D r .N ayana V G

1. Anatomy Of Tonsil & Acute Tonsillitis – Differential Diagnosis And Management Dr.NayanaV G

3. Embryology • Tonsillar fossa and Palatine tonsils - Dorsal wing of the 1st pharyngeal pouch & Ventral wing of the 2nd pouch – 8 weeks; • Tonsillar pillars - 2nd/3rd arches • Crypts - 3-6 months. • Capsule - 5th month. • Germinal centers after birth

4. ANATOMY • Tonsils are aggregates of lymphoid tissues • Forms part of WALDEYER’S ring • Inner ring – palatine tonsil, lingual tonsil, tubal tonsil and adenoid • Outer ring – RPLN, JDLN, submandibular and submental LN

5. TONSIL - ANATOMY • Palatine tonsils forms the lateral boundary of the inner ring of waldeyer • lymphoid mass • Lateral wall of oropharynx • b/w palatoglossal & palatopharyneal arch

6. MEDIAL SURFACE • Non keratinising stratified squamousepithelium • Dips into tonsils to form CRYPTS • 12-15 crypts • Largest – CRYPTA MAGNA or INTRATONSILLAR CLEFTRepresent opening of second pharyngeal pouch

7. LATERAL SURFACE • Covered by capsule • Extension of Pharyngobasilar fascia • Capsule extends to tonsil tissue - septa • b/w capsule & bed of tonsil –loose areolar tissue Plane of tonsillectomy Site of pus collection –peritonsilar abscess

9. UPPER POLE • Extends into soft palate • Semilunar fold-plica semilunaris extend b/w ant. & post. Pillar • Potential space –Supra tonsillar fossa LOWER POLE • Attached to tongue • Plica triangularis-triangular vestigial fold of mucous memb cover anteroinf part • Space-Ant. Tonsillar space

10. TONSIL BED

11. TONSIL – ARTERIAL SUPPLY

12. VENOUS DRIANAGE • Paratonsillar vein Common facial vein & pharyngeal plexus IJV

13. LYMPHATIC DRAINAGE No afferent lypmhatic supply Jugulodiastric node below angle of mandible NERVE SUPPLY Lesser palatine br of sphenopalatine ganglion Glossopharyneal Nerve.

14. Histology

15. DEVELOPMENT • EPITHELIUM DEVELOPS –VENTRAL PART OF SECOND PHARYNGEAL POUCH • LYMPHOCYTES –MESODERMAL ORIGIN

16. LINGUAL TONSIL • Base of tongue • 30-100 lymphoid follicles • ARTERIAL – lingual branches of ECA • VENOUS – lingual veins - IJV • LYMPHATICS – superior cervical or jugular nodes • NERVE - glossopharyngeal

18. NORMAL FLORA • - GABHS • - Hemophilus • - Staph. aureus • - Alpha hemolytic streptococci • - Moraxella • - Mycoplasma • - Chlamydia • - Anaerobes • - Respiratory viruses

19. DISORDERS • Infection / inflammation • Hypertrophy - U/L or B/L • Tumors - benign / malignant

20. ACUTE TONSILLITIS PRE DISPOSING FACTORS • Fatigue • Extremes of climate • Pre-existing URTI • Metabolic or immune disorder

21. EPIDEMIOLOGY • Affects both sexes • All age groups are affected; increased in children • Autumn and winter • Rare in infants and age more then 50 years

22. CLASSIFICATION • a/c catarrhal • a/c follicular • a/c membranous • a/c parenchymatous

23. A/c CATARRHAL • A/c superficial / congestive • Initiated by viral infection • As a part of pharyngitis • Mainly local symptoms

24. A/c FOLLICULAR • Suppurative • Follow superficial tonsillitis/reactivation of subclinical infections • Inflammation of mouth of crypts • Presents with both local and systemic symptoms

26. A/C MEMBRANOUS • Stage ahead of follicular • Exudates at the crypts coalesce to form a membrane • Local and constitutional symptoms

27. A/C PARENCHYMATOUS • Tonsillar substance is affected • Uniformly enlarged and congested • More obstructive symptoms

28. AETIOLOGY • GABHS • Staphylococci • Pneumococci • Hemophilus • Anaerobic • Secondary to viral infection

29. FEATURES • Fever with chills and rigor • Sorethroat • Odynophagia • Dysphagia • Voice changes • Pain neck • Cervical lymphadenopathy • Earache • Abdominal pain

30. OROPHARYNX

31. Grading the Size of TonsilsBRODSKY;MOORE;STANIEVICH • Grading system: • 0 – tonsils in fossa • +1 – tonsils less than 25% • +2 – tonsils less than 50% • +3 – tonsils less than 75% • +4 – tonsils greater than 75%

