24820633 adeno tonsillitis

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 ADENO TONS ILLITIS Dr. A. KARUNAGARAN, M.S. D.L.O,

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 ADENO TONSILLITIS

Dr. A. KARUNAGARAN, M.S. D.L.O,

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 Anatomy

• Waldeyer`s inner ring consists collectionof sub epithelial lymphoid tissue

• Adenoids• Palatine tonsil

• Tubal tonsil

• Lingual tonsil

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 Anatomy – tonsil

• Bilateral ovoid masses of lymphoid tissue

• Almond shape

• Partly covered by capsule• Medial surface has 15 – 20 crypts, biggest

is crypta magna

• Mucosal folds – in superior pole plicasemilunaris, in inferior pole plicatriangularis

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 Anatomy – adenoids

• Present at the junction of roof andposterior wall of nasopharynx

• Has furrows and ridges• Appear like bunch of banana

• Feels like bag of worms

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 Anatomy

Blood supply - Tonsils

Facial a.

Lingual a. Dorsal lingual Tonsil

 Ascending pharyngeal Tonsil

Maxillary Lesser descending palatine Tonsil

Tonsillar branch Tonsil (main branch)

 Ascending palatine Tonsil

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 Anatomy

Blood supply – Adenoids

• Ascending palatine branch of facial a.• Ascending pharyngeal a.

• Pharyngeal branch of IMAX.

• Ascending cervical branch of thyrocervicaltrunk.

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Tonsils  Adenoids Paired structure  Solitary structure

Present in lateral wall of oro

pharynx 

Present in naso pharynx

Covered by non keratinizingstratified sqamous

epithelium 

Coverd by ciliated columnar epithelium

Covered by capsule on the

lateral wall 

No capsule

Has crypts  No crypts, only furrows

 Almond shaped  Bunch of banana

Both afferent and efferents

present 

no afferent only efferents

present 

Differences between tonsils and adenoids

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Infecting Organisms 

Aerobic Bacteria• Strep pyogenes (Gr A beta-hemolytic)

• Strep pneumoniae

• Strep viridans & other Streptococci

• Staph aureus

• H. Influenzae

• Diphtheroids

•  Neisseria spp.

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Infecting Organisms 

Anaerobic Bacteria

• Bacteroides

• Peptococcus

• Peptostreptococcus

• Veillonella

• Fusobacteria

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Infecting Organisms 

Viruses

• Epstein-Barr 

• Cytomegalovirus• Adenovirus

• Herpes simplex

• Influenza A and B

• Parainfluenzae

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Microbiology of Tonsillitis 

Group A beta-hemolytic• Is most recognized - associated with a risk of 

rheumatic fever and glomerulonephritis

Beta-lactamase producing organisms

• Are of particular importance.

• Produced by Staph aureus, M. catarrhalis &

H.influenzae• Protect Group A Streptococci from eradication

with penicillins

• Accounts for 39% of all cultured organisms 

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Who gets Tonsillitis ?

• Most often occurs in children – allexperience at least 1 episode

• Rarely in children younger than 2 yr 

• Viral tonsillitis in younger children

• Streptococcal tonsillitis in children

aged 5-15 yr • Poor socioeconomic status & over 

crowding

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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

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Unanswered Questions

• Do virus infections in the pharynx and tonsilspredispose to bacterial infection?

• Is it possible to have an infective condition

involving the pharyngeal lymphoid tissuewithout affecting the tonsils?

• Is there such a condition as chronic tonsillitis?

• Why are some patients susceptible to acutepharyngitis and acute tonsillitis and othersnot?

• Does the tonsil become irreversibly diseased

after many episodes of acute tonsillitis?

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 Acute Tonsillitis

Symptoms: 

FeverSore throat

Dysphagia or Odynophagia

 Airway Obstruction

Lethargy / malaise

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 Acute Tonsillitis - Signs

• Enlarged

• Erythematous

• Exudative forming at

timespseudomembrane

• Enlarged neck nodes

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Grading the Size of Tonsils

Grading system:

 A. 0 – tonsils in fossaB. +1 – tonsils less than 25%C. +2 – tonsils less than 50%D. +3 – tonsils less than 75%E. +4 – tonsils greater than 75%

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Features of adenoid facies

• Open mouth and mouth breathing• Pinched nostrils• Crowded teeth andhyper plasia of gums

• Loss of naso labial fold• Under slung mandible• High arched V shaped palate• Short upper lip• Hypo plasia of maxilla•  Vacant expression• Pectus excavatum• Rouned shoulders•  Voice changes- nasal and lifeless

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Lingual Tonsils

• Hyperplasia is the most common abnormality of the lingualtonsil.

