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CLASSIFICATION OF TONSILLITIS.
QUINSY. COMPLICATIONS OF ACUTE
TONSILLITIS. CHRONIC TONSILLITIS.
ADENOIDS. TONSILLAR HYPERTROPHY.
Associate Professor Ukrainian National State Medical University,
Department of Otorhinolaryngology
DIDKOVSKYI
Viacheslav
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The Palatine Tonsils
(Anatomy and Function)
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Anatomy of the Tonsils
Paired, sit in tonsillar sinus
Limited anteriorly by
palatoglossal arch,
posteriorly by
palatopharyngeal arch,
laterally by superior
pharyngeal constrictor
Enclosed in a fibrous capsule
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Anatomy of the Tonsils
10-30 crypts
Innervation from
sphenopalatine ganglion via
lesser palatine and
glossopharyngeal nerves
No afferent lymphatics,
efferents drain to upper deep
cervical lymph nodes
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Immunology and Function
Part of secondary immune system
No afferent lymphatics
Exposed to ingested or inspired antigens passed through the epithelial layer
Immunologic structure is divided into 4 compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle
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Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle
Antigen is presented to T-helper cells
T-helper cells induce B cells in germinal center to produce antibody
Secretory IgA is primary antibody produced
Involved in local immunity
Immunology and Function
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Immunology and Function
B-cells
T-cells
IgM, IgG, IgA
Ци к ич а дія
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Adenotonsillar disease
Major divisions are:
– Infection/inflammation
– Obstructive
– Neoplasm
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Clinical Evaluation
Acute Tonsillitis
Chronic Tonsillitis
Obstructive Tonsillar Hyperplasia
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CLASSIFICATION OF TONSILLITIS ACUTE
Primary: catarrhal, lacunar, follicular, necrotic.
Secondary:
a) in case of acute infectious diseases
(diphtheria, scarlet fever, tularaemia, typhoid fever);
b) in case of circulatory system diseases
(infectious mononucleosis, agranulocytosis, leucosis, alimentary
toxic aleukia).
CHRONIC
Non-specific: a) compensated form; b) decompensated form.
Specific: in case of infectious granuloma (tuberculosis, syphilis).
*The classification by academician I.E. Soldatov is generally accepted.
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Acute Tonsillitis
Signs and symptoms:
– Fever
– Sore throat
– Tender cervical
lymphadenopathy
– Dysphagia
– Erythematous tonsils
with exudates
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Clinical evaluation
Viral
– Lower grade fever
– Lower WBC, Lymphocytic shift
– Less tonsillar exudate
Bacterial
– Higher WBC, Granulocytic shift
– More exudative
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CLINICAL EVALUATION
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LACUNAR FOLLICULAR
CLINICAL EVALUATION
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Differential Diagnosis
Infectious
Mononucleosis
– EBV
Scarlet Fever
Corynebacterium
diptheriae
Malignancy
Infectious mononucleosis should be
suspected if a sore throat and malaise
persist despite antibiotic treatment,
and a white cell analysis and
Paul–Bunnell test are indicated.
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Medical Management
Penicillin is first line treatment
Recurrent or unresponsive infections
require treatment with beta-lactamase
resistant antibiotics such as
– Clindamycin
– Augmentin
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Medical Therapy
First Line
– Penicillin/Cephalosporin for 10 days
– Injectable forms for noncompliance
BLPO, co pathogens
Macrolides
– Penicillin allergy
– Erythromycin/Clarithromycin 10 days
– Azithromycin (12mg/kg/day) 5 days
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Complications of Tonsillitis
Cervical Adenitis
Neck Abscess
Peritonsillar abscess
Intratonsillar abscess
Lemierre’s syndrome
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Peritonsillar Abscess (Quinsy)
Abscess formation outside tonsillar capsule
Signs and symptoms:
– Fever
– Sore throat
– Dysphagia/odynophagia
– Drooling
– Trismus
– Unilateral swelling of soft palate/pharynx with uvula deviation
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Peritonsillar Abscess
(Quinsy)
A peritonsillar abscess PTA is a collection
of pus located between the fibrous capsule
of the tonsil and the superior pharyngeal
constrictor muscle.
The most commonly held theory is that
PTA occurs secondary to the penetration of
bacteria from the tonsillar crypts through
the tonsillar capsule into the peritonsillar
space.
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TREATMENT
OF PARATONSILLAR ABSCESS
The treatment of paratonsillar abscess
consists in the abscess opening and
antibacterial treatment.
The abscess is opened in the place
where inflammatory infiltration is bulging
the most or, in case of an anterosuperior abscess,
along the imaginary line between the base
of the uvula and the last grinder tooth of the
lower jaw on the border between the medium
and the upper third of this line.
The cut is not made very deep because a greater
blood vessel can be damaged.
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TREATMENT
OF ABSCESS
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DIFFUSE PHLEGMON
Diffuse infection of the cervical fat is called diffuse phlegmon.
