Adenotonsillitis.pptx

Adeno tonsillitis

1. Adenotonsillitis

2. ANATOMY Palatine tonsils are two in number. Ovoid mass of lymphoid tissue situated in the lateral wall of oropharynx between the anterior and posterior pillars. They form lateral part of the Waldeyer's ring .while the adenoid form its superior part. Actual size of the tonsil is bigger than the one that appears

3. Waldeyer's ring

4. It has 2 surfaces: medial and lateral A- medial surface:- covered by nonkeratinising stratified squamous epithelium which dips into the substance of tonsil in the form of crypts. 12-15 crypts can be seen on the medial surface of the tonsil.( crypta magna) B-Lateral surface: This present well a defined fibrous capsule

5. Lateral to the capsule lies the superior constrictor muscle. Between the capsule and the SCM is the peritonsillar space that is filled by loose areolar tissue and is connected with the paraphayngeal space. The tonsil has 2 poles

6. Blood supply: Mainly from the tonsillar artery from the facial artery. Veins: paratonsillar vein ----facial vein Nerve supply: glossopharyngeal nerve.

7. Functions of Tonsils Like other lymphoid masses of Waldeyer's ring, palatine tonsils have a protective role. The crypts in tonsils increase the surface area for contact with foreign substances. Ags processing…..specialized B-lymphocyte that produce specialized IgA and IgG against that Ags . Tonsils are larger in childhood and gradually diminish near puberty.

8. Adenoids Similar to tonsils but have no crypts. Lies at the roof of the nasopharynx .

9. Introduction Annually, 35 million days are lost from school or work due to sore throats in the UK. GP consultations for sore throat cost around £60 million annually. In the 1950s over 200,000 tonsillectmoies were performed in any given year in UK Then surgeons set about refining the indications for carrying out this potentially risky operation.

10. Classification A- Acute catarrhal or superficial tonsillitis. Here tonsillitis is a part of generalized pharyngitis and is mostly seen in viral infections . B- Acute follicular tonsillitis. Infection spreads into the crypts which become filled with purulent material, presenting at the openings of crypts as yellowish spots. C- Acute parenchymatous tonsillitis. Here tonsil substance is affected. Tonsil is uniformly enlarged and red.

11. D- Acute membranous tonsillitis. It is a stage ahead of acute follicular tonsillitis when exudation from the crypts coalesces t o form a membrane on the surface of tonsil.

12. Epidemiology Affect mainly the school going children. It might affect adult but it is very rare above ages of 50s.

13. Microbiology and Immunology Bacteria Aerobic      Group A beta-hemolytic streptococci (GABHS)       Haemophilus influenza (type b and nontypeable )       Streptococcus pneumoniae       Moraxella catarrhalis  Anaerobic       Bacteroides sp.       Peptococcus sp.       Peptostreptococcus sp.       Actinomycosis sp

14. Viruses    Epstein-Barr    Adenovirus    Influenza A and B    Herpes simplex    Respiratory syncytial     Parainfluenza

15. Pathogenesis of Adenotonsillar Disease anatomic location inherent function as organs of immunity processing infectious material and other antigens focus of infection/inflammation

16. Viral infection with secondary bacterial invasion may be one mechanism but the effects of : environment host factors the widespread use of antibiotics ecologic considerations diet may all play a role.

17. Clinical Classification Adenoids      Acute adenoiditis ( nasopharyngitis ) aka common cold      Recurrent acute adenoiditis      Chronic (persistent) adenoiditis   Tonsils      Acute tonsillitis       Recurrent acute tonsillitis       Chronic (persistent) tonsillitis

18. Acute tonsillitis

19. Symptoms Sore throat Odynophagia Fever Earache . Offensive mouth odour . Constitutional symptoms. They are usually more marked than seen in simple pharyngitis and may include headache, general body aches , malaise and constipation . There may be abdominal pain due to mesenteric lymphadenitis simulating a clinical picture of acute appendicitis .

20. Signs Often the breath is foetid and tongue is coated. There is hyperemia of pillars, soft palate and uvula . Tonsils are red and swollen: The jugulodigastric lymph nodes are enlarged and tender.

21. D.D of membranous tonsilitis Membranous tonsillitis: exudative membrane forms over the medial surface of the tonsils, along with the features of acute tonsillitis. Diphtheria: = diphtheria is slower in onset with less local discomfort =the membrane in diphtheria extends beyond the tonsils. =It is adherent and its removal leaves a bleeding surface.