32. MANAGEMENT Blood routine - leucocytosis; ESR X-ray nasopharynx - adenoids X-ray PNS - associated sinusitis PTA and impedance Throat swab for C and S - posterior pharynx and tonsillarareas Rapid antigen testing (RAT) for GABHS

33. MEDICAL • Supportive - hydration; bed rest; warm saline gargles; analgesics; antibiotics • ANTIBIOTICS - shorten duration of illness • Decrease complications • Penicillin – DOC • Erythromycin; tetracycline • Beta lactamase –amoxycillin-clavulanate • Anaerobes –metronidazole • Dexamethasone –single dose for pain

34. LOCAL Quinsy Intratonsillar abscess Parapharyngeal abscess Retropharyngael abscess Suppurativejugulodigastric lymphadenitis Lemierre’s syndrome SYSTEMIC a/c glomerulonephritis SABE Exacerbation of psoriasis Acute rheumatic fever COMPLICATIONS

35. 1.QUINSY • Collection of pus between tonsillar capsule and bed • Follows recurrent tonsillitis/inadequately treated c/c tonsillitis • Theories- 1] pus tracking into the supratonsillarfossa • 2] infection of peritonsillar salivary gland-Webers gland

36. Diagnosis - physical examination • USG and CT. S Staphylococcus aureus is the most common organism. • Clinical presentation: • Dysphagia, odynophagia • Inability to swallow with drooling. • Muffled voice(hot potato voice) • Trismus

37. SIGNS • Uvula is deviated away from the abscess • Tonsil pillars and soft palate congested • u/l peritonsillar bulge • Cervical LNE • Torticollis; • Signs of dehydration

38. MANAGEMENT • Routine investigations • Supportive measures • Parenteral antibiotics • Early cellulitis can be managed conservatively • If frank abscess ;incision and drainage

39. INCISION AND DRAINAGE • Point of aspiration is point of maximum bulge above the upper pole of tonsil or just lateral to the point of junction of anterior pillar and a line through base of uvula • If pus is present; a stab incision and dilatation; pus for C and S • Usually recovery by 4-5 days

43. TONSILLECTOMY • Classic teaching - 4-6 weeks after quinsy(interval tonsillectomy) • Some argue for an abscess /hot tonsillectomy esp. in following situations: • - if antibiotics are not sufficient enough • - those with recurrent tonsillitis / abscesses • - avoidance of loss to follow up • - for rapid relief of symptoms

44. COMPLICATIONS • Rupture of abscess during surgery • Intra tonsillar abscess • Parapharyngeal abscess • Edema of larynx • Septicemia - endocarditis ;nephritis • If aspiration has taken place; pneumonitis/lung abscess • Internal jugular vein thrombosis • Necrotisingfascitis • Perichondritis of thyroid cartilage • Spontaneous hemorrhage from carotid or IJV

45. 2.Parapharyngeal abscess • If pus tracks through the superior constrictor and localises between superior constrictor and deep cervical fascia • Trismus • Tender neck swelling • Airway compromise • CT with contrast - inv. of choice • First conservative; not responding; external drainage

46. 3.Retropharyngeal abscess • Pus between posterior pharyngeal wall and prevertebral fascia • Usually children below 5 yrs-following suppuration of lymph nodes • Dysphagia ; dyspnoea; croupy cough; torticollis • O/e bulge in the posterior pharyngeal wall • X ray STN –widening of prevertebral shadow • I and D ; antibiotics; tracheostomy

47. 4.LEMIERRE’S SYNDROME • Septic thrombophlebitis of IJV • A fusiform bacillus • Severe neck pain; septicemia • Also secondary to tympanomastoid infection • Imaging - thrombus in neck veins • Antibiotics (beta-lactam with metronidazole or amoxycillin-clavulanate) and anticoagulation

48. 5.SPONTANEOUS HAEMORRHAGE • Occasionally spontaneous haemorrhagefrom inflamed tonsils may take place which is a rare but serious condition. Also occurs in response to minor trauma in inflamed tonsil. • Respond to cautery under LA • Tonsillectomy

49. SYSTEMIC COMPLICATIONS • a/c rheumatic fever } immune • a/c PSGN } complex • Exacerbation of psoriasis (guttate variety) • Scarlet fever • SABE

50. SUBACUTE TONSILLITIS • Patients never free of low grade discomfort in the throat • Enlarged inflamed tonsils • Punctuated with acute episodes which may be mild or severe