitis1). Chronic follicular tonsillitis
tonsillar crypts are full of cheesy tonsillar crypts are full of cheesy material resulting in yellow spots material resulting in yellow spots on the surface.on the surface.
2). Chronic parenchymatous 2). Chronic parenchymatous tonsillitistonsillitis
tonsils are very much enlarged tonsils are very much enlarged almost touching each other and almost touching each other and may interfere with speech, may interfere with speech, deglutition and respiration, long deglutition and respiration, long standing cases may develop standing cases may develop pulmonary hypertensionpulmonary hypertension
types of Chronic types of Chronic tonsillitistonsillitis
3).Chronic fibroid tonsillitis 3).Chronic fibroid tonsillitis Tonsils are small but infected , with Tonsils are small but infected , with
history of repeated sore throat.history of repeated sore throat.
CLINICAL FEATURESCLINICAL FEATURES
recurrent attacks of sore throatrecurrent attacks of sore throat chronic irritation in throat with coughchronic irritation in throat with cough halitosishalitosis dysphagiadysphagia odynophagiaodynophagia thick speech thick speech
ExaminationExamination Tonsil may show varying degree of enlargement Tonsil may show varying degree of enlargement
depending on the typedepending on the type
Irwin-moore signIrwin-moore sign tonsils are small but pressure on the tonsils are small but pressure on the anterior pillar expresses pus or cheesy material anterior pillar expresses pus or cheesy material mainly seen in fibroid typemainly seen in fibroid type
There bmay be yellowish beads of pus on the medial There bmay be yellowish beads of pus on the medial surface of tonsils chronic follicular tonsillitissurface of tonsils chronic follicular tonsillitis
Flushing of the anterior pillar compared to rest of the Flushing of the anterior pillar compared to rest of the pharyngeal mucosapharyngeal mucosa
Enlargement of the jugulo-digastric node soft non Enlargement of the jugulo-digastric node soft non tendertender
TREATMENTTREATMENTConservative managementConservative managementPay attention to the general Pay attention to the general
health ,diet,and treatment health ,diet,and treatment of co- existent infections of of co- existent infections of teeth , nose , and sinuses.teeth , nose , and sinuses.
TonsillectomyTonsillectomywhen recurrent when recurrent
attacks ,interference with attacks ,interference with speech , deglutination & speech , deglutination & respiration.respiration.
COMPLICATIONSCOMPLICATIONS Peritonsillar abscessPeritonsillar abscess Parapharyngeal abscessParapharyngeal abscess Retro pharyngeal Retro pharyngeal
abscessabscess Intra tonsillar abscessIntra tonsillar abscess Tonsillar cystTonsillar cyst TonsillolithTonsillolith Focus of infection for Focus of infection for
RF, AGNRF, AGN
Peritonsillar abscess
Compensated tonsillitisCompensated tonsillitis Compensated tonsillitisCompensated tonsillitis it is it is
usually a type of chronic usually a type of chronic tonsillitis. clinically manifests tonsillitis. clinically manifests itself with itself with absence of any absence of any complaintscomplaints and and presence presence of only local signsof only local signs of a of a chronic inflammation of the chronic inflammation of the tonsils. It is usually revealed tonsils. It is usually revealed during prophylactic during prophylactic examinations.examinations.
TonsillectomyTonsillectomy
It’s the surgical removal of tonsils , done in It’s the surgical removal of tonsils , done in the treatment of chronic infection of the treatment of chronic infection of tonsils ,obstructive sleep apnea , tonsils ,obstructive sleep apnea , supporative ottits media etc.supporative ottits media etc.
IndicationsIndicationsA. AbsoluteA. Absolute
1.1. Recurrent infections of throatRecurrent infections of throat2.2. Peritonsillar abscessPeritonsillar abscess3.3. Tonsillitis causing febrile seizuresTonsillitis causing febrile seizures4.4. Hypertrophy of tonsils causing obstructionHypertrophy of tonsils causing obstruction5.5. Suspicion of malignancySuspicion of malignancy
B. RelativeB. Relative1.1. Diphtheria carriers,Diphtheria carriers,2.2. Streptococcal carriersStreptococcal carriers3.3. Chronic tonsillitis with bad taste or halitosisChronic tonsillitis with bad taste or halitosis4.4. Recurrent streptococcal tonsillitis in a patient with valvular Recurrent streptococcal tonsillitis in a patient with valvular
heart diseaseheart diseaseC. As a Part of Another OperationC. As a Part of Another Operation
1.1. PalatopharyngoplastyPalatopharyngoplasty2.2. Glossopharyngeal neurectomy. Glossopharyngeal neurectomy. 3.3. Removal of styloid process.Removal of styloid process.
