CASE REPORT

CHRONIC TONSILLITIS WITH ACUTE

EXACERBATION

Moderator :
Dr. dr. L.P. Lusy Indrawati, M.Kes, Sp.THT-KL(K)

Presentators :
Ardilles Varian (15324)
Jimmy Sebastian (14883)
Eka Tuniasih (15154)
Finna Magdalena (15162)
Rizka Fauziyah (14915)
Chavia Zagita T(15307)

Department of Otorhinolaryngology - Head and Neck Surgery

Faculty of Medicine Gadjah Mada University
Dr. Sardjito General Hospital
2018
INTRODUCTION
Palatine tonsils are two in number,
and are also the biggest structure in the
Waldeyer Ring. Each tonsils is an ovoid
mass of lymphoid tissue situated in the
lateral wall of oropharynx between the
anterior and posterior pillars. Medial
surface of the tonsil is covered by
non-keratinizing stratified squamous
epithelium which dips into the substance
of tonsil in the form of crypts. Tonsils
act as sentinels to guard against foreign
intruders by providing local immunity
and providing a surveillance mechanism
so the entire body is prepared for
defence. Lymphatics from the tonsil
drain into upper deep cervical nodes
particularly the jugulodigastric node
situated below the angle of mandible,
and its nerve supplied by lesser palatine
branches of sphenopalatine ganglion
(CN V) and the sensory nerve supplied
by glossopharyngeal nerve . (1)
Tonsillitis is defined as
inflammation of pharyngeal tonsils,
which may also extend to the adenoid
and lingual tonsils . Tonsillitis most
(2)
often occurs in children, although the
condition is rarely seen in children
younger than 2 years old. Tonsillitis
caused by Streptococcus species
typically appeared in children aged 5-15
years old, while viral tonsillitis is more
common in younger children.
Tonsillitis may be caused by viral,
bacterial, or fungal infections. Viruses
that may cause tonsillitis are the same as
those involved in a variety of upper
respiratory illness: rhinovirus,
coronavirus, adenovirus, herpes simplex
virus, parainfluenza virus, Epstein-Barr
virus, and cytomegalovirus. Clinical
presentation of viral tonsillitis is similar
to that of bacterial infection, nut often
with less severe symptoms including
sore throat, odynophagia, otalgia,
headache, and fever. Tonsils may appear
enlarged and erythematous, with or
without exudates. Coxsackievirus may
cause herpangina which may present as
small vesicles with erythematous bases
that eventually ulcerate and typically
present on the anterior tonsillar pillars,
palate, and posterior pharyngeal wall.
Epstein-Barr virus may present as
tonsillopharyngitis with dramatic
tonsillar hypertrophy, sore throat, fever,
cervical and diffuse lymphadenopathy,
palatal petechiae, and malaise. (3)
Bacterial infections in tonsillitis
usually involved several microbial
pathogens in nature. The most common
bacterial pathogen which causes
tonsillitis is group A beta-hemolytic
streptococci, with varying contribution
from other pathogens, including group C As tonsillitis is clinical diagnosis,
beta-hemolytic streptococci, Neiserria laboratory studies is not indicated unless
gonorrheae, Corynebacterium when group A beta-hemolytic
diphtheria, Chlamydia pneumoniae, and streptococci (GABHS) infections is
Mycoplasma pneumoniae . (3)
suspected. Throat cultures are the
criterion standard for detecting GABHS.
Chronic tonsillitis may arise as a
Radiologic imaging is indicated for
complication of acute tonsillitis or
patients whom tonsillitis is suspected to
subclinical infections of tonsils without
have spread to deep neck structures . (2)

an acute attack. Chronic tonsillitis

mostly affects children and young adults, Treatment of chronic tonsillitis could
rarely occurs after 50 years . The (1)
be done by conservative treatment or
chronicity of tonsillitis may be attributed tonsillectomy. Conservative treatment
to multiple overlapping infections consists of attention to general health,
caused by different pathogens within diet, and treatment of existent infection . (1)

fistula and purulent pockets of the tonsil Paracetamol or ibuprofen is preferred for
parenchyma even in the absence of children presents with sore throat
clinical symptoms . (3)
without lockjaws or any other
complication . (4)
For tonsillitis with
Clinical features of chronic tonsillitis
GABHS infections, oral penicillin V or
are recurrent attack of sore throat or
oral amoxicillin for 10 days, or single
acute tonsillitis, chronic irritation in
dose of intramuscular Benzathine
throat with cough, and halitosis (bad
penicillin G are the antibiotic regimens
taste in mouth and foul breath due to pus
recommended. In case of penicillin
in crypts). Thick speech, difficulty in
allergy, oral cephalexin, cefadroxil,
swallowing, and choking spells at night
clindamycin, or clarithromycin
may also be found in chronic tonsillitis
administrations for 10 days are
when the tonsils are large and
recommended. Oral azithromycin
obstructive. In physical examination,
administration for 5 days is also
varying degree of tonsillar enlargement
recommended as alternative antibiotic
may be found . Peritonsillar erythema,
(1)

