Dr.

Ravikumar MS(ENT)

Etiology : Viral followed by secondarily invaded by Hemolytic streptococcus Staph aureas H.influenza Dipl. Pneumoniae Age : Commonest <9yrs

Spread : Droplet infection Types: Ac cattarhal Ac parenchymatous Ac follicular Ac membranous

Pathophysiology
Viral Infections Bacterial Infections Inflammatory exudates of the crypts

Epithelial keratinisation

Deep-seated multiple abscess formation with increasing germ centers

Parenchyma destruction
Immunologic Factors

When tonsils are inflamed as part of the generalised infection of the oropharyngeal mucosa it is called catarrhal tonsillitis.

Some times exudation from crypts may coalesce to form a membrane over the surface of tonsil, giving rise to clinical picture of membranous tonsillitis.

When the whole tonsil is uniformly congested and swollen it is called acute parenchymatou s tonsillitis

SYMPTOMS Sore throat Fever Malaise Odynophagia Thick speech Earache

Acute Tonsillitis - Signs

Enlarged
Erythematous Exudative forming at
times pseudomembrane

Enlarged neck nodes

Grading the Size of Tonsils

Grading system: A. 0 tonsils in fossa B. +1 tonsils less than 25% C. +2 tonsils less than 50% D. +3 tonsils less than 75% E. +4 tonsils greater than 75%

Rapid strep tests:latex agglutination or ELISA methods extract antigen from swab Throat swab:

Bed rest : Isolation Mouth gurgles : Analgesics : Antibiotics :

First Line
Penicillin/Cephalosporin for 10 days Injectable forms for noncompliance

Macrolides
Penicillin allergy

Erythromycin/Clarithromycin 10 days
Azithromycin (12mg/kg/day) 5 days

Peritonsillar abscess
Parapharyngeal abscess Retropharyngeal abscess Oedema of larynx Cervical supp. Lymphadenitis

Acute middle ear cleft infection Chronic tonsillitis

Rheumatic heart disease

Chorea S.B.E. Acute nephritis

Infectious Mononucleosis Faucial diphtheria Agranulocytosis Scarlet fever Oral thrush ALL Vincents angina Tertiary syphilis

Differential Diagnosis of pseudomembranous tonsillitis

Infectious Mononucleosis
Cheesy exudates
covering tonsil

Lymphadenopathy of
neck, axilla & groin

Hepato/Spleenomega
ly

Oral Thrush
Painful throat White candidiasis

patches when removed leaves erythematous ulcer Immunosuppressive state

Keratosis tonsils
Incidental finding May cause slight

discomfort Yellow horny outgrowths in the crypts

Agranulocytosis
Halistosis, fever,
headache & dysphagia Single , multiple or coalesce necrotic slough covered ulcers Leucopenia H/O causative drugs intake

Vincents angina
Fetor oris, pyrexia Tonsillar deep ulcers with
grey slough in its base Necrotising gingivitis Enlarged tender cervical adenitis Smear:

Spirochaetes & Fusiform bacilli

Acute lymphatic leukemia

Fever, anaemia &

bleeding disorders Slough covered membrane forming ulcerations Cervical lymphadenopathy Exaggerated leucocytosis

Diphtheria
Malaise, fever &

headache Greyish green membrane across tonsils to larynx Tender bilateral cervical lymphadenopathy

Diphtheria is an acute, toxin-mediated disease caused by toxigenic Corynebacterium diphtheriae Its a very contagious and potentially lifethreatening bacterial disease.

Causative organism of diphtheria

Gram- positive bacillus Produces exotoxin at site of infection Travels to heart and nervous system

 Spread by close contact via droplets or

contaminated articles

Humans are the sole carriers of the organism More common in children < 10 years
Rare occurrence today because of routine vaccination

 Clinical manifestations

Systemic symptoms from exotoxin Fatigued Lethargic

Tachycardic
toxic

Clinical characteristics Pharynx grayish membrane (composed of fibrin, leukocytes, and cellular debris) extends from pharynx to larynx Extensive cervical lymphadenopathy (bull neck)

Diagnosis Isolation of the organism

Culture from local lesion

Grows on selective media containing potassium tellurite Notify microbiology lab if diphtheria suspected

Treatment Started before culture confirmation

Airway Resuscitation

Skin test for allergy to horse serum

 Administer diphtheria antitoxin

Have epinephrine available

Antibiotics : penicillin G is the drug of choice Erythomycin Pt allergic to both drugs- rifampin, and clindamycin

Prevention Vaccine Trivalent vaccine diphtheria toxoid, tetanus toxoid and pertussis (DTP) 6 weeks of age, 2 more 4-8 weeks intervals, and 4th 6-12 months later.