• Lingual tonsils sit on the base of the tongue and extend tothe vallecula and do not have a capsule.

• Can be visualized by indirect mirror or flexible laryngoscopy

• Clinically, infection is marked by erythema and enlargementof tonsillar tissue.

• Suspension microlaryngoscopy with removal by CO2 laser,sharp dissection or hot knife cautery are some of thetreatments available.

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Lingual Tonsil

• History and Physical: – Sore throat

 – Globus sensation

 – Speech change – Dysphagia

 – Obstructive sleep apnea in adults

 – Pediatric airway obstruction

 – Often discovered incidentally during intubation inpreparation for surgery that is unrelated to the ear,nose, and throat.

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Lingual Tonsils

• Differential diagnosis – lingual thyroid tissue – thyroglossal duct cyst – dermoid cyst

 – lymphangioma – angioma – adenoma – fibroma

 – papilloma – lymphoma – squamous cell carcinoma – minor salivary gland tumors on the base of the tongue

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Lingual Tonsils

• Hypertrophy of lingual tonsils in 62% of personswith laryngoscopic signs of reflux and in 75% of persons with pharyngolaryngeal symptoms of LPR.

•  Although the lymphoid tissue in Waldeyer's ringtends to decrease with advancing age, the lingualtonsil may increase in size.

• The most important cause of lingual tonsilhypertrophy is the occurrence of compensatoryhyperplasia following adenotonsillectomy.

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Differential Diagnosis of pseudomembranous tonsillitis

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Infectious Mononucleosis

• Cheesy exudatescovering tonsil

• Lymphadenopathy of 

neck, axilla & groin

• Hepato/Spleenomegaly

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Oral Thrush

• Painful throat

• White candidiasis

patches whenremoved leaveserythematous ulcer

• Immunosuppressive

state

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Keratosis tonsils

• Incidental finding

• May cause slightdiscomfort

•  Yellow hornyoutgrowths in thecrypts

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 Agranulocytosis

• Halistosis, fever,headache & 

dysphagia• Single , multiple orcoalesce necroticslough covered

ulcers• Leucopenia

• H/O causative drugs

intake

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Diphtheria

• Malaise, fever & headache

• Greyish greenmembrane acrosstonsils to larynx

• Tender bilateral

cervicallymphadenopathy

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 Vincent‟s angina • Fetor oris, pyrexia

• Tonsillar deep ulcers withgrey slough in its base

• Necrotising gingivitis

• Enlarged tender cervicaladenitis

• Smear:

Spirochaetes & Fusiform

bacilli

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 Acute lymphatic leukemia

• Fever, anaemia & bleeding disorders

•Slough coveredmembrane formingulcerations

• Cervical

lymphadenopathy• Exaggeratedleucocytosis

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Recurrent Acute Tonsillitis

• Same signs andsymptoms as

acute• Occurring in 4-7separate episodesper year

• 5 episodes peryear for 2 years

• 3 episodes per

year for 3 years

•  Ant pillar peritonsillar erythema

• Smooth glisteningtonsil with dilatedblood vessels on thesurface

• Debris in cryptswhich are few dueto loss of tonsilarchitecture

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Chronic Tonsillitis

• Chronic sore throat

• Malodorous breath

• Presence of tonsilliths

• Peritonsillar erythema

• Persistent cervical lymphadenopathy

• Lasting at least 3 months

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Local Complications

• Respiratory obstruction

• Quinsy

• Acute retropharyngeal abscess

• Parapharyngeal abscess

• Neck space infections

• Acute otitis media

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Retropharyngeal abscess

• Dysphagia, fever

• Pharynx eithernormal or smoothbulge of posteriorpharyngeal wall

•  Airway obstruction

• Neck rigid

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Peritonsillar Abscess•  Abscess formation

outside tonsillar capsule• Signs and symptoms:

 – Fever

 – Sore throat

 – Dysphagia/odynophagia – Drooling

 – Trismus

 – Unilateral swelling of soft

palate/pharynx with uvuladeviation

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Peritonsillar Abscess

• Incidence: estimated 30 casesper 100,000 in US.

