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Pharyngitis and Tonsillitis
accounts for a substantial portion of visits to Pediatrician
and general practioners. Although rarely fatal, they are a
source of significant morbidity and carry a significant
economic burden.
Tonsils are paired mass of lymphoid tissue situated on lateral
wall of oropharynx. They are also enlarged along with adenoids
since they are situated in between two tonsillar pillars their
exact size is difficult to assess clinically. They are
concerned mainly with the local immunity and the immune
surveillance. From the clinical point, the enlargement of the
tonsils indicates a beta-lymphocyte proliferation.
Approximately two thirds of the lymphocytes that makeup the
lymphoid tissues of Waldeyer's ring are beta-lymphocytes, the
remainder being either T lymphocytes or plasma cells. The
immunologic role of Tonsils and Adenoids is to induce
secretary immunity and to regulate the production of the
secretary immunoglobulins and provide primary defense against
foreign matter. Lymphoid tissue of Waldeyer's ring is most
immunologically active between 4-10 years of age with a
decrease after puberty no major immunologic deficiency has
been demonstrated after removal of either or both of the
tonsils and adenoids.
Most of these infections are viral but a practioner should
always consider the likelihood of group. A beta-hemolytic
streptococcus (GABHS), which is important to identify and
treat because of its potentially serious complications. Other
less common causes should be considered when symptoms are
worrisome or prolonged.
:: ETIOLOGY
1. Age : More common in 3-8 years.
G.A.B.H.S. Pharyngitis > 3 Years
Adenovirus Pharyngitis< 3 years
Mycoplasma Pharyngitis > 8 years
2. Sex : Both males & females are equally affected.
3. Season : Winter Influenza virus & G.A.B.H.S. Spring Adeno &
Parainfluenzae Summer & fall Enterovirusesz Predisposing
factors-
a) Ingestion of cold foods.
b) Contact with infected children.
c) Polluted ill ventilated environment.
d) Pre existing upper respiratory tract infection.
e) Sinusitis.
f) Lowered general resistance.
4. Causative Agents :
a) Bacterial
i. Group A betahemolytic streptococcus (GABHS)
ii. Staph. Aureus; strep. Pneumonaiae; H.influenzae.
iii. Mycoplasma Pneumoniae and C. trachomatis.
iv. C. Diphtheriae.
v. Non-group A betahemolytic strep.(Group C).
vi. N. Gonorrhoeae.
vii. Aracano bacterium hemolyticum.
b) Viral
i. Rhino virus; corona virus 40 to 50%
ii. Influenza and Para influenza viruses 20 30%
iii. Adeno virus (Pharyngo conjunctival fever).
iv. Esptein Barr virus (Infectious mononucleosis).
v. Coxsackie virus (Herpangina) and hand foot mouth dis.
vi. Herpes simplex (Gingivostomatitis).
vii. Human metapneumo virus.
viii. Measles and chicken pox
::CLINICAL FEATURES
(a) Acute Infection
(1) Symptoms
i. Sore throat.
ii. Dysphasia.
iii. Refusal to eat.
iv. Fever; malaise; Headache.
v. Earache
(2) Signs
i. Hyperaemia of pillars; soft palate and uvula
ii. Red swollen tonsils.
iii. Tender juglodigastric L.N.
(b) Chronic Infection
(1) Symptoms
i. Halitosis.
ii. Chronic sore throat.
iii. Foreign body sensation or foul tasting sensation.
iv. Thick speech
(2) Signs
i. Varying degree of tonsilar enlargement
ii. Pus pockets on tonsils
iii. Pressure on the ant. Pillar frank pus or cheesy
material comes out from crypts.
iv. Flushing of ant. Pillar
v. Enlarged juglodigastric L.N.
:: DEGREE OF ILLNESS IN
PHARYNGITIS/ TONSILLITIS
:: DIAGNOSIS
Clinical
The onset of streptococcal pharyngitis is often rapid with
prominent sore throat, high fever, headache and g.i.
symptoms.(Abd. pain and vomitings).
Pharynx is red and the tonsils are enlarged and classically
covered with yellow exudates. There may be petechae or
'doughnut' lesions on the soft palate and posterior pharynx
and the uvula may be red stippled and swollen.
