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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Tonsillitis.

Jackie Anderson ; Elizabeth Paterek .

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Last Update: August 8, 2023 .

• Continuing Education Activity

Tonsillitis, or inflammation of the tonsils, is a common disease and makes up approximately 1.3% of outpatient visits. It is predominantly the result of a viral or bacterial infection and, when uncomplicated, presents as a sore throat. Acute tonsillitis is a clinical diagnosis. Differentiation between bacterial and viral causes can be difficult; however, this is crucial to prevent the overuse of antibiotics. This activity reviews the etiology, presentation, evaluation, and management of tonsillitis, and examines the role of the interprofessional team in evaluating, diagnosing, and managing the condition.

• Identify the etiology and pathophysiology of tonsillitis.
• Review the history, physical, and evaluation of tonsillitis as well as the need for a thorough differential.
• Outline the treatment and management options available for tonsillitis as well as the potential complications and prevention strategies.
• Explain interprofessional team strategies for improving care coordination and communication to enhance tonsillitis outcomes.
• Introduction

The palatine or faucial tonsils are in the lateral oropharynx. They are found between the palatoglossal arch anteriorly and the palatopharyngeal arch posteriorly, known as the palatine arches or pillars. The tonsils are composed of lymphatic tissue and are a component of Waldeyer's ring along with the adenoids (nasopharyngeal tonsil), tubal tonsil, and lingual tonsil. [1] [2] They serve as an important defense against inhaled or ingested pathogens by providing the initial immunological barrier to insults. [2]

Tonsillitis, or inflammation of the tonsils, is a common disease and makes up approximately 1.3% of outpatient visits. [3] It is predominantly the result of a viral or bacterial infection and, when uncomplicated, presents as a sore throat. [4] Acute tonsillitis is a clinical diagnosis. Differentiation between bacterial and viral causes can be difficult; however, this is crucial to prevent the overuse of antibiotics. 

Tonsillitis is generally the result of an infection, which may be viral or bacterial. Viral etiologies are the most common. The most common viral causes are usually those that cause the common cold, including rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. These typically have low virulence and rarely lead to complications. Other viral causes such as Epstein-Barr (causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause tonsilitis. [5] [6]

Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS), but Staphylococcus aureus , Streptococcus pneumoniae , and Haemophilus influenza have also been cultured. [7] Bacterial tonsillitis can result from both aerobic and anaerobic pathogens.  In unvaccinated patients, Corynebacterium diphtheriae causing diphtheria should even merit consideration as an etiology. [8]   In sexually active patients, HIV, syphilis, gonorrhea, and chlamydia are possible as additional causes. [9] [10] Tuberculosis has also been implicated in recurrent tonsilitis, and clinicians should assess patients' risks. [11]

• Epidemiology

Approximately 2% of ambulatory patient visits in the United States are due to a sore throat. Though it is more common in winter and early spring, the disease can occur at any time during the year. [12] GABHS accounts for 5% to 15% of adults with pharyngitis and 15% to 30% of patients between the ages of five and fifteen. Viral etiologies are more common in patients under five. GABHS is rare in children under two years of age. [13] [14]

• History and Physical

Symptoms of acute tonsillitis include fever, tonsillar exudates, sore throat, and tender anterior cervical chain lymphadenopathy. [15] Patients may also note odynophagia and dysphagia secondary to tonsillar swelling.

Examination of patients should involve a thorough history and physical exam focused on the oropharynx. Vaccination status and sexual activity should both undergo assessment. Visualization of the tonsils is paramount, and features such as swelling, erythema, and the examiner should note any exudates. Tonsillar enlargement resulting in decreased visualization of the posterior oropharynx and decreased ability to handle secretions and/or protect the airway should alert the provider to consider further imaging and assess the need for airway management. In the absence of direct visualization of a tonsillar abscess, uvular deviation should raise suspicion, and CT imaging can be an option. As with all otolaryngological complaints, a full examination of the ears and nose should also be performed. 