• Diagnosis is usually by physical exambut other modalities have been used such as US

and CT.• Widely accepted that Staphylococcus aureus is

the most common organism causing the infection

and origin is usually from the superior pole of thetonsil (from minor salivary gland - AKA: Webergland).

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Peritonsillar Abscess

• Quinsy tonsillectomy vs. Interval tonsillectomy – Quinsy tonsillectomy can be a treatment option inpediatric patients to young to withstand bedsideaspiration or I&D for recurrent PTA.

 – Quinsy tonsillectomy can be surgically easier thaninterval tonsillectomy as fibrosis has not had time to setinto the tonsillar capsule.

 – Review by Johnson, discussed interval tonsillectomy forrecurrent PTA with prevalence of 10%.

 – Interval tonsillectomy can be considered after successfulabscess drainage, usually from recurrent PTA after 6weeks.

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Parapharyngeal

abscess• Fever, dysphagia

& airway

obstruction• Swelling below

soft palate overthe pharynx

• Tender firmswelling in theupper part of neck 

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 Acute otits media

• Preceding URI & blocked ear

• Severe otalgia• Bulging congested

ear drum

• Eustachian catarrh

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Systemic Complications

• Acute rheumatic fever

• Acute glomerulonephritis

• Bacterial endocarditis

• Dermatitis

• Septicemia

• Septic abscesses

• Septic arthritis

• Menigitis

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Investigations

• CBC & serum electrolytes• Crypt swab culture & sensitivity – 60% specificity

• Crypt aspiration culture & sensitivity –ed specificity

•  A rapid antigen detection test (RADT) has 95%

specificity• Serum examined for anti-streptococcal antibodies – 

 ASO titre - Useful for documenting prior infections in – acute rheumatic fever, glomerulonephritis or other

complications• Monospot serum test

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Medical Management of  Acute Tonsillitis

Largely supportive

 Adequate hydration and caloric intake

Control pain Antibiotics – 

• Penicillin – 1st line treatment

• Macrolides, Cephalosporins, Clindamycin

• Vancomycin and Rifampin are also used

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Current Indications forTonsillectomy

• Recurrent tonsillitis

• Chronic persistent tonsillitis

• Hypertrophic obstructive Tonsillitis not responding to

medicine causing dysphagia or OSA• Diphtheria carrier state

• Rec Peritonsillar abscess +/_ Rec tonsillitis

• Unilateral tonsillar hypertrophy

• Benign tumours of tonsil like papilloma, adenoma• Chronic tonsillolith

•  As an approach to IX nerve, elongated styloid process

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 Adenoidectomy-Indications

• Recurrent or chronic sinusitis or adenoiditis – Poorly understood - possibly caused by obstructive

adenoid tissue causing stasis of secretions predisposingthe 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 presentor on 2nd set of tubes if needed.

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Contra indications for adenotonsillectomy

• 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

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Cold steel Instruments

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Complications of Tonsillectomy

• Haemorrhage

• Haematoma & oedema uvula

• Infection• Pulmonary complications

• Remnant tonsils

• Referred otalgia• Post operative scarring causing voice change ornasal regurgitation

C li i

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Complications• Noniatrogenic complications after adenoidectomy

 – Regrowth of adenoid tissue , particularly in very youngchildren, which may require revision (secondary)adenoidectomy.

 – Hypernasality , because of temporary pain splinting.Persistent hypernasality is rare and probably caused by

unrecognized pre-existing velopharyngeal weakness. – Atlantoaxial subluxation (Grisel‟s syndrome), which

presents with persistent torticollis 1-2 weeks aftersurgery.

• Iatrogenic complications after adenoidectomy include – Dental injury , from intubation or the mouth gag

 – Nasopharyngeal stenosis , caused by excessive tissueremoval.

