CASE REPORT Selasaaaaa

CASE REPORT

CHRONIC TONSILLITIS

OVERVIEW

A. ANATOMY OF THE TONSILS

Waldeyer’s Ring - circle of lymphoid tissue consisting of:

1. palatine (fauceal) tonsils

2. pharyngeal tonsils (adenoids)

3. lingual tonsils and

4. Tubal tonsils of Gerlach (near fossa of Rosenmüller)

Anatomy of The Palatine Tonsils

Palatine tonsils are two in number. Each tonsil is an ovoid mass of lymphoid tissue

situated in the lateral wall of oropharynx, created by the palatoglossus muscle anteriorly and the

palatopharyngeus and superior constrictor muscle posteriorly and laterally. Actual size of the

tonsil is bigger than the one that appears from its surface as parts of tonsil extend upwards into

the soft palate, downwards into the base of tongue and anteriorly into palatoglossal arch. A tonsil

presents two surfaces-a medial and a lateral, and two poles- an upper and a lower.

Medial surface of the tonsil is covered by non

keratinizing stratified squamous epithelium

which dips into the substance of tonsil in the

form of crypts. Openings of 12-15 crypts can be

seen on the medial surface of the tonsil. One of

the crypts, situated near the upper part of tonsil is

very large and deep and is called crypta magna or

intratonsillar cleft From the main crypts arise the

secondary crypts, within the substance of tonsil.

Crypts may be filled with cheesy material

consisting of epithelial cells, bacteria and food debris which can be expressed by pressure over

the anterior pillar.

Lateral surface of the tonsil presents a well -defined fibrous capsule. Between the

capsule and the bed of tonsil is the loose areolar tissue which makes it easy to dissect the tonsil

in the plane during tonsillectomy. It is also the site for collection of pus in peritonsillar abscess.

Some fibres of palatoglossus and palatopharyngeus muscles are attached to the capsule of the

tonsil.

Blood Supply

The tonsil is supplied by five arteries:

1. Tonsillar branch of facial artery. This is the main artery.

2. Ascending pharyngeal artery from external carotid.

3. Ascending palatine, a branch of facial artery.

4. Dorsal linguae branches of lingual artery.

5. Descending palatine branch of maxillary artery.

Venous Drainage

Veins from the tonsils drain into paratonsilar vein which joins the common facial vein

and pharyngeal venous plexus.

Lymphatic Drainage

Lymphatics from the tonsil pierce the superior constrictor and drain into upper deep

cervical nodes particularly the jugulodigastric (tonsillar) node situated below the angle of

mandible.

Nerve Supply

Lesser palatine branches of sphenopalatine ganglion (CN V) and glossopharyngeal

nerve provide sensory nerve supply.

Function of the Tonsils

Both tonsils and adenoid are part of the Waldeyer ring, which is a ring of lymphoid

tissue in the pharyngx. Lymphoid tissue in this ring provides defense against pathogens. The

waldeyer ring is involved in the production of immunogloblins and the development of both B-

cell and T-cell lymphocytes.

B. TONSILLITIS

Definition of Tonsillitis

Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends

to the adenoid and lingual tonsils. Lingual tonsillitis refers to isolated inflammation of the

lymphoid tissue at the tounge base.

Etiology

The oropharynx and Waldeyer tonsillar ring are normally colonized by many different

species of aerobic and anaerobic bacteria, including Staphylococcus, nonhemolytic streptococci,

Lactobacillus, Bacteroides, and Actinomyces. These organisms, as well as many other

pathogenic bacteria, viruses, fungi, and parasites, can cause infections of tonsillar and adenoid

tissue.

Viral Infections

Viruses such as adenovirus, rhinovirus, reovirus, respiratory syncytial virus (RSV), and

the influenza and parainfluenza viruses have all been shown to be possible pathogens. Most of

these infections are self-limited and require only symptomatic treatment.

The Epstein-Barr virus (EBV) causes acute pharyngitis as a part of infectious

mononucleosis syndrome. It is common in children and young adults, is transmitted by oral

contact, and manifests as fever, generalized malaise, lymphadenopathy, hepatosplenomegaly,

and pharyngitis. Upon examination, petechiae may be present at the junction of the soft and hard

palates. The tonsils are severely enlarged, sometimes to the point of compromising the airway,

and classically are covered with an extensive grayish-white exudate.

Tonsillar infections with the coxsackie virus result in herpangina, which presents as

ulcerative vesicles over the tonsils, posterior pharynx, and palate. The disease commonly occurs

in children under the age of 16. Patients present with generalized symptoms of headache, high

fever, anorexia, and odynophagia.