regimen in individuals with penicillin

tender cervical lymphadenopathy,
allergy .
(5)

tonsilloliths, smooth glistening tonsils,

or excessively cryptic tonsils are sign of Options to recommend tonsillectomy
chronic tonsillitis . (3)
are offered in cases of recurrent throat
infection with a frequency of at least 7 diagnosed with tonsillitis about 6 month
episodes in the past year or at least 5 ago and indicated for tonsillectomy but
episodes per year for 2 years or at least 3 refused by the parents. The history of
episodes per year for 3 years with asthma, diabetes mellitus, and allergy
documentation in the medical record for are denied.
each episode of sore throat and 1 or
General examination of the
more of the following:
patient was compos mentis, well-
temperature >38.3°C, cervical
nourished, and non-anemic. The vital
adenopathy, tonsillar exudate, or
sign pulse rate is 96 beat per minute, the
positive test for group A β-hemolytic
respiration rate is 22 times per minute,
streptococcus . (6)

and the temperature is 37 C. The body

0

Complications of chronic tonsillitis weight is 22, 5 kilogram and the height

which may occur are peritonsillar is 135 cm.
abscess, parapharyngeal abscess,
From nasal examination,
intratonsillar abscess, tonsilloliths,
Discharge is seen on both conchae. The
tonsillar cyst, or focus of infection in
discharge is clear and serous. There was
rheumatic fever, acute
no blood found on the conchae. There
glomerulonephritis, eye and skin
was no mass, no conchae edema, and no
disorders .(1)

hyperemia found from examination. On

CASE REPORT the face examination there is no
tenderness on the sinuses. There isn’t
A 9 year old boy came to ENT
any Salute sign, Shiner sign, and allergic
clinic in RS UGM on 29 January 2018,th

crease found on the patient.

with chief complaint of sore throat.
Patient had a sore throat since 4 days
ago accompanied by
temperature around 38,5 C. Patient also
0
had cough and sneezing complaint. The
discharge from the nose is clear and the
viscosity is serous. Patient doesn’t have
a swallowing pain, hoarseness, dyspnea,
vomiting, and regurgitation. Patient also
doesn’t have foul breath. Patient was
From ear examination, there is
fever with no hyperemic, deformity, and mass on
the right and left auricular. When
palpated, there is no tenderness on both
auricular. From otoscope examination,
the cerumen is minimum, there is no
mass and inflammation sign found, the
tympanic membrane is intact and the
light reflex is positive.
From oropharyngeal examination, the
lips is symmetrical, no deformity, and
no inflammation. There is no sign of
inflammation, mass and lesion in buccal
mucosa, tounge, gum, and teeth. The
uvula is hyperemic, no sign of mass,
lesion, post nasal drip, and granule. The
tonsils are hyperemic. Lacunar crypts
are present on the tonsils. Oedem
and hyperemic are found on palatum
DISCUSSION
Chronic tonsillitis is a common
condition in children and young adults,
rarely occurs after 50 years.
Treatment of chronic tonsillitis
could be done by conservative treatment
or tonsillectomy. Conservative treatment
consists of attention to general health,
diet, and treatment of existent infection . (1)

mole, anterior arch, and posterior arch. Paracetamol or ibuprofen is preferred for
The tonsils are enlarged with the grading children presents with sore throat
of T3. There are no detritus found on the without lockjaws or any other
tonsils. The oropharynx is hyperemic complication . (4)
For tonsillitis with
and inflamed. GABHS infections, oral penicillin V or
oral amoxicillin for 10 days, or single
Based on the data above, patient is
dose of intramuscular Benzathine
diagnosed with chronic tonsillitis with
penicillin G are the antibiotic regiments
acute exacerbation. Patient was treated
recommended. In case of penicillin
with amoxicillin 300 mg 3 times per day
allergy, oral cephalexin, cefadroxil,
for the duration of 7 days. The patient
clindamycin, or clarithromycin
was also given decongestant
administrations for 10 days are
pseudoephedrine HCL for 3 times per
recommended. Oral azithromycin
day if needed. Paracetamol 250 mg was
administration for 5 days is also
also given for 3 times per day for the
recommended as alternative antibiotic
duration of seven days. Patient is told to
regiment in individuals with penicillin
come back in a week to evaluate the
allergy .
(5)