 – Eustachian tube injury  

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The Modern

Tonsillectomy

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• History

• Indications• Innovative Techniques and Comorbidites

 – Intracapsular tonsillectomy

 – Harmonic scalpel – Laser

 – Coblation 

• Adjuvant Therapy – Local Anesthesia: Bupivacaine

 – Postoperative Antibiotics

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History

•  Aulus Cornelius Celsus – 1st Century AD

 – “the tonsils are loosened by scraping around themand then torn out” with a finger 

 – Used vinegar and medication for postoperative

hemostasis•  Aetius of Amida

 – 6th Century AD

 – Hook and knife method

• Philip Syng Physick (“Father of Americansurgery”) – First to develop the tonsillotome

• Mackenzie – Late 1800s

 – Made tonsillotome use common

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Innovative Techniques

• IntracapsularTonsillectomy

• Harmonic Scalpel• Laser

• Coblation

• Guiding Principle:reduce morbidity – Hemorrhage

 – Pain

 – Diet

 – Activity

 – Cost

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Intracapsular Tonsillectomy

 – Tonsillar hypertrophy causing sleep disordered

breathing• Intracapsular tonsillectomy

 – Microdebrider at 1500 rpm in oscillating mode

 – Hemostasis with suction cautery

• Total tonsillectomy – Subcapsular

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• Conclusions – Intracapsular tonsillectomy is safe andefficacious in children under 3 years fortonsillar hypertrophy and sleep disordered

breathing without need for admission• Limitations

 – Retrospective study

 – Uneven distribution

 – Long term results of tonsillar regrowthunknown

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Harmonic Scalpel Tonsillectomy

• Ultrasonic dissector and coagulator

• Vibratory energy

 – Cutting: sharp blade with frequency of 55.5kHz over distance of 80 μm 

 – Coagulating: vibration breaks H-bonds,thermal energy

• 50° – 100° C• Electrocautery 150° – 400° C

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• Operative time statistically significant – Harmonic scalpel 8 min 42 sec – Electrocautery 4 min 33 sec

• No significant difference in intraoperative bloodloss and postoperative ability to eat and drink 

• Level of activity for the first postop daysignificantly lower in harmonic scalpel group

• Postoperative pain scores tended to be lower inharmonic scalpel group

• Postoperative bleeding – Harmonic scalpel: 6 – Electrocautery: 3 – Not statistically significant

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Laser Tonsillectomy

Compared the use of KTP laser tonsillectomyversus cold dissection and snare

 – KTP 532 laser at 10W, continuous beam

 – Outcomes measured• Operative time

• Operative bleeding

• Postoperative pain• Postoperative advancement to diet

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• Results – Operative time:

• Laser 12 min• Dissection 10 min• Not statistically significant

 – Intraoperative blood loss• Laser 20 mL• Dissection 95 mL• Statistically significant

 – Laser group with higher postop pain scores – Laser group with greater difficulty resuming

postoperative diet – Readmission for delayed hemorrhage was 8% in the

laser group and 4% in the dissection group• Not statistically significant

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• Conclusion

 – KTP laser provides little benefit overdissection tonsillectomy except to minimize

intraoperative bleeding• Limitations

 – Technical expertise

 – Electrocautery not included

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Coblation Tonsillectomy

• Bipolar radiofrequency energy transferred tosodium molecules to create an ion or plasmafield

• This thin layer of plasma is utilized to ablatetissues at molecular level

• No need for electrocautery for hemostasis

• Temperature from 40° to 85° C• Electrocautery at 20W: above 400° C

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• Coblation

 – From surface out laterally – Coblate 9 setting to ablate tissues

 – Coblate 5 setting to coagulate

 – Capsule not penetrated

• Electrocautery – Bovie set to 20 W

• Outcomes measured – Questionnaire

• Pain

•  Analgesics• Nausea/vomiting

• Diet

•  Activity

 – Complications

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Coblation Tonsillectomy

• Future considerations

 – To evaluate coblation forintracapsular tonsillectomy,

a fair study would useanother intracapsulartechnique such as power-assisted tonsillectomy witha microdebrider

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• Technique – Monopolar electrocautery used most often• Greatest for otolaryngologists in practice < 20 years