Fungal Infections

Oropharyngeal candidiasis (ie, thrush) often presents in immunocompromised patients

or in patients who have undergone prolonged treatment with antibiotics. On exam, there are

white cottage-cheese-like plaques over the pharyngeal mucosa, which bleed if removed with a

tongue depressor. Treatment consists of topical nystatin or clotrimazole (eg, Mycelex) troches.

Bacterial Infections

Group A beta-hemolytic Streptococcus is the most common and important pathogen

causing acute bacterial pharyngotonsillitis. This infection most commonly presents in children

aged 5–6 and is characterized by fever, dry sore throat, cervical adenopathy, dysphagia, and

odynophagia. The tonsils and pharyngeal mucosa are erythematous and may be covered with

purulent exudate; the tongue may also become red ("strawberry tongue").

Classification

1. Acute Tonsillitis

Primarily, the tonsil consists of (a) surface epithelium which is continuous with the

oropharyngeal lining; (b) crypts which are tube-like invaginations from the surface epithelium;

and (c) the lymphoid tissue.

Acute infections of tonsil may involve these components and are thus classified as:

1. Acute catarrhal or superficial tonsillitis. Here tonsillitis is a part of generalised pharyngitis

and is mostly seen in viral infections.

2. Acute follicular tonsillitis. Infection spreads into the crypts which become filled with

purulent material, presenting at the openings of crypts as yellowish spots

3. Acute parenchymatous tonsillitis. Here tonsil substance is affected. Tonsil is uniformly

enlarged and red.

4. Acute membranous tonsillitis. It is a stage ahead of acute follicular tonsillitis when exudation

from the crypts coalesces to form a membrane on the surface of tonsil.

Etiology

Haemolytic streptococcus is the most commonly infecting organism. Other causes of infect ion

may be staphylococci, pneumococci or H. influenzae. These bacteria may primarily infect the

tonsil or may be secondary to a viral infection.

2. Chronic Tonsillitis

Etiology

1. It may be a complication ot acute tonsillitis. Pathologically, microabscesses walled off by

fibrous tissue have been seen in the lymphoid follicles of the tonsils.

2. Subclinical infections of tonsils without an acute attack.

3. Mostly affects children and young adults. Rarely occurs after 50 years.

4. Chronic infection in sinuses or teeth may be a predisposing factor.

Types

1. Chronic follicular tonsillitis. Here tonsillar crypts are full of infected cheesy material which

shows on the surface as yellowish spots.

2. Chronic parenchymatous tonsillitis. There is hyperplasia of lymphoid tissue Tonsils are very

much enlarged and may interfere with speech, deglutition and respiration. Attacks of sleep

apnoea may occur. Longstanding cases develop features of cor pulmonale.

3. Chronic fibroid tonsillitis. Tonsils are small but infected,with history of repeated sore

throats.

PATHOPHYSIOLOGY

Immunology

The tonsils and adenoids are unique insofar as they involved in both local immunity and

in immune surveillance for the development of the body’s immunologic defense system. Chronic

bacterial infection (and other ongoing antigenic stimulators) in the tonsils and adenoids may

results in the production of local antibody, a shift of B and T cells ratios and according to some

researchers, an increase in the serum immunoglobulin levels, which return into normal after

tonsillectomy and adenoidectomy. In contrast to proper lymph nodes, the tonsils and adenoids

have no afferent lymphatics; therefore, their specialized epithelium plays an important role in

antigen presentation and processing. This is followed by both T cell and B cell responses,

including immunoglobulin production, expansion of memory clones and hyperplasia.

Pathogenesis of Adenotonsillar Disease

The pathogenesis of infectious and inflammatory disease in the tonsils and adenoids

most likely has its basis in their anatomic location and their inherent function as organs of

immunity, processing infectious material and other antigens, and then becoming, paradoxically a

focus of infection or inflammation. However, no single theory of pathogenesis has been

accepted. Viral infection with secondary bacterial invasion may be one mechanism of the

initiation of chronic disease, but the effects if the environment, host factors, the widespread use

of antibiotics, ecological considerations, and diet all may play role.

Recent work reveals that inflammation and loss of integrity of the crypt epithelium result

in chronic cryptitis and crypt obstruction, leading to stasis of crypt debris and persistence of

antigen. Bacteria even infrequently found in normal tonsil crypts may multiply and eventually

establish chronic infection.