For the majority of patients, evaluation for tonsillitis includes physical examination, risk stratification by scoring systems, and consideration of rapid antigen testing and/or throat culture.  Imaging is rarely necessary for uncomplicated infections. Evaluation should begin with a thorough history and physical exam, and this information can be used to calculate a Centor Score. This scoring system uses the following criteria: the presence of a fever, tonsillar enlargement and/or exudates, tender cervical lymphadenopathy, and absence of a cough. Each finding warrants one point. This criterion was updated to include an age modification, giving an extra point for age groups 3 to 15 years and subtracting a point for patients 45 years of age and older. [16] [17] In patients scoring 0 to 1, no further testing or antibiotics is necessary. In patients scoring 2 to 3 points, rapid strep testing and throat culture is an option. In patients with scores of 4 or more, clinicians should consider testing and empiric antibiotics.

Testing for GABHS can occur via throat culture alone or in conjunction with rapid antigen testing. When using rapid antigen testing, it is important to note that while this test is specific (88% to 100%), it is not sensitive (61% to 95%); false negatives are possible. [5] In the appropriate clinical setting, clinicians should consider also obtaining pharyngeal swabs for gonorrhea and chlamydia and HIV testing. In rare cases, syphilis can cause tonsilitis, and an RPR can be sent to establish the diagnosis. [18] A mononucleosis spot test can be a consideration when the Ebstein-Barr virus is suspected. 

In complicated infections, including patients with unstable vital signs, toxic appearance, inability to swallow, inability to tolerate oral intake, or trismus, a more extensive evaluation may be required. Examples include CT imaging of the neck with intravenous contrast to exclude dangerous causes such as abscess, Lemierre disease, and epiglottitis. Laboratory testing, including complete blood count and basic metabolic panel to assess renal function, merits consideration.

• Treatment / Management

For the majority of patients, tonsilitis is a self-limiting disease. Given the frequency of viral etiologies, the mainstay of treatment of acute tonsillitis is supportive care, including analgesia and hydration; patients rarely require hospitalization. [4] Medications such as NSAIDs can provide symptomatic relief. [19] Corticosteroids can be considered as an adjunct therapy to decrease pain scores and improve time to recovery, typically given as a single dose of dexamethasone. While studies have shown limited harm from steroids, their use requires care in patients with medical comorbidities such as diabetes. [20] [21] Holistic treatments and herbal remedies have shown inconsistent and limited utility. The use of zinc gluconate is not a recommended therapy. [17]

For patients at high risk of bacterial pharyngitis based on Centor criteria and antigen testing or throat culture, antibiotics are often used in treatment. Streptococcus pyogenes is the most common cause of bacterial tonsillitis and, if antibiotic treatment is deemed to be appropriate, penicillins are generally the antibiotic of choice. [22] In patients with a penicillin allergy, antibiotic therapy with azithromycin or cephalosporins is comparable to treatment with penicillin. However, when considering the use of antibiotics, the provider should weigh the risks against the benefits. It is important to note that most pathogens responsible for tonsillitis belong to healthy flora and do not require full eradication. [19] The risks of antibiotic use include increased antibacterial resistance, GI upset, diarrhea, Clostridium   difficile  infection, and cost. [17] Additionally, while antibiotics may reduce suppurative complications and symptom duration, the effect is small. [15] A Cochrane review found that the duration of symptoms only decreases by 16 hours. The benefit from antibiotics is more likely to be seen in populations with high rates of complications, especially rheumatic heart disease and rheumatic fever. [3]   Antibiotics are most important in patients at high risk of rheumatic heart disease, including indigenous populations in Australia and certain lower socioeconomic status communities. 

Recurrent tonsillitis is arbitrarily defined but generally identified as five or more tonsillitis episodes in one year. [5] Special consideration should be given to cause, and, while rare, primary immunodeficiency requires consideration. [23] Treatment may be surgical, including tonsillectomy or tonsillotomy.  The American Academy of Otolaryngology, Head, and Neck Surgery outlines the criteria for surgical management decision making. Tonsillectomy provides mostly short term benefits reflected in studies as a decrease in absence from school, sore throat days, and diagnosed infections with limited long term benefits. [24]

• Differential Diagnosis

The differential diagnosis for tonsillitis is broad and includes pharyngitis, retropharyngeal abscess, epiglottitis, and Ludwig angina. The presence of dental or peritonsillar abscess is also a possibility. Kawasaki disease, Coxsackie virus, primary HIV, Ebstein-Barr virus, and oral Candidiasis may also present with throat pain, and differentiation can be via history and other clinical features. [15]