• Hemostasis

 – Sharp dissection most common for group inpractice > 20 years• Decreased pain

• Method of hemostasis not mentioned• Local Anesthetic evenly distributed

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Conclusions

• Tonsillectomy is a surgical procedure thatcarries significant postoperative morbidity

• To minimize postoperative morbidityvarious techniques and adjuvant therapieshave been studied

• There are many options available and itbehooves an otolaryngologist to stay as upto date as possible

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THANK YOU

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DISEASES OF TONSILS

& ADENOID

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 ACUTE TONSILLITIS

• Etiology : Viral followed bysecondarily invaded by

•Hemolytic streptococcus•Staph aureas

•H.influenza

•Dipl. Pneumoniae

• Age : Commonest <9yrs

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• Spread : Droplet infection

• Types:

 – Ac cattarhal – Ac parenchymatous

 – Ac follicular – Ac membranous

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A t b t illiti

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 Acute membraneous tonsillitis

A t h t t illiti

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 Acute parenchymatous tonsillitis

ACUTE TONSILLITIS:CLINICAL

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ACUTE TONSILLITIS:CLINICALFEATURES

SYMPTOMS

• Sore throat

• Fever• Malaise

• Odynophagia

• Thick speech• Earache

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SIGNS

• Pyrexia,halitosis.

• Furred tongue.• Enlarged congested tonsil.

• Others signs according to type.

• Tender & enlarged J-D nodes.

ACUTE TONSILLITIS :

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 ACUTE TONSILLITIS :TREATMENT

• Bed rest : Isolation

• Mouth gurgles : How it helps ?

• Analgesics :

• Antibiotics :

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Medical Therapy

• First Line – Penicillin/Cephalosporin for 10 days

 – Injectable forms for noncompliance

• Macrolides – Penicillin allergy

 – Erythromycin/Clarithromycin 10 days

 – Azithromycin (12mg/kg/day) 5 days

DYNAMICS OF TONSILLITIS

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DYNAMICS OF TONSILLITIS

Group AStreptococci

 Viruses

Other aerobicand anaerobic

bacteria

Recurrence PersistenceCure

Nonsepticcomplications

SepticComplications

Penicillin Rx

ACUTE TONSILLITIS

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  ACUTE TONSILLITISCOMPLICATIONS :

• Peritonsillar abscess

• Parapharyngeal abscess

• Retropharyngeal abscess

• Oedema of larynx

• Cervical supp. Lymphadenitis

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• Acute middle ear cleft infection

• Chronic tonsillitis

• Septicaemia

• Acute rheumatism

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• Rheumatic heart disease

• Chorea

• S.B.E.

• Acute nephritis

ACUTE TONSILLITIS : d/ds

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 ACUTE TONSILLITIS : d/ds

• Infectious Mononucleosis• Faucial diphtheria

• Agranulocytosis

• Scarlet fever• Oral thrush

• ALL

• Vincent‟s angina • Tertiary syphilis

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Differential Diagnosis of pseudomembranous tonsillitis

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Infectious Mononucleosis

• Cheesy exudatescovering tonsil

• Lymphadenopathy of 

neck, axilla & groin

• Hepato/Spleenomegaly

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Oral Thrush

• Painful throat

• White candidiasis

patches whenremoved leaveserythematous ulcer

• Immunosuppressive

state

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Keratosis tonsils

• Incidental finding

• May cause slightdiscomfort

•  Yellow hornyoutgrowths in the

crypts

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 Agranulocytosis

• Halistosis, fever,headache & dysphagia

• Single , multiple orcoalesce necroticslough covered

ulcers• Leucopenia

• H/O causative drugsintake

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Diphtheria

• Malaise, fever & headache

• Greyish greenmembrane acrosstonsils to larynx

• Tender bilateral

cervicallymphadenopathy

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 Vincent‟s angina • Fetor oris, pyrexia

• Tonsillar deep ulcers withgrey slough in its base

• Necrotising gingivitis• Enlarged tender cervical

adenitis

• Smear:

Spirochaetes & Fusiformbacilli

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 Acute lymphatic leukemia

• Fever, anaemia & bleeding disorders

• Slough covered

membrane formingulcerations

• Cervicallymphadenopathy

• Exaggeratedleucocytosis

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FAUCIAL DIPHTHERIA

fi i i

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Definition

• Diphtheria is an acute, toxin-mediateddisease caused by toxigenicCorynebacterium diphtheriae ( 白喉棒状杆菌

 ).