It is a severe inflammatory disease requiring an urgent surgical intervention.
The clinical course of the phlegmon is acute.
It can be located in any fat tissue space of the neck.
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DIFFUSE PHLEGMON
The peculiarities of the anatomical neck structure promote rapid
extension of suppurative process from one fat tissue space to another
and even to mediastinum, skull cavity, axillary region,
infraclavicular fossa and the anterior thoracic wall.
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DIFFUSE PHLEGMON
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Chronic Tonsillitis
Chronic sore throat
Malodorous breath
Presence of tonsilliths
Peritonsillar erythema
Persistent tender cervical
lymphadenopathy
Lasting at least 3 months
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Chronic Tonsillitis
The following are the true signs of
chronic tonsillitis:
Hyperaemia and roller-shaped
thickening of palatine arch edges.
adhesions between the tonsils and the
palatine arches.
Loosened and sclerotic tonsils.
Presence of purulent masses and
liquid pus in the tonsil lacunas.
Regional lymphadenitis - enlargement
of retromaxillary lymphatic nodes.
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LAVAGE OF PALATINE TONSIL
lavage of palatine tonsil
lacunas with disinfecting
solutions
suction of lacuna contents
Conservative treatment is taken as different courses two
times a year (in spring and autumn).
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Tonsillectomy
Current clinical indicators are:
– 2 or more infections per year despite adequate medical therapy
– Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by orthodontist
– Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorder, cardiopulmonary complications
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– Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage
– Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy
– Chronic or recurrent tonsillitis associated with streptococcal carrier state and not responding to beta-lactamase resistant antibiotics
– Unilateral tonsil hypertrophy presumed neoplastic
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Surgical Indications Absolute
– Obstructive airway with cor pulmonale
– Severe dysphagia
– Failure to thrive
Relative
– Recurrent acute tonsillitis
– Chronic tonsillitis
– Obstructive Sleep Apnea
– Peritonsillar Abscess
– Halitosis
– Suspected Neoplasia/ Tonsillar hyperplasia
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32
TONSILLECTOMY
(step of operation)
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Tonsillectomy
– Tonsillotome
– Cold dissection with snare
– Monopolar/bipolar
electrocautery
– CO2 or KTP laser
– Hemostasis with packing,
electrocautery, sutures
TONSILLECTOMY
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TONSILLECTOMY
(position of patient)
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TONSILLECTOMY
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TONSILLECTOMY
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Tonsillectomy
– Tonsillotome
– Cold dissection with
snare
– Monopolar/bipolar
electrocautery
– CO2 or KTP laser
– Hemostasis with
packing,
electrocautery, sutures
TONSILLECTOMY
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Obstructive Tonsillar
Hyperplasia
Snoring and other
symptoms of sleep
disturbance
Muffled voice
Dysphagia
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TONSILLTOMY
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ANATOMY OF THE ADENOIDS
Single pyramidal mass of tissue based on posterior-superior nasopharynx
Surface folded without true crypts
Blood supply – ascending palatine branch of facial artery, ascending pharyngeal artery, pharyngeal branch of internal maxillary artery
Innervation – n.glossopharyngeal and n.vagus
No afferent lymphatics, efferents drain to retropharyngeal and upper deep cervical nodes
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ANATOMY OF THE ADENOIDS
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Acute adenoiditis
Symptoms include:
– Purulent rhinorrhea
– Nasal obstruction
– Fever
– Associated Otitis Media
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Chronic adenoiditis
Symptoms include:
– Persistent rhinorrhea
– Postnasal drip
– Malodorous breath
– Associated otitis media >3 months
– Think of reflux
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Obstructive Adenoid
Hyperplasia
Signs and Symptoms
– Obligate mouth breathing
– Hyponasal voice
– Snoring and other signs of sleep disturbance
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Adenoidectomy
Current clinical indicators are:
– 4 or more episodes of recurrent purulent rhinorrhea in prior 12 months in a child <12. One episode documented by intranasal examination or diagnostic imaging.
– Persisting symptoms of adenoiditis after 2 courses of antibiotic therapy. One course of antibiotics should be with a beta-lactamase stable antibiotic for at least 2 weeks.
– Sleep disturbance with nasal airway obstruction persisting for at least 3 months
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Surgical Indications
Adenoidectomy
– Absolute
Airway obstruction w/ cor pulmonale
Failure to thrive
– Relative
Chronic Nasal Obstruction
Recurrent/ Chronic Adenoiditis
Recurrent/ Chronic Sinusitis
Recurrent acute otitis media/ Recurrent COME
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– Hyponasal or hypernasal speech
– Otitis media with effusion >3 months or second set of
tubes
– Dental malocclusion or orofacial growth disturbance
documented by orthodontist
– Cardiopulmonary complications including cor
pulmonale, pulmonary hypertension, right ventricular
hypertrophy associated with upper airway obstruction
– Otitis media with effusion over age 4