• Treatment Planning

Acute tonsillitis treatment is usually via outpatient supportive management, including analgesia and oral hydration; hospital admission is rarely necessary. [4] Medications such as steroids and NSAIDs can provide symptomatic relief. [19] Streptococcus pyogenes (GABHS) is the most common cause of bacterial tonsillitis, and penicillins are the antibiotic of choice; these are usually a 10-day oral regimen or a single benzathine penicillin G intramuscular injection. In penicillin-allergic patients, a 5-day course of azithromycin or a 10-day course of cephalosporin or clindamycin are also options. [22] [19]

The prognosis of acute tonsillitis in the absence of complications is excellent. Most cases are self-limiting infections in healthy patient populations who improve and have minimal sequela. Those with recurrent infections may require surgery; however, even these patients have good long term prognosis. In the age of antibiotics, even patients with complications, including peritonsillar abscess and Lemierre syndrome, have excellent long-term outcomes. In cases with GABHS complications, including rheumatic fever and glomerulonephritis, patients can have long-term sequela, including cardiac valvular disease and decreased renal function. These entities are very rare in the developed world, and incidence has dropped with the advent of penicillin treatment. If symptoms do not improve, another diagnosis should be considered, including HIV, TB, gonorrhea, chlamydia, syphilis, mononucleosis, Kawasaki disease, abscess, and Lemierre syndrome. Overall prognosis in these cases is related to the underlying condition. [5]

• Complications

While tonsillitis is typically symptomatically managed with good clinical outcomes, complications do occur. Although rare, abscesses, rheumatic fever, scarlet fever, and acute glomerulonephritis are known complications.

Peritonsillar abscesses are a collection of pus between the pharyngeal constrictor muscle and tonsillar capsule, and tonsillitis symptoms often precede their appearance. It is worth noting that this symptom development does not prove causation. While the two diagnoses are clinically distinct, antibiotic treatment for tonsillitis reduces abscess development risk. [25] Adolescents and younger adults are the most commonly affected. Smokers are at higher risk. Most infections are polymicrobial and respond well to a combination of antibiotics, steroids, and drainage. [26]

Acute tonsillitis caused by group A beta-hemolytic streptococci, in rare cases, causes rheumatic fever and rheumatic heart disease. Rheumatic fever is an inflammatory, immunological disease that occurs following infection with group A Streptococcus. It most commonly presents in patients between 5 to 18 years old. While rare in the developed world, in developing nations, the incidence is as high as 24 per 1000. The disease affects multiple organ systems, most commonly causing arthritis, which presents in the large joints as migratory, asymmetrical, and painful. Carditis affects nearly 50% of patients and often causes valvular pathology, with the mitral valve being the most commonly affected. Sydenham chorea is a classic delayed presentation of involuntary movements of the limbs and facial muscles with associated speech and gait abnormalities. Patients may present with a rash known as erythema marginatum and subcutaneous nodules. [27]  

Post-streptococcal glomerulonephritis is an immune-mediated disorder following infection with Group A streptococcus. Patients present with edema, hypertension, abnormalities on urine sediment, hypoproteinemia, elevated inflammatory markers, and low complement levels. It affects approximately 470000 individuals globally, with an estimated 5000 deaths. Children in developing nations are most commonly affected; however, any individuals with crowded living situations are at increased risk. It generally occurs in outbreaks of disease due to nephritogenic strains of Group A Streptococcus. The majority of patients will have spontaneous resolution of the illness and return to normal renal function though the prognosis is worse in older patients. Antibiotics do not actually alter the course of the disease but help to decrease disease transmission. [28]

Lemierre disease is a rare complication of oropharyngeal infections. It commonly presents as sepsis following a sore throat with associated thrombosis of the internal jugular vein and septic emboli. It is most commonly associated with  Fusobacterium necrophorum , though it has also occurred with Staphylococcal and Streptococcal infections. In the era of modern antibiotics, mortality is low though complications can include ARDS, osteomyelitis, and meningitis. [29]

• Deterrence and Patient Education

As a provider, it is essential to educate patients on the likely cause of their tonsillitis and provide a thorough explanation of the diagnosis. The provider should address patients' expectations for antibiotics as well as the potential for harmful side effects. Patients should receive education on possible complications of pharyngitis and the rationale for treatment plans. Given that the majority of these infections are viral, this is an opportunity to employ antibiotic stewardship. The Centor criteria can be used to risk-stratify patients and explain the rationale for testing. Properly outlining the disease course and managing symptoms can help to reduce bouncebacks and decrease the overuse of antibiotics.