• It’s a very contagious and potentially life-threatening bacterial disease.

Corynebacterium 

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ydiphtheriae 

• • Causative organism of diphtheria

• • Gram- positive bacillus

• • Produces exotoxin at site of infection

• Travels to heart and nervous

system

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• • Spread by close contact viadroplets or

• contaminated articles

• • Humans are the sole carriers of the organism

• • More common in children < 10

years• • Rare occurrence today because of 

routine vaccination

C di hth i

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C. diphtheria 

• • Clinical manifestations 

• – Systemic symptoms fromexotoxin

• • Fatigued 

• • Lethargic 

• • Tachycardic • • toxic 

C diphtheria

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C. diphtheria 

• • Clinical characteristics • – Pharynx

• • grayish membrane (composed of fibrin,

• leukocytes, and cellular debris)

• • extends from pharynx to larynx • – Extensive cervicallymphadenopathy („bull neck‟) 

Ph l di hth i

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Pharyngeal diphtheria 

Ph l di hth i

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Pharyngeal diphtheria 

L l di hth i

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Laryngeal diphtheria 

C diphtheria

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C. diphtheria 

• Diagnosis• – Isolation of the organism

• • Culture from local lesion • • Grows on selective mediacontaining potassium tellurite

• • Notify microbiology lab if diphtheriasuspected

C diphtheria

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C. diphtheria 

• • Treatment • – Started before culture

confirmation

• – Airway

• – Resuscitation

• – Skin test for allergy to horseserum

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• –  Administer diphtheria antitoxin

• – Have epinephrine available

• – Antibiotics (erythromycin,penicillin G, rifampin, orclindamycin) used to eradicate

carrier state

C. Diphtheria 

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p

• • 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.

Complications

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Complications:

• Myocarditis.

• Cardiac arrhythmias.

• Acute circulatory failure.• Paralysis of soft palate,diaphragm & ocular

muscles.

• Laryngeal-airway obstruction.

 Ac tonsillitis Faucialdiphtheria

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diphtheria

Onset Acute Insidious

Membrane Yellowish,easily

separable

 Ashy gray ,bleeds onseparation

Fever High Low

Pulse Proportionate Disproportionate

Toxaemia +/- + +

Throat swab Heam.strepto CBD / KLB

Urine:

 Albuminuria

+/- + +

Recurrent Acute Tonsillitis

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Recurrent Acute Tonsillitis

• Seven episodes in a single year

• Five or more episodes in 2 years

• Three or more episodes in 3 years

Chronic Tonsillitis

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Chronic Tonsillitis

• No true consensus on the definition.

• Symptoms greater than 4 weeks

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CHRONIC TOSILLITIS

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SYMPTOMS

• RECURRENT PAINHALITOSIS

• COUGH

• SNORING

• SLEEP APNOEA

•  ASYMPTOMATIC

• SEPTIC FOCUS

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CHRONIC TONSILLITIS-SIGNS

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CHRONIC TONSILLITIS SIGNS

• LARGE TONSILS

• SMALL FIBROTIC IN ADULTS

•  ANTERIOR PILLAR CONGESTED

• SQUEEZE – IRWINMOORE‟S SIGN 

• LYMPHADENOPATH Y 

JUGULODIGASTRIC LYMPH

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NODES

ADENOIDS

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 ADENOIDS

• Normally regress by 10 yrs

• Etiology:

 – Age ; 3-4 years

 –Physiological hypertrophy

 –Infection

 –Rarely tuberculosis

• Predisposing factors

 Adenoiditis : Clinical features

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• 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

Adenoid Hypertrophy

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 Adenoid Hypertrophy

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• Palate – High arched.

• Feeding difficulties.

• Face - Loss of nasolabial furrow,dulllook.

• Chest – Pigeon shaped.

• Pot belly.

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• NASAL DISCHARGE.

• SINUSITIS.

• EPISTAXIS.

• VOICE CHANGE.