ContraindicationsContraindications1.1. Haemoglobin level less than 10 g%. Haemoglobin level less than 10 g%.2.2. Acute upper respiratory tract infection, acute Acute upper respiratory tract infection, acute
tonsillitis. tonsillitis. 3.3. Children under 3 years of age. Children under 3 years of age. 4.4. Overt or submucous cleft palate. Overt or submucous cleft palate.5.5. Bleeding disorders, e.g. leukaemia, purpura, Bleeding disorders, e.g. leukaemia, purpura,
aplastic anaemia, haemophilia.aplastic anaemia, haemophilia.6.6. At the time of epidemic of polio. At the time of epidemic of polio.7.7. Uncontrolled systemic disease, e.g. diabetes, Uncontrolled systemic disease, e.g. diabetes,
cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma.8.8. Tonsillectomy is avoided during the period of Tonsillectomy is avoided during the period of
menses.menses.
ContraindicationsContraindications1.1. Haemoglobin level less than 10 g%. Haemoglobin level less than 10 g%.2.2. Acute infection in upper respiratory tract, acute Acute infection in upper respiratory tract, acute
tonsillitis. Bleeding is more in the presence of tonsillitis. Bleeding is more in the presence of acute infection.acute infection.
3.3. Children under 3 years of age. Children under 3 years of age. 4.4. submucous cleft palate. submucous cleft palate.5.5. Bleeding disorders, e.g. leukaemia, haemophilia. Bleeding disorders, e.g. leukaemia, haemophilia.6.6. At the time of epidemic of polio. At the time of epidemic of polio.7.7. Uncontrolled systemic disease, e.g. diabetes, Uncontrolled systemic disease, e.g. diabetes,
cardiac disease, hypertension or asthma.cardiac disease, hypertension or asthma.8.8. Tonsillectomy is avoided during the period of Tonsillectomy is avoided during the period of
menses.menses.
AnaesthesiaAnaesthesia Usually done under Usually done under generalgeneral anaesthesia anaesthesia
with endotracheal intubation. with endotracheal intubation. In adults, it may be done under In adults, it may be done under local local
anaesthesia.anaesthesia.
PositionPosition Rose's positionRose's position, i.e. patient lies supine with head , i.e. patient lies supine with head
extended by placing a pillow under the shoulders extended by placing a pillow under the shoulders and a rubber pad under the head. In this position and a rubber pad under the head. In this position both the head and neck are extended.both the head and neck are extended.
Advantages of Rose Advantages of Rose position:position:
1. There is virtually no aspiration of blood or secretions 1. There is virtually no aspiration of blood or secretions into the airway.into the airway.
2. Both hands of the surgeon are free. This position helps 2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag. in proper application of the Boyles Davis mouth gag.
3. The surgeon can be comfortably seated at the head 3. The surgeon can be comfortably seated at the head end of the patientend of the patient
Boyle-Davis mouth gagBoyle-Davis mouth gag
Boyles Davis mouth gagBoyles Davis mouth gag
Davis mouth gagDavis mouth gagBoyles tongue bladeBoyles tongue blade
Boyle-Davis mouth gagBoyle-Davis mouth gag
Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7)
Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs,
(15) Nasopharyngeal pack, (16) Towel clips.Downloaded from: StudentConsult (on 6 December 2012 06:54 PM)© 2005 Elsevier
Steps of Operation Steps of Operation (Dissection and Snare (Dissection and Snare Method)Method)1.1. Boyle-Davis mouth gag is introduced and Boyle-Davis mouth gag is introduced and
opened. It is held in place by Draffin's opened. It is held in place by Draffin's bipods .bipods .
2.2. Tonsil is grasped with tonsil-holding Tonsil is grasped with tonsil-holding forceps and pulled medially.forceps and pulled medially.