Myocarditis. Cardiac arrhythmias.

Acute circulatory failure.

Paralysis of soft palate,diaphragm & ocular muscles. Laryngeal-airway obstruction.

Ac tonsillitis
Onset Membrane Acute Yellowish,easily separable High Proportionate +/-

Faucial diphtheria
Insidious Ashy gray ,bleeds on separation Low Disproportiona te ++ CBD / KLB ++

Fever Pulse Toxaemia

Throat swab Heam.strepto Urine: +/Albuminuria

Local Complications
Respiratory obstruction Quinsy Acute retropharyngeal abscess Parapharyngeal abscess Neck space infections Acute otitis media

Peritonsillar Abscess or Quinsy

. Comp of acute tonsillitis or

denovo with no preceding tonsillitis
. Collection pus b/w supr constrictor & fibrous capsule at upper pole

The bacteriology of acute tonsillitis and peritonsillar abscess is different although one is a complication of the other. The bacteriology of the quinsy is characterized by mixed flora with multiple organisms both aerobic and anaerobic.

repeated attacks of acute tonsillitis Fever severe throat pain referred otalgia swelling in the neck patients voice develops a characteristic plummy quality

Ill looking patient Pyrexia Often with severe trismus Striking asymmetry with oedema and hyperaemia of the soft palate. Enlarged hyperaemic and displaced tonsil Usually enlarged lymph nodes in JD region.

Preferably admitted to hospital and treated with analgesics and antibiotics. In a patient with an early peritonsillar abscess which is really a peritonsillar cellulitis incision and drainage are not recommended.

Indications for I/D include marked bulging of soft palate This is undertaken at the point of maximum bulge. Interval tonsillectomy after 6 weeks. Abscess tonsillectomy.

Quinsy is a potentially lethal condition Pharyngeal & Laryngeal oedema Parapharyngeal space abscess

Recurrent Acute Tonsillitis

Same signs and
tonsillar erythema symptoms as acute Smooth glistening tonsil with dilated Occurring in 4-7 blood vessels on the separate episodes surface per year Debris in crypts 5 episodes per which are few due year for 2 years to loss of tonsil 3 episodes per architecture year for 3 years

Ant pillar peri

Chronic Tonsillitis
Chronic sore throat Malodorous breath Presence of tonsilliths Peritonsillar erythema Persistent cervical lymphadenopathy Lasting at least 3 months

RECURRENT PAIN HALITOSIS COUGH SNORING SLEEP APNOEA ASYMPTOMATIC

LARGE TONSILS SMALL FIBROTIC IN ADULTS ANTERIOR PILLAR CONGESTED SQUEEZE

IRWIN MOORES SIGN

LYMPHADENOPATHY

Apparent enlargement vs true enlargement Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital Neoplastic

Pleomorphic Adenoma

ICAAneurysm

Normally regress by 10 yrs Etiology: Age ; 3-4 years Physiological hypertrophy Infection Rarely tuberculosis Predisposing factors

Associated with nasal obstruction : Adenoid facies (develop gradually) Nose Pinched ,narrow Mouth - Remains open,dribbling of saliva,mouth breathing Teeth Protruded,irregular,crowded Lower jaw Undershot

Palate High arched. Feeding difficulties. Face - Loss of nasolabial furrow,dull look. Chest Pigeon shaped. Pot belly.

Hyponasality

Triad
Snoring
Open mouth breathi ng

NASAL DISCHARGE. SINUSITIS. EPISTAXIS. VOICE CHANGE.