Adenoid Hyperplasia

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 Adenoid Hyperplasia

• Triad

 – Hyponasality

 – Snoring – Open mouth breathing

• Purulent rhinorrhea, post nasal drip,chronic cough, and headache

Adenoiditis : Clinical features(contd)

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Adenoiditis : Clinical features(contd)

• Associated with E-T obstruction:

•ET cattarh,SOM,AOM,CSOM

• Associated with infection :•Rhinitis,Sinusitis,URTI,

Tonsillopharyngitis.•Lymphadenitis

•General :

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•General :

•Nocturnal enuresis

•Deafness leads to mentalretardation

 Adenoiditis :Diagnosis &Diff diagnosis

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diagnosis

• Diagnosis : –Clinical features: clinch diagnosis

 – Posterior rhinoscopy:

 – Digital palpation :--bag of worms – X-ray nasopharynx soft tissue lateral

view

 – Nasal endoscopy ,Nasopharyngoscopy

PreOp Evaluation of Ad id Di

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 Adenoid Disease 

Lateral neck films areuseful only whenhistory and physical

exam are not inagreement.

 Accuracy of lateralneck films isdependent onproper positioning

and patient 

cooperation

Adenoiditis : Treatment

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 Adenoiditis : Treatment

• Conservative : in acute & mild cases

 – Antibiotics,Decongestants,Breathing exercises

• Surgical : – Adeoidectomy-for persistent & rec. infection

 – Precautions:

 – Grommet insertion : in case of SOM

TONSILLECTOMY 

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Chronic Tonsillitis

Sleep apnoea

Quinsy

Tonsillolith

Foreign body

Benign tumor 

Diphtheria carrier 

 Approach for Styloid

 Approach for IX

LOCAL

JD lymphadenopathy Middle ear disease

FOCAL

RHD SBE

Glomerulonephritis

RF RA

GENERAL

INDICATIONS

CONTRAINDICATIONS

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CONTRAINDICATIONS

• AGE < 5 yrs

• Hb < 10

• BLEEDING DISORDERS / BT CT• EPIDEMIC OF POLIO

• HT

• DM

Preoperative evaluation

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Preoperative evaluation

• Most common lab test is a CBC

• Coagulation studies when the history or

physical examination suggests a bleedingdisorder.

• Lateral Neck/Adenoid films

METHODS

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O S

• DISSECTION• GUILLOTINE

• ELECTROCAUTERY 

• CRYOSURGERY • LASER 

• HARMONIC SCALPEL

•COBLATION

• MICRODEBRIDER 

ROSE‟S POSITION

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ROSE S POSITION 

INSTRUMENTS

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INSTRUMENTS

TONSILLAR DISSECTOR 

EVE’S TONSILLAR SNARE 

DISSECTION METHOD

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DISSECTION METHOD

Adjuvant Therapies

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 Adjuvant Therapies

• Perioperative Steroids

 – Dexamethasone (0.15-1.0mg/kg)

 – Two times less likely to have an episode of postoperative emesis, and more likely toadvance to eating a soft diet.

 – Reducing postoperative pulmonary distress,

subglottic edema, pain reduction.

POST OP CARE

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• POSITION

• PULSE BP

• W/F BLEEDING

• DIET COLD FEEDS

•  ANTIBIOTICS

•  ANALGESICS

• GARGLES

COMPLICATIONS

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COMPLICATIONS

• HAEMORRHAGE

• PRIMARY 

• REACTIONARY 48 hrs

• SECONDARY 5-8 days

• Trauma

• TM joint

•  ASPIRATION

•  VOICE CHANGE

Unilateral TonsillarE l t

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Enlargement

 Apparent enlargement vs true enlargement

Non-neoplastic:

•  Acute infective

• Chronic infective

• Hypertrophy

• Congenital

Neoplastic

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Peritonsillar Abscess 

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RetentionCysts 

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Pleomorphic Adenoma 

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• Ca tonsil

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ICA Aneurysm 

Peritonsillar abscess

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•  Abscess formation outside tonsillar capsule

• Signs and symptoms: – Fever

 – Sore throat

 – Dysphagia/odynophagia

 – Drooling

 – Trismus

 – Unilateral swelling of soft palate/pharynx with uvuladeviation

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The End