3.3. Incision is made in the mucous Incision is made in the mucous membrane where it reflects from the tonsil membrane where it reflects from the tonsil to anterior pillar. It may be extended along to anterior pillar. It may be extended along the upper pole to mucous membrane the upper pole to mucous membrane between the tonsil and posterior pillar.between the tonsil and posterior pillar.
Steps of Operation cont..Steps of Operation cont..
4.4. A blunt curved scissor may be used to A blunt curved scissor may be used to dissect the tonsil from the peritonsillar dissect the tonsil from the peritonsillar tissue and separate its upper pole.tissue and separate its upper pole.
5.5. Now the tonsil is held at its upper pole Now the tonsil is held at its upper pole and traction applied downwards and and traction applied downwards and medially. Dissection is continued with medially. Dissection is continued with tonsillar dissector or scissors until lower tonsillar dissector or scissors until lower pole is reached pole is reached
Steps of Operation cont..Steps of Operation cont..
6.6. Now wire loop of tonsillar snare is Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle, threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and the tightened, and the pedicle cut and the tonsil removed.tonsil removed.
7.7. A gauze sponge is placed in the fossa A gauze sponge is placed in the fossa and pressure applied for a few minutes.and pressure applied for a few minutes.
8.8. Bleeding points are tied with silk. Bleeding points are tied with silk. Procedure is repeated on the other side.Procedure is repeated on the other side.
Post-operative CarePost-operative Care
1. Immediate general care 1. Immediate general care (a)(a) Keep the patient in coma position until Keep the patient in coma position until
fully recovered from anaesthesia.fully recovered from anaesthesia.(b)(b) Keep a watch on bleeding from the Keep a watch on bleeding from the
nose and mouth.nose and mouth.(c)(c) Keep check on vital signs, e.g. pulse, Keep check on vital signs, e.g. pulse,
respiration and blood pressure.respiration and blood pressure.
Post-operative Care Post-operative Care cont..cont..
2. Diet 2. Diet a.a.When patient is fully recovered he is to take When patient is fully recovered he is to take
liquids, e.g. cold milk or ice cream. liquids, e.g. cold milk or ice cream. b.b.Sucking of ice cubes gives relief from pain.Sucking of ice cubes gives relief from pain.c.c.Diet is gradually built from soft to solid food. Diet is gradually built from soft to solid food.
They may take custard, jelly, soft boiled eggs They may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2nd or slice of bread soaked in milk on the 2nd day.day.
d.d. Plenty of fluids should be encouraged.Plenty of fluids should be encouraged.
ComplicationsComplicationsA. Immediate A. Immediate 11 immediate haemorrhage. immediate haemorrhage. Occurs at the Occurs at the
time of operation. It can be controlled by time of operation. It can be controlled by pressure, ligation or electrocoagulation of pressure, ligation or electrocoagulation of the bleeding vessels. the bleeding vessels.
2. 2. Reactionary haemorrhage.Reactionary haemorrhage. Occurs within Occurs within a period of 24 hours and can be controlled a period of 24 hours and can be controlled by simple measures such as removal of the by simple measures such as removal of the clot, application of pressure or clot, application of pressure or vasoconstrictor. vasoconstrictor.
3. 3. Injury to tonsillar pillars, uvula, soft Injury to tonsillar pillars, uvula, soft palatepalate, tongue or superior constrictor , tongue or superior constrictor muscle due to bad surgical technique. muscle due to bad surgical technique.
Immediate Complications Immediate Complications cont..cont..
4. 4. Injury to teeth.Injury to teeth. 5. 5. Aspiration of blood.Aspiration of blood. 6. 6. Facial oedema.Facial oedema. Some patients get oedema Some patients get oedema
of the face particularly of the eyelids. of the face particularly of the eyelids. 7. 7. Surgical emphysema.Surgical emphysema. Rarely occurs due to Rarely occurs due to
injury to superior constrictor muscle.injury to superior constrictor muscle.
Delayed Complications Delayed Complications cont..cont..
1. 1. Infection.Infection. Infection of tonsillar fossa may Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis lead to parapharyngeal abscess or otitis media.media.
2. 2. Lung complications.Lung complications. Aspiration of blood, Aspiration of blood, mucus or tissue fragments may cause mucus or tissue fragments may cause atelectasis or lung abscess. atelectasis or lung abscess.
3. 3. Scarring in soft palate and pillarsScarring in soft palate and pillars. .
Thank YouThank You