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Ravikumar MS(ENT)
Etiology : Viral followed by secondarily invaded by Hemolytic streptococcus Staph aureas H.influenza Dipl. Pneumoniae Age : Commonest <9yrs
Pathophysiology
Viral Infections Bacterial Infections Inflammatory exudates of the crypts
Epithelial keratinisation
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
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:
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
Infectious Mononucleosis Faucial diphtheria Agranulocytosis Scarlet fever Oral thrush ALL Vincents angina Tertiary syphilis
Infectious Mononucleosis
Cheesy exudates
covering tonsil
Lymphadenopathy of
neck, axilla & groin
Hepato/Spleenomega
ly
Oral Thrush
Painful throat White candidiasis
Keratosis tonsils
Incidental finding May cause slight
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:
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.
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
Tachycardic
toxic
Clinical characteristics Pharynx grayish membrane (composed of fibrin, leukocytes, and cellular debris) extends from pharynx to larynx Extensive cervical lymphadenopathy (bull neck)
Grows on selective media containing potassium tellurite Notify microbiology lab if diphtheria suspected
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.
Ac tonsillitis
Onset Membrane Acute Yellowish,easily separable High Proportionate +/-
Faucial diphtheria
Insidious Ashy gray ,bleeds on separation Low Disproportiona te ++ CBD / KLB ++
Local Complications
Respiratory obstruction Quinsy Acute retropharyngeal abscess Parapharyngeal abscess Neck space infections Acute otitis media
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
Chronic Tonsillitis
Chronic sore throat Malodorous breath Presence of tonsilliths Peritonsillar erythema Persistent cervical lymphadenopathy Lasting at least 3 months
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
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
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
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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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
TONSILLAR DISSECTOR
(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
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
Transfusion of blood or plasma Systemic antibiotics are given for control of infection
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