efficacy of the therapy. Patient also has

been educated to keep the hygiene of the Brook, 1989 in his study
mouth and body. The patient also told to demonstrates the efficacy of amoxicillin
rest until the fever gone and wear mask / clavulanate potassium in the therapy of
if going outside. Patient also been told to acute episodes of recurrent tonsillitis and
avoid cold and spicy food and prevention of recurrent infection . (13)

beverages.
 Clarithromycin was more In contrast, there is still
effective than amoxicillin/clavulanic controversy about the effectiveness of
acid in eradicating pathogenic bacteria tonsillectomy in adults as there is a lack
in the tonsil core. Pseudomonas of high-level evidence . (9)

aeruginosa might be responsible for Current evidence suggests that in

resistant or recurrent tonsil infections. adults with recurrent episodes of
To prevent endocarditis, antibiotic pharyngitis tonsillectomy may not lead
prophylaxis toward S. viridians, which is to a clinically significant reduction in
the most prevalent bacterium in the the number of sore throat episodes and
tonsil core, should be kept in mind for sore throat days in the first five to six
patients with heart valve damage . (12)
months following surgery as compared
to (initial) non-surgical treatment . (10)

Options to recommend
Tonsillectomy is chosen to
tonsillectomy are offered in cases of
relieve patient’s complaints, such as
recurrent throat infection with a
pain on swallowing, dysphagia, and
frequency of at least 7 episodes in the
snoring when sleeping which resulted
past year or at least 5 episodes per year
from obstruction in oropharynx . (11)

for 2 years or at least 3 episodes per year

Complications of chronic
for 3 years with documentation in the
tonsillitis which may occur are
medical record for each episode of sore
peritonsillar abscess, parapharyngeal
throat and 1 or more of the following:
abscess, intratonsillar abscess,
temperature >38.3°C, cervical
tonsilloliths, tonsillar cyst, or focus of
adenopathy, tonsillar exudate, or
infection in rheumatic fever, acute
positive test for group A β-hemolytic
glomerulonephritis, eye and skin
streptococcus . (6)

disorders . (1)

The main potential complication

for tonsillectomy is hemorrhage. In REFERENCES
cases of minor bleeding, the clot can be
1. Dhringa, PL and Dhringa,
removed through suction or forceps and
S. Diseases of Ear, Nose and
the bleeding area can be catheterized
Throat & Head and Neck Surgery,
using silver nitrate. In cases of major
6 Ed. New Delhi. Elsevier. 2014.
th

bleeding, ABC principle must be

observed . (8)
2. Shah, UK. Tonsillitis and The Open Otorhinolaryngology
peritonsillar abscess. Medscape. Journal. 2010;4;34-46.
2017 (accessed 8 February 2018). 10. Burton MJ, Glasziou PP, Chong LY,
3. Johnson, JT and Rosen, CA. Venekamp RP. Tonsillectomy or
Bailey;s head & neck surgery adenotonsillectomy versus
otolaryngology, 5 Ed. Lippincott
th
non-surgical treatment for
Williams & Wilkins. 2014. chronic/recurrent acute tonsillitis.
4. Cervoni, E, and Leech, K. ENT in Cochrane Database of Systematic
Primary Care: A Concise Guide. Reviews. 2014;11; DOI:
Cham, Springer. 2017. 10.1002/14651858.CD001802.pub3
5. Shulman, ST., et al. Clinical 11. American Academy of
practice guideline for the diagnosis Otolaryngology-Head and Neck
and management of Group A surgery. Clinical Indicators
Streptococcal Pharyngitis: 2012 compendium. Virginia, 1995.
Update by the Infectious Diseases 12. Yildizoglu U, Polat B, Gumral
Society of America. Clinical R, Kilic A, Tosun F, Gerek M.
Infectious Diseases. Effect of antibiotic use on bacterial
2012;55;10;e86-e102. flora of tonsil core in patients with
6. Baugh, RF, et al. Clinical Practice recurrent tonsillitis. Pubmed. 2015.
Guideline: Tonsillectomy in doi:10.1007/s00405-014-3434-3
Children. Otolaryngology-Head and 13. Brook l. Treatment of patients with
Neck Surgery. 2011;144;1S;S1-S30. acute recurrent tonsillitis due to
7. McCulloch MT., Jaffe D. Head and group A beta-haemolytic
neck disorders affecting swallowing. streptococci: a prospective
GI Motility online. randomized study comparing
2006; doi:10.1038/gimo36. penicillin and amoxicillin /
8.
Health Technology Assessment clavulanate potassium. Pubmed,
Indonesia Tonsilektomi pada Anak 1989.
dan Dewasa. Jakarta. Depkes RI.
2004.
9. Skevas, T., Klingmann, C., Sertel,
S., Plinkert, P.K., and Baumann, I.
Measuring Quality of Life in Adult
Patients with Chronic Tonsillitis.