Both rheumatic heart disease and rheumatic fever can be prevented via treatment with antibiotics, most commonly penicillin. Given the extremely low incidence of rheumatic fever in developed, resource-rich countries, aggressive antibiotic therapy for group A strep tonsillitis may not be necessary. [6] The overall duration of tonsilitis is improved by less than one day, and antibiotics have side effects, including GI upset and diarrhea, as well as increased risk for Clostridium difficile infection. If pursuing antibiotic therapy, shared decision making should take place between the patient and the provider. [15] [6]

• Enhancing Healthcare Team Outcomes

Patients with tonsillitis often present with a sore throat, a common symptom with a myriad of possible diagnoses. A thorough history and physical exam performed by the healthcare team is paramount to hone in on a diagnosis.

When diagnosing tonsillitis and implementing treatments, it is important for the healthcare provider to discuss treatment options and choices with the patient, especially when considering the administration of antibiotics. Risks and adverse reactions should be disclosed to the patient when prescribing any drug.

In cases where other diagnoses are possible, it can be helpful to recruit specialists, including otolaryngology, internal medicine, and nephrology, depending on the patient's clinical picture and test results. Additionally, when ordering imaging, it is important to provide the radiologist with physical exam findings to hone in on areas of interest when reading films.

Evidence of treatment effectiveness includes multiple large randomized controlled trials included in several Cochrane review articles. The decision-to treat-model, Centor criteria, has also been evaluated in several extensive studies. The evidence on this topic consists of a broad range of evidence and overall study quality though level 1 evidence is available in regards to the use of antibiotics in GABHS, causing tonsilitis and the use of Centor criteria in risk stratification. Rarer etiologies such as tuberculosis and Lemierre disease, however, exist primarily as level 5 evidence simply as a result of rarity.

Tonsillitis diagnosis and treatment requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. Primary care providers evaluate and order treatments. Ambulatory and otolaryngologic nurses educate patients and their families, updating the team as needed. Pharmacists assess doses, interactions, and compliance. [Level 5]

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Tonsillitis Image courtesy S Bhimji MD

Disclosure: Jackie Anderson declares no relevant financial relationships with ineligible companies.

Disclosure: Elizabeth Paterek declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Anderson J, Paterek E. Tonsillitis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Tonsillitis PPT: Symptoms, Causes, Prevention and Diagnosis

Tonsillitis PPT: Symptoms, Causes, Prevention and Diagnosis Free Download: To understand Tonsillitis, you must understand what are tonsils. Tonsils are two oval shaped soft tissues present at both the sides-one tonsil each side of the back of our throat. Tonsillitis is a common infection of the tonsils. Its symptoms are sore throat, swollen tonsils, tender lymph nodes on the sides of the neck and difficulty swallowing food.

Tonsillitis can cause mainly because of any common cold virus. But sometimes, bacteria also cause tonsillitis. Tonsillitis generally get cured by its own, but you must know when to visit a doctor. When tonsillitis occurs frequently, you must have to go through a surgery to remove the tonsils.

Table of Content

• What is Tonsillitis?
• Types of Tonsillitis
• Tonsillitis vs. strep throat
• Causes of Tonsillitis
• Home Remedies

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Acute Tonsillitis – Clinical presentation and Treatment

This article is mainly intedend for use by medical professionals.

Acute tonsillitis is an inflammatory condition of tonsil lasting less than 3 weeks duration.