DIAGNOSIS

Symptoms include:

red and/or swollen tonsils

white or yellow patches on the tonsils

tender of jaw and throat, stiff, and/or swollen neck

sore throat – last longer than 48 hours and may be severe

painful or difficult swallowing

cough

headache

sore eyes

body aches

otalgia

fever

chills

nasal congestions

Voice changes, loss of voice

Physical Examination:

Signs of infection (redness, discharge, swollen lymph glands)

Abscess  (a shift in 1 tonsil toward the center and a shift of the uvula away from the

infected side)

Airway compromise (muffled speech, drooling, and inability to swallow)

Tests:

Blood count

Mononucleosis test

Sometimes, when the body reacts to an infection, antibodies are made that have nothing

to do with the germ. These are called heterophile antibodies. This test looks for such

antibodies. It is used to diagnosis infectious mononucleosis, a disease caused by the Epstein-

Barr virus (EBV). About 1 week after the onset of the disease, many patients develop

heterophile antibodies. Antibodies reach peak levels in 2 - 5 weeks and may persist for up to

1 year. However, a small number of persons with mononucleosis may never develop such

antibodies. A positive test means heterophile antibodies are present. These are usually a sign

of infectious mononucleosis.

Rapid strep test

The test requires a throat swab. The swab is tested to identify group A streptococcus.

Indications: pharingitis. An abnormal result means Group A streptococcus is present, and

confirms strep throat.

Throat swab culture

DIFFERENTIAL DIAGNOSIS

Acute Tonsillitis

Differential Diagnosis: must be made from the many conditions causing an acute pharyngitis.

The most important are:

1. Scarlet fever

2. Diphteriae-especially from the attenuated form seen in inoculated persons

3. Vincent’s infection

4. Agranulocytosis

5. Glandular fever (infectious mononucleosis)

Chronic tonsilitis

Differential Diagnosis: mainly from physiological enlargement, especially in childhood. Sinusitis

must be excluded

THERAPY

Acute Tonsillitis

Treatment:

1. patient is put to bed and encourage to take plenty of fluids

2. analgetics (aspirin or paracetamol) are given according to the age of the patient to relieve

local pain and bring down the fever

3. antimicrobial therapy. Most of the infections are due to streptococcus, and penicillin is the

drug of choice. Patient allergic to penicillin can be treated with erythromycin. Antibiotics

should be continued for 7- 10 days.

Chronic tonsillitis

Treatment:

1. Conservative treatment consist of attention to general health, diet, treatment of co-existent

infection of teeth, nose, and sinuses.

2. Tonsillectomy by indications.

Indications of tonsillectomy:

a. Absolute indications:

Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or

cardiopulmonary complications

Peritonsillar abcess that is unresponsive to medical management and drainage documented

by surgeon, unless surgery is performed during acute stage

Tonsillitis resulting in febrile convulsions

Tonsils requiring biopsy to define tissue pathology

b. Relative indications:

Three or more tonsils infections per year despite adequate medical therapy

Persistent foul taste or breath due to chronic tonsillis that is not responsive that is not

responsive to medical history

Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-

resistant antibiotics

Unilateral tonsil hypertrophy that is presumed to be neoplastic

COMPLICATION

Acute Tonsillitis

1. Chronic tonsillitis

2. Peritonsillar abcess

3. Parapharyngeal abcess

4. Servical abcess

5. Acute otitis media

6. Rheumatic fever

7. Acute glomerulonephritis (rare)

8. Subacute bacterial endocarditis

Chronic Tonsilitis

1. Peritonsillar abcess

2. Parapharyngeal abcess

3. Intratonsillar abcess

4. Tonsilloliths

5. Tonsillar cyst

6. Focus of infection in rheumatic fever, acute glomerulonephritis, eye and skin disorders.

CASE REPORT

PATIENT IDENTITY

Name : B.R (child)Sex : MaleAge :7 y.o. Address : Kemiri, Purworejo Date : March, 24th 2012

ANAMNESIS

Chief complain :Sore throat

Present Illness history :

Patient keep on complaining sore throat for a year. Having pain on swallowing , cough, coryza, and fever . He had check up to General Practitioner, was diagnosed with “amandel”. Had been prescribed antibiotic, medicine for flu and cough but his mother forgot the drug’s name. The symptoms relieve but have been recurrent (almost every month). A month ago, sore throat is getting worse. Patient felt pain on swallowing (eat). Patient’s mother also complained her child always snoring but didn’t effect his sleeping time, and have less interest on studies.

