1)acute pharyngitis

1. Acute pharyngitis
Definition :acute pharyngitis is defined by its predominant symptom, i.e. acute onset sore throat &
has a primarly infectious aetiology. The term is frequently used synonymously with acute tonsillitis;
however, in reality, there is a spectrum of conditions, from acute inflammation localised primarily to
the tonsils, often although not exclusively of bacterial origin, to acute pharyngitis implying
generalized inflammation of the whole pharynx.
Epidemiology
Sore throat affects both sexes & all age groups, but is much more common in children in late autumn
& early winter. The rate is higher for females in all age bands.
Aetiology
The causes of pharyngitis include 1)viruses, isolated in approximately 40-60% of cases.
2) Primary bacterial pathogen approximately 5-30%
3) No pathogen approximately 30%
A)Group A beta-haemolytic streptococcus are the commonest cause of bacterial pharyngitis.and
spread via respiratory secrection through close contact. Incubation period one to five days.
The risk of contagion most probably depends on innoculum size & virulence of the infecting strain.
More than 120 M-protein types GABHS have been isolated with serotypes 1,3,5,6,18,19, 24
associated with rheumatic fever. Others sero types 49,55 & 57 associated with acute post-
streptococcoal glomerulonephritis. Others bacteria includes:
1)Haemophphilus influenza & neisseria gonorrhoea are uncommon.
2)Corynebacterium diphtheria, Moraxella catarrhalis (Branhamella), group C & G
streptococcus are rare.
3)Corynbacterium haemolyticum extremely rare.
4)Chlamydia trachomatis & Mycoplasma pneumoniae are less common.
5) Borrelia species, Francisella tularensis & yersinia species are unusual bacteria.
6) Others possible co-pathogens for pharyngitis in children include staphylococcus aureus,
H.influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis,
Bacteroides melaninogencus, Fusibacterium species & Peptostreptococcus species.
B)Viral causes of acute pharyngitis in order of frequency include:

2. Rhinovirus , adenovirus 5%, parainfluenza virus, Coxsacievirus<5%, coronavirus, echovirus,
herpes simplex virus<5%, Epistein-Barr virus, cytomegalovirus(CMV) & human immunodeficiency
virus.
C)Others causes of pharyngitis are
Oral thrush due to candidal species
Non-infectious cause include dry air, allergy/post-nasal drip, chemical injury, GERD,
neoplasm & endotracheal, intubation smoke inhalation, indoor heating sources & excessive air
conditioning.
Pathophysiology
1)In infectious pharyngitis: bacteria or viruses may directly invade the pharyngeal mucosa, causing a
local inflammatory response.
2)Others viruses such as rhinovirus cause irritation of pharyngeal mucosa secondary to nasal
secrection.
3) Streptococcal infections causes local invasion & release of extracellur toxins &
protease>inflammation. In addition M-protein are similar to myocardial sarcolemma antigen>
rheumatic fever& subsequent heart valve damage. Acute glomerulonephritis may result from
antibody-antigen complex deposition in glomeruli.
Clinical features
The classical history of sore throat , fever, chills, malaise, headaches, anorexia, abdominal pains as
well as history of exposure to known carriers is not always present.
GABHS features are suggestive : enlarged tonsils, pharyngeal erythema, tonsillar crypts containing
necrotic or purulent exudates, soft palate petechiae, cervical lymphadenopathy,fever, scarlet fever
rash(punctuate erythematous macules with reddened flexor creases & circumoral pallor), the so-
called sandpaper rash.
Specific viral infections have characteristic rash:
Viral pharynhitis associated with rhinitis(sneezing & rhinorrhoea) & cough .
Conjunctivitis more common in adenovirus infections.
Infectious mononucleosis is typically exudative with extensive false membrane;
Herpangina (usually Coxsackievirus A or herpes virus) is associated with papulovesicular lesion.
Comcomitant vesicles on the hands & feet are associated with Coxsackievirus (hand,foot& mouth
disease).
Tonsillopharyngeal /palatal petechiae are seen in GABHS & infectious mononucleosis.
Exudates does not differentiate viral & bacterial causes.