The tonsils are composed of lymphatic tissue and are a component of Waldeyer’s ring in the lateral oropharynx. They are found between the palatoglossal arch anteriorly and the palatopharyngeal arch posteriorly, known as the palatine arches or pillars. They serve as an important defense against ingested pathogens by providing the initial immunological barrier to insults

It may occur

• as an isolated episode
• most common viruses are rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus.
• other viral causes such as Epstein-Barr (causing mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV may also cause tonsillitis.
• as a part of systemic infections like Infectious Mononucleosis (IMN)
• Staphylococcus aureus ,  Streptococcus pneumoniae , and  Haemophilus influenza have also been cultured.
• Corynebacterium diphtheriae causing diphtheria in unvaccinated patients.
• a wide variety of other organisms, anaerobes and virus are also implicated – HIV, syphilis, gonorrhea, chlamydia and Tuberculosis

Epidemiology

• It constitutes approximately 1.3% of outpatient visits
• The condition is more common in children, during autumn and winter months.
• GABHS accounts for 5% to 15% of adults with pharyngitis and 15% to 30% of patients between the ages of five and fifteen.
• GABHS is rare in children under two years of age.
• Viral etiologies are more common in patients under five.

Types of acute tonsillitis

• Acute catarrhal / superficial tonsillitis – Tonsillitis is part of generalized pharyngitis and mostly seen in viral infections.
• Acute follicular tonsillitis – Infection spreads to tonsillar crypts which become filled with purulent material presenting at openings of crypts as yellow spots
• Acute membranous tonsillitis – Exudation from crypts coalesces to form a membrane on surface of tonsil.
• Acute parenchymatous tonsillitis – uniformly enlarged and red tonsil because of involvement of tonsil substance.

Clinical presentation

• Symptoms – History or fever, sore throat, painful swallowing
• Signs – pharyngeal congestion with or without tonsillar exudates, tender anterior cervical lymphadenopathy.

Differential diagnosis

• Pharyngitis, retropharyngeal abscess, epiglottitis, and Ludwig angina
• Dental or peritonsillar abscess
• Kawasaki disease, Coxsackie virus, primary HIV, Ebstein-Barr virus, and oral Candidiasis
• Acute tonsillitis is a clinical diagnosis
• Diagnosis of causative agent has little role in management as both bacterial and viral tonsillitis tend to resolve quickly without treatment in most cases. Hence throat swab and culture is usually indicated in severe cases only.
• Results can take upto 24-48 hours.
• Throat swab may yield positive culture for GABHS. But this may be false positive as positive culture is seen in upto 40% of asymptomatic carriers.
• Carrier states are common among false negative patients – can be identified by ASO titer assessment – will have a positive culture for hemolytic streptococci with a negative ASO titer.
• This is an office procedure with high speed in reporting – results obtained usually within 10 minutes.
• Specific (88% to 100%) but is not sensitive (61% to 95%) – false negatives are possible.
• A mononucleosis spot test can be a consideration when the Ebstein-Barr virus is suspected (usually will have kissing tonsils ).
• Indicated in patients with unstable vital signs, toxic appearance, inability to swallow, inability to tolerate oral intake, or trismus etc.
• CT imaging of the neck with intravenous contrast to exclude dangerous causes such as abscess, Lemierre disease, and epiglottitis.
• Complete blood count and basic metabolic panel to assess renal function, etc. also to be considered accordingly.

