Tonsillitis

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1. TONSILLITIS

2. Tonsils- the Waldeyer’s Ring Annular arrangement of lymphoid tissue in the pharynx Circumscribes the nasopharyx and the oropharyx Constituents: (superior to inferior) a) nasopharygeal tonsils b) tubal tonsils c) palatine tonsil d) lingual tonsil

3. Anatomy of the palatine tonsils Also called “ faucial ” tonsil Two in number, lying in the tonsilar fossa in the lateral wall of the oropharynx Extends upwards into the soft palate Downward into the base of tongue Anteriorly into the palatoglossal arch Two pillars, two surfaces, two poles Anterior pillar- palatoglossal arch Posterior pillar – palatophargeal arch

4. ANTERIOR PILLAR POSTERIOR PILLAR

5. Medial surface of tonsil – nonkeratinized stratified squamous epithelium – which dips into the substance to form 12-15 crypts – openings on the surface The largest – crypta magna or intratonsillar cleft- ventral part of 2 nd pharyngeal pouch – seperates upper pole from the tonsillar body Lateral surface of tonsil – well defined fibrous capsule – seperates tonsil from its bed

6. Tonsillar bed : superior constrictor muscle styloglossus muscle glossopharyngeal nerve buccopharygeal fascia Between capsule and the tonsillar bed is a layer of loose areolar fat

7. Blood supply 5 arteries Facial artery Ascending pharyngeal artery – external carotid Dorsal lingual branches – lingual artery Descending palatine branch – maxillary artery TONSILLAR BRANCH Ascending palatine

8. Veins ---- paratonsillar vein----common facial vein----pharyngeal venous plexus Lymphatics ---no afferents--- efferents (pierce the superior constrictor)---upper deep cervical nodes especially the jugulodigastic ( tonsillar ) nodes located below the angle of mandible Nerve supply – lesser palatine branches of sphenopalatine ganglion and glossopharyngeal nerve provide sensory supply

9. tonsillitis Divided into two: ACUTE and CHRONIC

10. Acute Tonsillitis The tonsil consists of i ) surface epithelium which is continuous with the oropharyngeal lining ii) crypts- invaginations of the surface epithelium iii) lymphoid tissue

11. Acute cattarhal /superficial as part of general pharyngitis , usually in viral infections

12. Acute follicular infection spreads into the crypts – filled with purulent material – yellowish spots at the openings

13. Acute parenchymatous uniformly enlarged and erythematous with exudates, edema of uvula and soft palate

14. Acute membranous exudation from crypts coalesces to form a membrane on the surface exudation fro

15. Etiology Most commonly seen in school-going children Rare in infants and elderly Haemolytic streptococcus is most common Others: staph, pneumococci , H.influenzae Can be primary or secondary to a viral

16. Symptoms Sore throat Difficulty in swallowing Fever Earache Constitutional symptoms : headache, myalgia , malaise, constipation

17. Signs Breath is foetid , tongue coasted Hyperaemia of pillars, soft palate, uvula Tonsils appear red and enlarged (purulent, parachymatous , membranous – the membrane can be easily wiped away with a swab) Jugulodigastic nodes are enlarged and tender

18. treatment Bed rest and fluids Analgesics – aspirin or paracetamol according to age- to relieve local pain and bring down fever Antibiotics- for 7 to 10 days- penicillin is the drug of choice- if allergic, erthyromycin

19. complications Chronic tonsillitis : due to incomplete resolution of acute attacks; may persist in lymphoid follicles forming microabscesses Peritonsillar abscess Parapharygeal abscess Cervical abscess : suppuration of jugulodigastic lymph nodes Acute otitis media Rheumatic fever Acute glomerulonephritis Subacute bacterial endocarditis : mostly due to viridans , infection in people with valvular heart disease

20. Differential diagnosis Diphtheria Vincent angina Infectious mononucleosis Agranulocytosis Leukaemia Aphthous ulcers Malignancy of tonsil Candidal infection of tonsil Traumatic ulcer

21. etiology Complication of acute attacks : pathologically microabscess walled off by fibrous tissue is seen in the lymphoid follicles of the tonsils Subclinical infections of tonsils without an acute attack Chronic infections of sinuses or teeth can be predisposing Usually occurs in children and young adults, rarely in elderly

22. TYPES Chronic follicular tonsillitis: tonsillar crpypts with cheesy infected material – yellow spots Chronic parenchymatous tonsillitis : hyperplasia of the lymphoid tissue of tonsil, profound enlargement, obstructive symptoms Chronic fibroid tonsillitis: small but infected, history of repeated sore throats

23. Clinical Features Recurrent attacks of sore throat or acute tonsillitis Bad breath/ hallitosis due to puss in throat Chronic irritation in throat in cough Obstructive symptoms: thick speech, difficulty swallowing, choking spells and sleep apnoea

24. examination chronic parenchymatous type Chronic follicular type Small tonsils, pressure on anterior pillar expesses frank pus or cheesy material – chronic fibroid Flushing of anterior pillars compared to the rest of the pharyngeal mucosa Enlargement and tenderness of jugulodigastic lymph nodes

25. signs Chronic sore throat Malodorous breath Peritonsillar erythema Persistent cervical lymphadenopathy Presence of tonsillotiths

26. treatment Attention to general health, diet, treatment of coexistent infection of teeth, nose and sinuses Tonsillectomy absolute indictations : i ) 7 or more episodes in one year, 5 py for 2, 3 py for 3, 2 wks or more of lost school or work in 1year ii) peritonsillar abscess: 4-6 wks after treatment, two attacks in adults iii) tonsillitis causing febrile seizes iv) hypertrophy of tonsils v) suspicion of malignancy

27. complications Peritonsillar abscess Parapharyngeal abscess Intratonsillar abscess usually follows acute follicular red and swollen, pain and dysphagia Tonsilloliths cypyt is blocked with the retention of debris inorganic salts of ca, mg are deposited to form a calculus/stone, may ulcerate through the surface local discomfort/foreign body sensation felt on palpation or gritty feeling on probing Tonsillar cyst yellowish swelling over tonsil due to blockage Focus of infection in rheumatic fever, acute glomerulonephritis , eye and skin disorders