22. = culture of throat swab will reveal Corynebacterium diphtheriae Vincent's angina: = insidious in onset with less fever and less discomfort in throat. =the Membrane which usually forms over one tonsil, can be easily removed revealing an irregular ulcer on the tonsil. = Throat swab will show both the organisms typical of disease, namely fusiform bacilli and spirochaetes .

23. Infectious mononucleosis: =This often affects young adults. =Both tonsils are very much enlarged , congeted and covered with membrane . =Local discomfort is marked. =Lymph nodes are enlarged in the posterior triangle of neck along with splenomegally . = blood smears 50% lymphocyte 10% are atypical = paul bunnell : high titer of hetrophilic Abs.

24. Agranulocytosis . Aphthous ulcers.

25. ttt 1. Patient is put to bed and encouraged to take plenty of fluids . 2. Analgesics (aspirin or paracetamol ) are given according to the age of the patient to relieve local pain and bring down the fever. 3. Antimicrobial therapy.

26. Complications of acute tonsillitis systemic sepsis: A- septicaemia and septic arthritis. B-scarlet fever noninfective sequelae : A-rheumatic fever. B- glomerulonephritis . PERITONSILLAR ABSCESS RETROPHARYNGEAL ABSCESS PARAPHARYNGEAL ABSCESS LEMIERRE'S SYNDROME

27. Recurrent Acute Tonsillitis defined as: Six to seven episodes of acute tonsillitis in 1 year Five episodes for 2 consecutive years Three episodes per year for 3 consecutive years.

28. Chronic tonsillitis

29. Chronic (Persistent) Tonsillitis Chronic sore throat malodorous breath excessive tonsillar debris ( tonsilloliths ) peritonsillar erythema persistent, tender cervical adenopathy are consistent with a diagnosis of chronic tonsillitis

30. Indications for Tonsillectomy 6 or more episodes/year Hypertrophy causing malocclusion, UAO PTA unresponsive to nonsurgical mgmt Halitosis, not responsive to medical therapy UTE, suspicious for malignancy Individual considerations 10/4/2013 [email protected] 37

31. Contraindications for Tonsillectomy Definite : Bleeding disorder Uncontrolled systemic diseases Relative : Recent acute infection Poliomyelitis epidemics Children ages less than 3 yrs Anaemia Submucous cleft palate Drugs : aspirin, oral contraceptive .

32. Acute Adenoiditis Rhinorrhea (sometimes purulent) nasal obstruction fever often otitis media may be seen. difficult to differentiate from a generalized viral-induced URI or a true bacterial rhinosinusitis . loud snoring lingering course and appear sicker

33. Recurrent Acute Adenoiditis presence of four or greater discrete episodes of acute adenoiditis during a 6-month period.

34. Chronic Adenoiditis Persistent nasal discharge malodorous breath postnasal drip chronic congestion differentiation from chronic sinusitis clinically challenging but association of otitis media may be more indicative of chronic adenoiditis.

35. Obstructive Adenoid Hyperplasia The triad of symptoms: chronic nasal obstruction (associated with snoring and obligate mouth breathing) rhinorrhea hyponasal voice, are most consistent with nasopharyngeal obstruction by enlarged adenoids.

36. Symptoms of OSA in Children . Snoring . Hyperactivity . Developmental delay . Poor concentration . Bed wetting . Nightmares . Night terrors

37. Headaches Restless sleeps Obesity Large tonsils Noisy breathers Chronic runny noses Frequent upper airway infections / earaches

38. Clinical Evaluation Adenoids - Assessment of the external nose - Assessment of the nasal airway - Anterior rhinoscopy - Nasendoscopy : A grading system has been proposed to assist in the decision to recommend surgery . - Lateral neck films.

39. Management Adenoid : Recurrent or chronic adenoiditis due to infection should be treated initially with an antimicrobial. Adenoid hyperplasia also may respond to a 6- to 8-week course of intranasal steroids. Surgery .

40. Indications for Adenoidectomy Obstruction: Chronic nasal obstruction or obligate mouth breathing OSA with FTT, cor pulmonale Dysphagia Speech problems Severe orofacial/dental abnormalities Infection: Recurrent/chronic adenoiditis (3 or more episodes/year) Recurrent/chronic OME (+/- previous BMT) 10/4/2013 [email protected] 55