Chronic tonsillitis

A female patient of age 9 yrs was admitted in VBGH at ENT male ward with chief complaints of :
Difficulty in swallowing
Pain during swallowing since few days and is diagnosed as Chronic tonsillitis

1. PRESENTED BY Dr. P.Asma Afreen case presentation on chronic tonsillitis

2. Name:-BHAVYA SREE Age:- 9 years Sex:-Female Ward:- P aediatric PATIENT DETAILS

3. CHIEF COMPLAINTS Difficulty in swallowing Pain during swallowing since few days PRESENT HISTORY Difficulty in swallowing insidious & progressive when taking both solid & liquid food Not relieved by taking medication PAST HISTORY Difficulty in swallowing insidious & progressive when taking both solid & liquid food

4. ON EXAMINATION CVS S1 S2 Present R.S Clear RR 24 Bpm PR 86 Bpm BP 120/80 mm Hg

5. CBP RESULTS REFERENCE RANGE HB 13.9 gm/dl 13.0-18.0 gm/dl TC(WBC) 7900 cells/cumm 4000-11000 cells/cumm Neutrophils 50 % 40 -70 % Lymphocytes 45 % 20-45 % Eosinophils 03 % 0-6 % Monocytes 02 % 2-10 % Platelets 2.0 lakhs /cumm 1.5-4.0 lakhs /cumm LABORATORY INVESTIGATIONS

6. SAMPLE:BLOOD RESULTS REFERENCE RANGE Bleeding time 2:15 min/sec 1 – 5 min Clotting time 6:00 min/sec 5 -10 min PARAMETERS RESULTS REFERENCE RANGE Serum creatinine 0.8 mg/dl 0.6-1.5 mg/dl RBS 88 mg/dl 80-130 mg/dl Blood urea 22 mg/dl 10-50 mg/dl

7. CHRONIC TONSILLITIS DIAGNOSIS

8. SUBJECTIVE A female patient of age 9 yrs was admitted in VBGH at ENT male ward with chief complaints of : Difficulty in swallowing Pain during swallowing since few days SOAP NOTES

9. OBJECTIVE Difficulty in swallowing insidious & progressive when taking both solid & liquid food Not relieved by taking medication ASSESSMENT Based on the subjective and objective data the physician diagnosed that the patient is suffering with CHRONIC TONSILLITIS

10. Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils. Therefore, the term pharyngitis may also be used. Lingual tonsillitis refers to isolated inflammation of the lymphoid tissue at the tongue base. A "carrier state" is defined by a positive pharyngeal culture of group A beta hemolytic Streptococcus pyogenes (GABHS),without evidence of an antistreptococcal immunologic response. DEFINITION

11. Tonsillitis is most often caused by common viruses, but bacterial infections can also be the cause. The most common bacterium causing tonsillitis is Streptococcus pyogenes (group A streptococcus), the bacterium that causes strep throat. Other strains of strep and other bacteria also may cause tonsillitis. Why do tonsils get infected? The tonsils are the immune system's first line of defense against bacteria and viruses that enter your mouth. This function may make the tonsils particularly vulnerable to infection and inflammation CAUSES

12. A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and beta-hemolytic streptococcal species, S aureus , H influenzae , and  Bacteroides  species having been identified. A study that was based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy suggested that antibiotics prescribed 6 months before surgery did not alter the tonsillar bacteriology at the time of tonsillectomy.  [4]  A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. PATHOPHYSIOLOGY

13. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes. H influenzae  is the bacterium most often isolated in hypertrophic tonsils and adenoids. With regard to penicillin resistance or beta- lactamase production, the microbiology of tonsils removed from patients with recurrent GABHS pharyngitis has not been shown to be significantly different from the microbiology oftonsilsremovedfrom patients with tonsillar hypertrophy.

14. Local immunologic mechanisms are important in chronic tonsillitis. The distribution of dendritic cells and antigen-presenting cells is altered during disease, with fewer dendritic cells on the surface epithelium and more in the crypts and extrafollicular areas. Study of immunologic markers may permit differentiation between recurrent and chronic tonsillitis. Such markers in one study indicated that children more often experience recurrent tonsillitis, whereas adults requiring tonsillectomy more often experience chronic tonsillitis.  