Treatment of acute tonsillitis

• a four-point scoring system used to assist with risk stratification for pharyngitis and clinical decision making.
• The four components of the Centor Criteria are: fever, tonsillar exudate, anterior cervical lymphadenopathy, and absence of cough.
• The Centor Criteria was originally validated in patients 15 years of age and older. The McIsaac Criteria, which is also referred to as the modified Centor criteria, uses the same four clinical features, but also provides an age adjustment to the final score and can be used in patients 3 years of age and older.
• In patients scoring 0 to 1, no further testing or antibiotics is necessary. In patients scoring 2 to 3 points, rapid strep testing and throat culture is an option. In patients with scores of 4 or more, clinicians should consider testing and empiric antibiotics.
• Hospital admission is rarely necessary.
• Principally supportive with use of analgesics and adequate hydration.
• Paracetamol (Acetaminophen) is the first line.
• Average duration of an acute tonsillitis is 2-3 days.
• But studies have shown only marginal evidence in blanket antibiotic therapy. Evidence shows only a limited role for antibiotics.
• at high risk of bacterial pharyngitis based on Centor criteria and antigen testing or throat culture, antibiotics are often used in treatment.
• in whom no signs of improvement within 48-72 hours.
• with high rates of complications, especially rheumatic heart disease and rheumatic fever.
• Drug of choice is penicillins for a seven-ten-day oral regimen course / or a single benzathine penicillin G intramuscular injection.
• In patients who are allergic to penicillins a 5-day course of azithromycin or a 10-day course of cephalosporin to be considered.
• A single dose of dexamethasone as adjuvant therapy is of significant benefit in reducing pain of acute tonsillopharyngitis with no evidence of predisposition to abscess formation.
• Most cases are self-limiting infections with excellent prognosis.
• In cases with GABHS complications, (e.g. rheumatic fever and glomerulonephritis) patients can have long-term sequela, like cardiac valvular disease and decreased renal function.
• Alternative diagnosis like HIV, Tuberculosis, gonorrhea, chlamydia, syphilis, mononucleosis, Kawasaki disease, abscess, and Lemierre syndrome should be suspected in patients with no symptomatic improvement.

Complications of acute tonsillitis

• Sepsis – septicemia, septic arthritis
• GABHS – exanthematous reaction – Scarlet fever, Rheumatic fever and Glomerulonephritis.
• Psoriasis exacerbation – mainly by GABHS – probably immune related
• Peritonsillar cellulitis
• Peritonsillar abscess / Quinsy
• Retropharyngeal Abscess (RPA)
• Parapharyngeal Abscess (PPA)
• Lemierre’s syndrome
• Recurring infections every few weeks or months arbitrarily defined as five or more tonsillitis episodes in one year.
• There is currently no way in predicting those individuals whom recurrence can happen.
• Primary immunodeficiency requires consideration in such patients.
• Supportive measures continue to be appropriate, and management of more severe symptoms may need antibiotic therapy.
• Tonsillectomy should be recommended in cases where quality of life is affected (refer Paradise criteria for tonsillectomy ).
• Clinical condition where patient is never free from discomfort in throat associated with enlarged inflamed looking tonsil punctuated with acute episodes which may be either mild or severe.
• Chronic low grade symptoms like feeling of ill health, throat discomfort, production of unpleasant smelly white or yellow debris from tonsillar crypts lasting more than 3 weeks.
• Squeeze test / Irwin Moore sign – squeezing out of pus / whitish material from the tonsillar follicles on pressing of anterior pillars is a classical sign in chronic tonsillitis.
• Children with chronic tonsillitis may have failure to thrive, low body weight etc. Recommend tonsillectomy in such cases.
• Rarely these debris may become inspissated and calcified to form tonsillolith .
• Chronic Follicular tonsillitis : Tonsillar enlargement is associated with the presence of prominent inflamed follicles.
• Chronic parenchymatous tonsillitis : Tonsils are enlarged but the follicles are not prominent. Infection is found within the substance of the tonsil.
• Chronic fibroid tonsils : Tonsils are small, infected with repeated history of sore throats.

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4:  Pharyngitis

Frank S. Yu; Jonathan C. Cho

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Chief Complaint

“Mommy, my throat is on fire!”

History of Present Illness

JT is a 7-year-old Chinese American female, accompanied by her mother, who presents to the community pharmacy with complaints of sore throat and fever, looking for medications to take to relieve her symptoms. She is fussy and describes the pain when she swallows as feeling if her throat is “on fire.” Her symptoms began yesterday morning, and she has only tried drinking a pei pa koa syrup containing medicinal herbs (main active herb is elm bark) and honey to relieve the sore throat. This provided some relief but the pain has been getting worse. She did not have a temperature taken, but her forehead was hot to the touch. She was not given any medications to relieve the fever. She was dressed with additional clothing and blankets to “sweat the fever out,” but the fever still persisted. She reports that there may have been other sick classmates. She denies a prior history of sore throat.

Past Medical History

Attention-deficit disorder, recurrent otitis media (resolved)

Surgical History

Family history.

Non-contributory

Social History

Ear tubes at age 2

Amoxicillin (throat swelling, difficulty breathing)

Home Medications

Methylphenidate ER 18 mg PO daily

Physical Examination

Vital signs.