3. Tender anterior cervical lymphadenopathy is consistent with streptococcal infection while
generalised adenopathy is consistent with infectious mononucleosis or acute lymphoglandular
syndrome of HIV infection.
Murmur should be documented in an acute episode of pharyngitis to monitor for potential
rheumatic fever.
Pharyngitis together with lower respiratory tract infection are more consistent with M.pneumoniae
or C. Pneumonia particularly when a persistent non-productive cough is present.
Investigations
Throat culture is the gold standard diagnostic test for GABHS. A positive throat culture for GABHS
makes the diagnosis but negative does not rule out such diagnosis. There is evidence that
asymptomatic carrier of upto 40% positive for GABHS. The flora of surface of the tonsil correlates
poorly with that deep in tonsil crypts which is most likely cause of infection. Throat swab should not
routinely be carried out in sore throat.
Rapid antigen testing is commonly used in USA to identify GABHS. The sensitivity of rapid antigen
testing measured against throat swab culture is broad & varies 61% & 95%. Rapid antigen testing
should not routinely be carried out in sore throat. Rapid antigen testing is not positive for group C&
G streptococci or others pathogens.
Leucocytosis is highly suggestive of bacterial infection. A peripheral smear may show atypical
lymphocytes in infectious mononucleosis. (Monospot test 95% sensitive in children & 60% in infant).
Thayer martin plate for screening for gonococcoal infection.
Treatment
Paracetamole is the drug of choice for analgesia in sore throat, taking account of the increased risks
associated with other analgesics.
A single dose of oral dexamethasone .6mg/kg with moderate to severe sore throat resulted in
significant earlier onset of pain relief & shorter duration of sore throat. A similar 60mg oral
prednisolone for one or two days resulted in significant more rapid resolution of throat pain.
Antibiotic
In sore throat: oral penicllinV 500mg/ 6 hourly for 10 days is widely regarded as gold-standard
treatment. Others more expensive antibiotic mainly cephalosporin, clinical advantage is much less
clear.
Nonstrptococcal sore throat , erythromycin & metronidazole may provide symptomatic relieve. Or
cepahalosporin may improve ofsymptoms.
In an attempt to reduce prescribing antibiotics, delayed prescription, i.e. more than 48hours after
the onset of symptoms has been recommended. Delayed antibiotic group has much less diarrhoea.
Doctors need to be aware that infectious mononucleosis may present with severe sore throat with
exudates & anterior cervical lymphadenopathy. Therefore should avoid prescription of ampicillin-
based antibiotics including co-amoxiclav, as first-line treatment.

4. In recurrent sore throat:
When sore throat recurs in patients who have received antibiotic, reason may include
1)inappropriate antibiotic therapy, 2)inadequate dose or duration 3) patients noncompliance 4)
reinfection 5) local breakdown of pencillin by beta-lactamase producing commonsals. Benzathine
penicillin cefuroxime & clindamycin have been shown to be superior to penicillin V.
There is no evidence to support a recommendation of the use of antiobiotic in recurrent non-
streptococcal sore throat.
To prevent rheumatic fever & AGN
Oral penicillin V or Benzathine penicllin.
To prevent suppurative complications:
No evidence that routine use of antibiotic with sore throats will reduce the occurance of
suppurative complications such as quinsy. But reduce incidence of acute otitis media about 1/4
th
&
acute sinusitis about ½.
To relieve symtoms: although antibiotic therapy has been shown to alleviate symptoms even in
sore throat not caused by bacteria, the superiority of antibiotic over simple analgesics is marginal in
reducing duration or severity.
To prevent cross infection: antibiotic may prevent cross infection with GABHS in closed institutions
(barracks, boarding school). When GABHS has been identified in children, a full 24huor of antibiotic
should be given before return to school or day care.
Attempting to eradicate GABHS with routine antibiotic therapy for sore will produce an emergence
of antibiotic-resistance strains of others organisms although GABHS remain sensitive to penicillin
despite its widespread use.
The carrier state
Patients exposed to GABHS may continue to carry the organism asymptomatically even after
adequqte antibiotic therpy. Carrier are recognized as those who demonstrate a positive culture but
no rise in antistreptolysin O convalescent titre. Carrier are little risk of transmitting the disease.
Special concerns
While prevention of rheumatic fever remains the primary reason for treating GABHS in USA, finding
suggest that outbreaks may , in fact, be more related to the rheumatogenic quality of the GABHS
rather than antibiotic are given.
Best clinical practice
1.Investigation are of limited value in the management of acute sore throat. More specifically, throat
do not give representative data about infectious agents deep in the tonsillar crypts & rapid antigen
testing rarely alter prescerbing decision.
2.In streptococcal tonsillitis , use of antibiotic is discretionary rather than prohibited or mandatory.