The onset of viral pharyngitis may be more gradual and
symptoms more often include rhinorrhoea, cough and diarrhea. A
viral etiology is suggested by presence of conjunctivitis;
cough and hoarseness of voice. Adeno virus pharnygitis is with
concurrent conjunctivitis and fever (phango conjunctival
fever). Coxsackie virus pharyngitis produce small 1-2mm
grayish vesicles and punched out ulcers in the posterior
pharynx or 3-6mm yellowish white nodules on posterior pharynx
(Acute lymphnoduclar pharyngitis).
:: Streptoccal V/s viral pharyngitis
:: LABORATORY DIAGNOSIS
Even when the clinical picture is highly suggestive of
streptococcal pharyngitis, laboratory confirmation is strongly
recommended. Rapid antigen detection tests (RST) are highly
specific with sensitivity from 80-90%. Throat cultures are the
gold standard for diagnosis and indicated when ever the RST
results are negative.
CLINICAL
Laboratory
Blood counts & P.B.F. examination
Increased TLC with increased polys bact. inf.
Decreased TLC with increased lympho viral. inf.
Atypical lymphocytes E.B.V. inf.
Rapid Antigen Detection Test
Highly specific (>95%) and early results. Less sensitive
(80-85%).
Throat swab culture
for G.A.B.H.S. Highly sensitive (90-95%) Delay in
diagnosis (>24 hrs).
for Viruses Too expensive Usually not available
Viral P.C.R.
More rapid Too expensive Not always necessary
COMPLICATIONS
(a) Local
Chronic Tonsillitis Peritonsillar Abscess (Qunisy)
Retropharyngeal abscess Acute otitis media; mastoiditis;
sinusitis
Supputative cervical lymphadeuitis
(b) Systemic
Acute Rheumatic fever. Post streptococcal reactive
arthritis
Acute glomerulonephritis. Pediatric autoimmune
neuropsychiatric
disorders (PANDAS).
DIFFERENTIAL DIAGNOSIS
Infectious mononucleosis. Diphtheria
Vincents angina Thrush
Scarlet fever Leukemia
Keratosis of the tonsil.
TREATMENT
(1) Bed rest
(2) Analgesics to reduce fever and throat pain.
(3) Hot saline gargles.
(4) Antibiotics
(5) Tonsillectomy
Role of Antibiotics
Most untreated episodes of streptococcal pharyngitis
resolves spontaneously in a few days but early antibiotic
therapy hastens recovery by 12-24 hours. The primary benefit
of treatment is prevention of acute rheumatic fever if an
antibiotic is started within in nine days of illness. Do not
wait for the culture.
Indications of Antibiotic Therapy
Rapid streptococcal Antigen Test Positive.
Household contacts with strep.pharyngitis.
A past history of Acute Rheumatic fever.
Recent history of Acute Rheumatic fever in a family member.
Clinical Diagnosis of Scarlet fever.
Antibacterial agents
Penicillin V : <13yrs 250mgB.I.D. x10days; >13yrs 500mg
B.I.D.x10days
Amoxycillin : 50mg/kg/d x 6days. Or >3yrs 750mg O.D. x10days
Erythromycin estolate : 20-40mg/k/dx10days
Azithromycin : 12mg/kg/d x5days
Cefadroxil : 30mg/kg/d x10days
Inj. Benzathine Penicillin:
6lac units - <27kg. IM single dose; 12lac unit >27kg IM single
dose
If after treatment for 10days therapy S.pyogenes still persist
:
Inj. Benzathine penicillin or Amoxycillin clavulanate or
cephalosporin x10days If this fails
Clindamycin 20mg/kg/day x10days. Or
Inj. Benzathine penicillin + Rifampicin -20mg/kg/days
x4days.
TONSILLECTOMY
Tonsillectomy alone is usually performed for recurrent or
chronic pharyngotonsillitis. Although there are no strict
criteria for number of infections, many experts support for
the criteria developed for the childrens hospital of
Pittsburgh study.
(a) Absolute
(1) Recurrent infections of throat defined as :
a) 7 or more episodes in preceding one year. Or
b) 5 or more episodes per year for 2 years. Or
c) 3 or more episodes per year for 3 years. Or
d) Two weeks or more of lost school or work in one year.
However clinical indicators developed by the American Academy
of otolaryngology suggest the occurrence of 3 or more treated
infections per year is sufficient to warrant surgical
intervention.