Current complains:

Snoring (+), nasal congestion (-), runny nose (-), sneezing (-), difficulty swallowing (-),

decreased appetite (-).

Ear Complains: hearing loss (-), ringing sensation in ear/ ears (-), ear pain (-), ear itching (-), sensation of fullness in the ear (-).

Past Illness History :

similar disease history (+)

allergy history (-)

asthma history (-)

Family Illness History :

similar disease history (-)

allergy history (-)

active smoker (+) father

Resume of Anamnesis

Sore throat (+)

History of cough and cold (+)

Recurrent (+)

Snoring (+)

Fever (+)

Physical Examination

General status : compos mentis, good nutritional status

Weight : 30 kg, Height : 135 cm

Vital signs :

BP : 110 / 80 mmHg

Pulse : 88 times/minute

RR : 20 times/minute

T : 38 ºC

Head and neck : icteric sclera -/-, anemic conjunctiva -/-, lnn normal

Thorax : symmetrical retraction: -. Vesicular +/+, murmur -/-

Abdomen : flat, peristaltic + , no liver and spleen enlargement, tenderness –

Extremity : warm limb, swelling -

Local status of ear, nose, and throat

Physical examination of the ear:

Inspection:

Auricula

AD : Hyperemic (-), swelling (-), discharge (-), Laceration (-)

AS : Hyperemic (-), swelling (-), discharge (-), Laceration (-)

Auditory canal

AD : cerumen (-), swelling (-), pruritic (-), narrow lumen (-), discharge (-)

AS : cerumen (-), swelling (-), pruritic (-), narrow lumen (-), discharge (-)

Palpation :

Tragus pain : AD (-), AS (-)

Auricle pain : AD (-), AS (-)

Otoscopy

AD : tympanic membrane intact, cone of light (+), hyperemic (-), Effusion (-),

Bulging (-), retraction (-)

AS : tympanic membrane intact, cone of light (+), hyperemic (-), Effusion (-),

Bulging (-), retraction (-)

Nose and paranasal sinuses

Inspection

Septum deviation (-), edema conchae (-), post nasal drip (-)

Palpation

Pain on palpation (-), crepitation (-)

Anterior rhinoscopy

Hyperemic mucosa (-/-), discharge (-/-), concha hypertrophy (-/-), septum deviation (-/-),

inferior nasal cavity and opening is normal

Posterior Rhinoscopy (-)

Oral cavity and oropharynx

Inspection

Lip : labioschisis (-), inflammation (-), mass (-)

Teeth and gum : caries dentis (-)

Tounge : inflammation (-)

Palatum mole : swelling (-), hyperemic (-)

Uvula : low

Tonsil dextra : hyperemic (+), swelling (+) T3, widen crypts, detritus (+)

Tonsil sinistra : hyperemic (+), swelling (+) T3, widen crypts, detritus (+)

Pharynx : hyperemic (-), granule (-)

Resume of physical examination

Tonsil dextra : hyperemic (+), swelling (+) T3, widen crypts, detritus (+)

Tonsil sinistra : hyperemic (+), swelling (+) T3, widen crypts, detritus (+)

Pharynx : hyperemic (-), granule (-)

DIAGNOSIS

Chronic tonsillitis

PLAN

Tonsillectomy

DISCUSSION

In this patient, chronic tonsillitis is diagnosed based on anamnesis and physical

examination. From the anamnesis we found that the patient has experienced snoring (+), sleep

apnea (-), recurrent fever(-), recurrent cough and flu (-) for four times in a year. From the

physical examination, the patient has hyperemic, swelling of left and right tonsils (T3), detritus

(+), and widened crypts (+).

Symptoms of tonsillitis are red and/or swollen tonsils, white or yellow patches on the

tonsils, tender of jaw and throat, stiff, and/or swollen neck, sore throat – last longer than 48 hours

and may be severe, painful or difficult swallowing, cough, headache, sore eyes, body aches,

otalgia, fever, chills, nasal congestions, and voice changes, loss of voice. From physical

examination, we can found some signs of infection (redness, swollen lymph glands), and airway

compromise (difficulty to swallow). This patient has swelling of left and right tonsils (T3),

detritus (+), widened crypts (+). All of that signs indicate signs of chronic tonsillitis.

Tonsillectomy is suggested since the patient has absolute and relative indications for

tonsillectomy. The patient has tonsil hypertrophy without sleep apnea which is one of absolute

indication of tonsillectomy. Patient also suffers from tonsillitis for few times in a year; a relative

indication.