5. This is because the benefit in terms of symptoms is only 16 hours compared with placebo.
3. In severe cases, where GP is concern about clinical condition of the patient,antibiotic should not
be withheld.
4. In cases of recurrent sore throat associated with GABHS that a ten-days course of antibiotic may
reduce the number & frequency of attack.
5.There is no support in the literature for the routine treatment of sore throat with penicillin to
prevent the development of rheumatic fever.
6.There is no evidence that the routine use of antibiotic with sore throats will reduce the occurance
of suppurative complications.
7. Antibiotic should not be used to secure symptomatic relief in sore throat.
Tonsillectomy
Indications of tonsillectomy
1.Recurrent acute tonsillitis
2.Following resolution of a second PTA.( first PTA can be managed by either needle aspiration/
incision & drainage /abscess tonsillectomy. Inadequately drain quinsy, chance of recurrence
is high. So tonsillectomy is curative).
3.Tonsillectomy can be indicated for biopsy purposes.
Asymmetrical adult tonsil with normal mucosa in the absence of cervical
adenopathy has an 7% risk of malignancy(lymphoma).
Asymmetrical adult tonsil with mucosal abnormality and or cervical
adenopathy has a very risk of malignancy. FNAC may be helpful.
As a oncological procedure for ca tonsil. Radical tonsillectomy for T1 or as a
composite resection for advanced tonsil cancer.
4.For obstructive sleep apnoea in children in conjunction with adenoidectomy is a well
recognized indication.
5. In adult with gross tonsil hypertrophy or OSA or as a part of uvulopalatopharygnplasty or
laser-assisted uvulopalatoplasty.
6, Severe haemorrhagic tonsillitis
7. Severe infectious mononucleosis with upper repiratory tract obstruction.
8. Large symptomatic tonsillar tonsoliths.(tonsillar concretions).
9. As a long term management of IgA nephopathy.

6. New variant Creutzfeld-Jakob disease & tonsillectomy
vCJD is the human form of Bovine spongiform encephalopathy.vCJD prion is knowm to concentrate
in human lymphoid tissue & difficult to remove from surgical instruments even sterilization.
So use disposable single-use instrument for tonsillectomy.
Tonsillectomy techniques
Dissection techniques includes:
1.Cold dissection techniques sharp/blunt±snares and haemostasis with ties or diathermy
mono or bipolar;
2.diathermy or electrocautery dissection which uses an electrically heated instrument to cut
or coagulate tissues;
-monopolar
-bipolar forceps tonsillectomy
-bipolar scissor tonsillectomy;
3. radiofrequency/ electrosurgery tonsillectomy in which the instrument itself does not
become hot but rather produces a current flow that generates heat within the tissue;
-Somnoplasty tonsillectomy: bipolar thermal radiofrequency ablation;
-coblation (plasma-mediated ablation) tonsillectomy.
-argon plasma coagulator tonsillectomy
4.harmonic scalpel (ultrasound) tonsillectomy;
5.laser dissection tonsillectomy; CO2 laser, potassium titanyl phosphate(KTP)& Nd-YAG laser
tonsillectomy.
Non-dissection techniques include:
-guillotine tonsillectomy
-intracapsular partial tonsillectomy
Post-operative care
1.oral paracetamol 20mg/kg & diclofenac 1mg/kg except in asthma two hours preoperatively as well
as the uniform post-operative prescription of upto 100mg/kg of paracetamole & 3mg/kg of
diclofenac in 24 hours as rescue analgesic.
Rescue analgesic: paracetamol plus ketoprofen plus codine for adult.
The median time for cessation of pain is 11(3-24), the median time for cessation of pain on drinking
is seven days (1-18)& on eating solid 11 (1-20)days.