THE DEVELOPMENT OF EXUDATIVE OTITIS

The lack of mobility of eardrum

The accumulation of exudate in the middle ear The closing of Eustachian tube

Diagnosis : Clinical features: clinch diagnosis Posterior rhinoscopy: Digital palpation :--bag of worms X-ray nasopharynx soft tissue lateral view Nasal endoscopy , Nasopharyngoscopy

Lateral neck films are useful only when history and physical exam are not in agreement. Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.

Conservative : in acute & mild cases Antibiotics,Decongestants,Breathing exercises Surgical : Adeoidectomy-for persistent & rec. infection Precautions: Grommet insertion : in case of SOM

A. Absolute
1. 2. 3. 4. 5. 1. 2. 3. 4. 1. 2. 3. Recurrent infections of throat Peritonsillar abscess Tonsillitis causing febrile seizures Hypertrophy of tonsils causing obstruction Suspicion of malignancy Diphtheria carriers, Streptococcal carriers Chronic tonsillitis with bad taste or halitosis Recurrent streptococcal tonsillitis in a patient with valvular heart disease Palatopharyngoplasty Glossopharyngeal neurectomy. Removal of styloid process.

B. Relative

C. As a Part of Another Operation

Adenoidectomy-Indications
Recurrent or chronic sinusitis or adenoiditis
Poorly understood - possibly caused by obstructive adenoid tissue causing stasis of secretions predisposing the nasal cavity to infection.

Otitis media
Proximity of adenoid tissue to eustachian tube Adenoidectomy can be recommended on 1st set of tubes if nasal obstruction and recurrent rhinorrhea is present or on 2nd set of tubes if needed.

Epidemic of polio Age below 3 years Acute infections Blood dyscrasiasis: hemophilia, purpura Uncontrolled systemic diseases like diabetes and heart diseases Velopharyngeal insufficiency
Overt cleft palate, submucous (covert) cleft Neurologic or neuromuscular abnormality leading to impaired palate

ABSOULTE CONTRAINDICATIONPULSATILE TONSILE

function

Anemia

Most common lab test is a CBC Coagulation studies when the history or physical examination suggests a bleeding disorder. Lateral Neck/Adenoid films

Rose's position

Rose's position for tonsillectomy. Neck is extended by a sand bag under the shoulders and the head is supported on a ring.
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DAVIS MOUTH GAG

BOYLES TONGUE BLADE

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

DISSECTION GUILLOTINE ELECTROCAUTERY CRYOSURGERY LASER HARMONIC SCALPEL COBLATION MICRODEBRIDER

TONSILLAR DISSECTOR

EVES TONSILLAR SNARE

(A) Tonsil being dissected from its bed. (B) The pedicle at the lower pole of tonsil being cut with a snare.
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Cold
Dissection and snare Guillotine method Intracapsular (capsule preserving) tonsillectomy Harmonic scalpel Plasma-mediated ablation technique Cryosurgical technique

Hot
Electrocautery Laser tonsillectomy (CO2 or KTP) Coblation tonsillectomy Radio frequency

TONSIL GUILLOTINE

GUILLOTINE TONSILLECTOMY

HARMONIC SCALPEL KNIFE

HARMONIC SCALPEL TONSILLECTOMY

Primary haemorrhage. Occurs at the

time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels

Reactionary haemorrhage. Occurs

within a period of 24 hours and can be controlled by simple measures such as removal of the clot, application of pressure or vasoconstrictor.

3. Injury to teeth.
4. Aspiration of blood. 5. Facial oedema. Some patients get oedema of the face particularly of the eyelids. 6. Surgical emphysema. Rarely occurs due to injury to superior constrictor muscle.

topical application of dilute adrenaline or hydrogen peroxide with pressure usually suffice. profuse bleeding, general anaesthesia is given and bleeding vessel is electrocoagulated or ligated

approximation of pillars

, external carotid ligation

Transfusion of blood or plasma Systemic antibiotics are given for control of infection

Delayed Complications cont..

1. Infection 2. Lung complications 3. Scarring in soft palate and pillars. 4. Tonsillar remnants. 5. Hypertrophy of lingual tonsil

Thank u