15. Tonsillitis most commonly affects children between preschool ages and the mid-teenage years. Common signs and symptoms of tonsillitis include: Red, swollen tonsils White or yellow coating or patches on the tonsils Sore throat Difficult or painful swallowing Fever Enlarged, tender glands (lymph nodes) in the neck CLINICAL PRESENTATIONS

16. Enlarged, tender glands (lymph nodes) in the neck A scratchy, muffled or throaty voice Bad breath Stiff neck Headache Signs Drooling due to difficult or painful swallowing Refusal to eat Unusual fussiness

17. Young age.  Tonsillitis most often occurs in children, but rarely in those younger than age 2. Tonsillitis caused by bacteria is most common in children ages 5 to 15, while viral tonsillitis is more common in younger children. Frequent exposure to germs.  School-age children are in close contact with their peers and frequently exposed to viruses or bacteria that can cause tonsillitis. RISK FACTORS

18. Inflammation or swelling of the tonsils from frequent or ongoing (chronic) tonsillitis can cause complications such as: Difficulty breathing Disrupted breathing during sleep (obstructive sleep apnea) Infection that spreads deep into surrounding tissue ( tonsillar cellulitis ) Infection that results in a collection of pus behind a tonsil ( peritonsillar abscess) C omplications

19. Strep infection If tonsillitis caused by group A streptococcus or another strain of streptococcal bacteria isn't treated, or if antibiotic treatment is incomplete, your child has an increased risk of rare disorders such as: Rheumatic fever:-  An inflammatory disorder that affects the heart, joints and other tissues Poststreptococcal glomerulonephritis :- An inflammatory disorder of the kidneys that results in inadequate removal of waste and excess fluids from blood

20. Your child's doctor will start with a physical exam that will include: Using a lighted instrument to look at your child's throat and likely his or her ears and nose, which may also be sites of infection Checking for a rash known as scarlatina , which is associated with some cases of strep throat Gently feeling (palpating) your child's neck to check for swollen glands (lymph nodes) Listening to his or her breathing with a stethoscope Checking for enlargement of the spleen (for consideration of mononucleosis, which also inflames the tonsils) Complete blood cell count (CBC) Throat swab D iagnosis

21. Encourage rest  Encourage your child to get plenty of sleep. Provide adequate fluids  Give your child plenty of water to keep his or her throat moist and prevent dehydration. Provide comforting foods and beverage Warm liquids broth, caffeine-free tea or warm water with honey and cold treats like ice pops can soothe a sore throat. Prepare a saltwater gargle  If your child can gargle, a saltwater gargle of 1 teaspoon (5 milliliters) of table salt to 8 ounces (237 milliliters) of warm water can help soothe a sore throat. Have your child gargle the solution and then spit it out. T reatment

22. Humidify the air Use a cool-air humidifier to eliminate dry air that may further irritate a sore throat, or sit with your child for several minutes in a steamy bathroom. Offer lozenges  Children older than age 4 can suck on lozenges to relieve a sore throat. Avoid irritants  Keep your home free from cigarette smoke and cleaning products that can irritate the throat. Treat pain and fever  Talk to your doctor about using ibuprofen (Advil, Children's Motrin, others) or acetaminophen (Tylenol, others) to minimize throat pain and control a fever. Low fevers without pain do not require treatment.

23. Antibiotics If tonsillitis is caused by a bacterial infection, your doctor will prescribe a course of antibiotics. Penicillin taken by mouth for 10 days is the most common antibiotic treatment prescribed for tonsillitis caused by group A streptococcus. If your child is allergic to penicillin, your doctor will prescribe an alternative antibiotic. Your child must take the full course of antibiotics as prescribed even if the symptoms go away completely. Failure to take all of the medication as directed may result in the infection worsening or spreading to other parts of the body. Not completing the full course of antibiotics can, in particular, increase your child's risk of rheumatic fever and serious kidney inflammation.

24. Surgery to remove tonsils (tonsillectomy) may be used to treat frequently recurring tonsillitis, chronic tonsillitis or bacterial tonsillitis that doesn't respond to antibiotic treatment. Frequent tonsillitis is generally defined as: More than seven episodes in one year More than four to five episodes a year in each of the preceding two years More than three episodes a year in each of the preceding three years A tonsillectomy may also be performed if tonsillitis results in difficult-to-manage complications, such as: S urgery

25. Obstructive sleep apnea Breathing difficulty Swallowing difficulty, especially meats and other chunky foods An abscess that doesn't improve with antibiotic treatment Tonsillectomy is usually done as an outpatient procedure, unless your child is very young, has a complex medical condition or if complications arise during surgery. That means your child should be able to go home the day of the surgery. A complete recovery usually takes seven to 14 days.

26. TREATMENT S.NO DRUGS GENERIC NAME DOSE ROA FREQUENCY 1 2 3 1 Monocef-o Monocef 1gm IV BD 2 Dolo 650 Acetaminophen 500mg ORAL BD 3 Asthakind Asthakind 5ml ORAL, SYRUP TID

27. Standard treatment guidelines:

28. Points to Patients Practice good oral hygiene,including cleaning the bacteria off the back of your brush your teeth. Smoking Gargle salt water,which can prevent tonsil stone formation and eliminate the odor theycause Drink the recommended daily requirement of water and stay hydrated.