7. First normal sleep at seven (0-18)days & normal daily activities 12 (2-24). Cryotherapy patients
required less analgesic, less pain, less time off work.
2.antiemetic therapy: single-dose antiemetic therapy using ondansetron.
3. diet post-tonsillectomy;there is no evidence to suggest that particular post-operative diets have
any impact on rate of recovery or complication rates.
4.adjunct therapy: local anesthesia, antibiotics & steroids.
-Peri-operative injection of local anaesthesia has been advocated for pain reduction,
diminished peri-operative bleeding & facilitation of dissection.
-post-operative antibiotic, recent study suggest a range of benefits including lower pain
score, less pain & shorter time to a normal diet.
-A single intra-operative dose of dexamethasone in paediatric tonsillectomy suggests a
significant reduction in post-tonsillectomy.
-A recent study suggest intravenous hydration for 24hours reduced post-operative pain in
the late post-operative period following paediatric adenotonsillectomy.
Post-tonsillectomy complications
Immediate
1.Reactionary haemorrhage(bleeding preoperatively & within the first 24 hours) is the most feared
complication post-tonsillectomy because of the risk of airway obstruction, shock & ultimately death
if inappropriately treated or untreated. Majority occur within four hours. Secodary haemorrhage
often greater than 500ml. Reactionary haemorrhage main occur in male, history of Infections with
Infectious mononucleosis & recurrent acute tonsillitis.
None of the techniques seem to be significantly more prone to reactionary haemorrhage
than others.
The incidence of haemorrhage is not related to grade & seniority of the surgeon.
Use of diclofenac increasing the rate of reactionary haemorrhage have not been rule out.
Many units use it routinely.
2. Airway obstruction secondary to reactionary haemorrhage with blood entering airway,
laryngospasm, dislodge teeth or forgotten swabs.
3.Nausea & vomiting relating to anaesthesia, opiate analgesia or swallowed blood.
4. Excessive pain due to greater than expected tissue trauma related to insertion of Boyle Davis
mouth gag. Uvula or pillar trauma during dissection.
5. Airway fires due to the use of diathermy in the presence of high oxygen concentrations & burning
of swab.

8. 6. Subcutaneous emphysema;
7.Temporomandibular joint dislocation or dysfunction.
8. Dental injuries
9. Post-operative fever(first 24 hours): Post-operative fever is a common problem after
tonsillectomy,fever is not caused by infection & therefore does not routinely require antibiotics.
10.Hypoglucaemia
11. Hypovolaemia
12.hyponatraemia.
Intermediate
1.Secondary haemorrhage: The incidence of secondary haemorrhage increases with age(peaking
between 30-34) in both sexes. Most present between days 4&7.
2.Oedema of uvula
3. Excessive pain often associated with otalgia.
3.Infection in tonsillar fossae promoting secondary haemorrhage;
4. Atlantoaxial subluxation(Grisel’s syndrome);
5.Peritonsillar abscess;
6.Pneumonia extremely rare;
7.Subcutaneous bacterial endocarditis related to bacteraemia in patients with abnormal heart
valves.
8.Pulmonary embolus;
9. Pulmonary oedema;
10.Subcutaneous emphysema & pneumomediastinum.
Late
1.Post-operative scarring 2.Tonsil remnants,3. Pharyngeaal stenosis. 4. Nasopharygeal
regurgitation/velopharyngeal insufficiency due to excess removal of anterior pillars. 5. Taste
distortion after tonsillectomy may be either permanent due to insult to the lingual branch of
the glossopharyngeal nerve or temporary due to pressure on the tongue & zinc deficiency.
Temporary cases reported resolved within 6weeks.7. Glossopharyngeal nerve paralysis.