Temp 101.9°F (oral), Ht 4′4″, Wt 29.55 kg

Appears uncomfortable, tired, grimacing when swallowing

Anterior cervical lymph nodes enlarged and tender; tonsils moist, red, with white exudates

Point-of-Care GAS Rapid Antigen Detection Test

1. What is the most common pathogen responsible for acute bacterial pharyngitis in children?

A. Corynebacterium diphtheriae

B. Neisseria gonorrhoeae

C. Group C streptococcus

D. Group A streptococcus

2. What signs and symptoms in this patient definitely discriminate between GAS pharyngitis rather than viral pharyngitis?

A. Tonsils with white exudates

B. Temperature 101.9°F

C. Pain on swallowing

D. All of the above

3. If GAS is suspected, what age range is typically excluded for testing for GAS?

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Tonsillectomy

Sep 05, 2014

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Tonsillectomy. Prof. Dr. Medni Mahmoud Otolaryngealology Ain Shams University. Indications. 1- Frequent attacks of acute tonsillitis ( more than 3 attacks/year for at least 2 years). 2- One attack of Quinsy. 3- Chronic tonsillitis.

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• cervical adenitis
• rheumatic fever
• 2 advantages
• 3 fasting 6 hours

Presentation Transcript

Tonsillectomy Prof. Dr. Medni Mahmoud Otolaryngealology Ain Shams University

Indications • 1- Frequent attacks of acute tonsillitis ( more than 3 attacks/year for at least 2 years). • 2- One attack of Quinsy. • 3- Chronic tonsillitis. • 4- Chronic marked hypertrophy of tonsils interfering with respiration. • 5- When acts as septic focus. • 6- Diphtheria carrier. • 7- Cervical adenitis ( non specific). • 8- T.B. cervical adenitis. • 9- Impacted F.B. • 10- Benign tumour or for excision biopsy. • 11- Recurrent otitis media, sinusitis, arthritis. • 12- As a part of other surgeries: a) part of UVPP. b) Resection of styloid process.

Contraindications • 1- Absolute ( rare): A- Hemorrhagic blood diseases e.g : hemophilia. B- Vital organs failure. C- Short or cleft palate. D- Malignancy or when it’s a part of systemic affection. • 2- Relative : A- Acute tonsillitis: after 2-3 weeks. B- Acute URTI : commenst cause to postpone surgery. C- Active Rheumatic fever. D- Poliomyelitis epidemics. E- D.M. or HTN.

Preoperative preparations • 1- History : to exclude contraindications. • 2- General examination: to evaluate condition of the patient and anesthesia. • 3- Investigations: A) Blood : CBC, ESR, Hb%, PT and bleeding and clotting time. B) Urine analysis. C) CXR. D) ECG.

Preparations few days before surgery • 1- Penicillin for at least 4 days for any cardiac patient e.g. M.S. • 2- Patients with history of Rheumatic fever: a- All signs of activity should disappear. b- Stop salicylates 2 weeks before. c- Double dose of cortisone if patient on it. • 3- fasting 6 hours before surgery. • At morning of operation: 1- measure temp. 2- ask about menses. 3- immediately before surgery give atropine to decrease saliva in pharynx. ( not in cardiac patient).

Postoperative care • Immediate: 1- Position. 2- Advantages of position: a- allows early detection of bleeding. b- any vomitus not inhaled. c- avoid falling back of tongue and obstruction of airway. d- allow observation of lips and cyanosis. • Late ( 7-10 days): 1- Antibiotics for 7-10 days. 2- Pain killer 3- Diet: A- fasting 2-3 hours after operation. B- first 24 hours give cold soft diet and fluids. C- second day : Semi-solid at normal temp. D- third day : normal diet and avoid hard spicy foods. E- avoid constipations. F- Rest for 7 days.

Complications • 1- complication of anesthesia. • 2- Hemorrhage: commenst A- Primary. B- Reactionary . C- Secondary. • 3- Injury of nearby structures. • 4- Infection. • 5- Incomplete removal. • 6- Inhalation. • 7- Pulmonary complications.: A- respiratory obstruction. B- aspiration pneumonia. C- lung abscess.

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