(2) Peritonsillar abscess
(3) Hypertrophy of tonsils causing
a) Airway obstruction (sleep apnoea)
b) Difficulty in deglutition
c) Interference with speech.
(4) Suspicion of malignancy (Biopsy)
(b) Relative Indications of Tonsillectomy
(1) Diphtheria carriers, who donot respond to antibiotics.
(2) Streptococcal carriers.
(3) Recurrent streptococcal tonsillitis in a patient with
valvular heart disease.
(4) Chronic cryptic tonsillitis.
Tonsillectomy has been shown to be effective in reducing the
number of infections and the symptoms of chronic tonsillitis
such as halitosis, persistent or recurrent sore throats, and
recurrent cervical adenitis.
ADENOIDS (Nasopharyngeal Tonsils)
Adenoids is sub epithelial collection of lymphoid tissue
shaped like a bunch of bananas occupying the space between the
nasal septum and posterior pharyngeal wall.
Enlargement of the adenoids is common is young children and is
often associated with chronic rhinosinusitis. Size of adenoids
varies from child to child. The maximum size is attained
between 3-7 years and then regress.
Adenoid enlargement is mainly due to infection and at times
due to allergy also.
The situation of the adenoids is in close relation to
Eustachian tube, posterior end of the nose and to the
oropharynx. Hence its enlargement could impair the functions
of the Eustachian tube, nasal breathing and middle ear. The
enlarged adenoids cause blockage of normal nasal drainage and
later sinusitis. Both infections and enlargement of adenoids
can result in disease of sinuses and the ears.
Clinical features
1. Due to nasal obstruction- mouth breathing, nasal
discharge and voice
become nasal (rhinolalia clausa).
2. Due to eustachians tube blockage- Earhche, deafness,
secretory otitis media
and later on chronic S.O.M.
3. Due to mouth breathing- dribbling of saliva, noisy
breathing at night, high
arched palate and chronic pharyngitis.
4. General- mental backwardness and lethargy.
Diagnosis
1. Adenoid facies develops due to chronic infection of the
adnoids and
characterized by -
a. Open mouth b. Pinched nostrils
c. Nasal discharge d. Narrow maxillary arch
e. Crowded protruding teeth f. Vacant facial expression
2. X-ray lateral skull
3. Nasal endoscopy
4. Examination under general anesthesia to visualize or
palpate adenoids.
5. CT Scan.
Differential Diagnosis
1. Nasal obstruction due ot antrochoanal polyp, sinusitis,
rhinitis, turbinate hypertrophy, etc.
2. Dental abnormality giving an appearance of high arched
palate and crowded protruding teeth.
3. Thornwaldts cyst, which is found in the midline of the
nasopharynx.
ADENOIDECTOMY (Alone)
Adenoidectomy alone may be indicated for the treatment of
chronic nasal infection (chronic adenoidits), and chronic
sinusitis that have failed medical management.. In
Adenoidectomy with tonsillectomy adenoids are removed first
and nasopharynx is packed before tonsillectomy.
Indications
(1) Adenoid hypertrophy causing nasal obstruction.
Snoring; mouth breathing
Sleep apnoea syndrome (Sleep disordered breathing)
Speech abnormalities (rhinolalia clausa)
(2) Recurrent rhinosinusitis.
(3) Chronic secretory otitis media
(4) Recurrent ear discharge in benign CSOM.
(5) Dental malocclusion.
ADENOIDECTOMY AND TONSILLECTOMY (Adenotonsillectomy)
The Criteria are same as that of tonsillectomy alone, the
other indications are: Upper airway obstruction secondary to
adenotonsillar hypertrophy that results in
Sleep disordered breathing.
Failure to thrive.
Craniofacial or occlusive developmental abnormalities;
Speech abnormalities.
Cor pulmonale.
Recurrent or persistent middle ear problem.
OUTCOME OF SURGERY
Tonsillectomy
Reduced number of visits to the G.P. for sore throat.
School absentsism due to sore throat reduced.
Reduced courses of Antibiotics for sore throat.
Patients and parent satisfaction rate > 90% (Scottish
Tonsillectomy Audit)
Adenoidectomy
Relief from OME and number of ear infections.
Clears the mouth breathing, snoring and hyponasality
Reduced number of visits to GP for ear complaints.
Improvement in speech and educational performance.
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