Acute Tonsillitis

Ieva MuižnieceMF III 1st group

Mentor: Dr. Gunta Sumeraga

Waldeyer’s ring

• The lymphoid tissue surrounding opening into respiratory and digestive systems forms a ring.

• The lateral part is formed by palatine tonsils and tubal tonsils (around the auditory tube opening).

• The upper part is formed by pharyngeal tonsil (on the roof of the nasopharynx).

• The lower part – lingual tonsil (on the posterior 1/3 of tongue)

Waldeyer’s ring

Anatomy of Palatine Tonsils

Situated bilaterally in the lateral wall of the oropharynx in the tonsillar recess bounded by the palatoglossal fold anteriorly and the palatopharyngeal fold posteriorly.

Anatomy of Palatine Tonsils

• Size: 10-15 mm transverse diameter, 20-25 mm vertical diameter.

• Consists of two surfaces (medial and lateral) and two poles (upper and lower)

• Medial surface is covered by non - keratinizing stratified squamous epithelium

• There are 12-15 tonsillar crypts on the medial surface that increase the surface area and the efficiency of protection against pathogens

• Lateral surface is covered by fibrous capsule

Anatomy of Palatine Tonsils• Upper pole extends into soft

palate and lower pole is attached to the tongue

• Total surface: 295 cm²• Lymphatic drainage: lack

afferent lymphatic vessels, only efferent drainage → upper deep cervical lymph nodes (jugulodigastric group of lymph nodes behind the angle of mandible)

Functional Importance in the Immune System

• Significant role in the defense against upper respiratory infections.

• One of the MALT of the upper respiratory tract, which has the ability to mount specific immune reactions in response to antigens.

• Activity is pronounced during childhood, when immunologic challenges from the environment induce hyperplasia.

• ‘’Active phase’’ lasts until about 8 – 10 years of age. • The lymphatic tonsillar tissue becomes less important as

an immune organ.

Functional Importance in the Immune System

• While ‘’learning’’ their immune function during childhood, extreme tonsillar hyperplasia may develop (‘’kissing tonsils’’). Can lead to eating difficulties, respiratory dysfunction, apnea and cor pulmonale. Recommendation – tonsillectomy.

Epidemiology of acute tonsillitis

• Affecting children between the ages of 5 and 15 years.

• Approximately 30% to 40% of tonsillitis cases in children can be attributed to a bacterial cause. Group A beta-hemolytic streptococcus is the most common bacterial pathogen causing tonsillitis.

Definition• Synonym: streptococcal

angina• Acute tonsillitis is the

infectious disease of the whole organism with clinical manifestation in tonsils. The most common place – palatine tonsils, but also lingual, pharyngeal tonsil can be involved.

Etiology• Generally caused by group A beta - haemolytic streptococci

(GABHS)• Moraxella  catarrhalis• Haemophilus influenzae• Staphylococcus aureus• S. pneumoniae• Bacteroides• E. Coli• diphtheria, syphilis, Neisseria• viruses (adenovirus, influenza A and B virus, Epstein-Barr virus 

(EBV), parainfluenza virus, enterovirus, herpes simplex virus)

Etiology

Signs and symptoms

• high fever (38o – 40o C), may be associated with chills and rigors

• severe pain on swallowing, which often radiates to the ear (n.glossopharyngeus)

• swollen tonsillar lymph nodes (cervical adenopathy)• muffling of speech due to oropharyngeal swelling• dysphagia• erythematous tonsils with exudates• halitosis

Signs and symptoms

• general – headache, malaise, anorexia, abdominal pain, pain in the back and limbs

• viral infections tend to have lower grade fevers and less exudative tonsils

• not all signs and symptoms are present in every patient

Classification of Acute Tonsillitis

• Acute catarrhal/superficial• Acute follicular• Acute membranous• Acute parenchymatous• Acute ulcerative

Classification of Acute Tonsillitis

Acute catarrhal/superficial – tonsillitis is a part of generalized infection of the oropharyngeal mucosa, mostly in viral infections.

Classification of Acute Tonsillitis

Acute follicular – infection spreads into the crypts with purulent material, presenting at the opening of crypts as yellow spots.

Classification of Acute Tonsillitis

Acute membranous – follows the stage of an acute follicular tonsillitis where exudates coalesce to form a membrane on the surface.

Classification of Acute Tonsillitis

Acute parenchymatous – the whole tonsil is uniformly congested and swollen.

Classification of Acute Tonsillitis

Acute ulcerative – various subtypes, ulceration can be superficial or deep. Vincent’s angina is a form of ulcerative tonsillitis, ulceration also occurs secondary in syphilis and in diphtheria.

Diagnosis

• Complaints and symptoms• Examination of the throat • Inflammatory parameters – leukocytosis, ESR

and CRP are elevated• Bacteriological testing – rarely taken because it

takes 2 – 3 days to obtain a definitive result.• Rapid immunoassay - can identify the causative

organism as a group A streptococcus in 10 minutes.

Treatment

• For streptococcal tonsillitis is a 10 – 14 day course of penicillin V, amoxicillin + β lactamase inhibitors (clavulanic acid).

• Macrolides or oral cephalosporin can be used in patients allergic to penicillin.

• Analgesics for pain relief, antipyretics to reduce fever (diclofenac, ibuprofen)

• Bed rest, hydration, oral hygiene

ComplicationsLocal/regional Recurrent tonsillitis (6 - 7

episodes in 1 year, 5 episodes per year for 2 consecutive years, 3 episodes per year for 3 consecutive years)

Chronic tonsillitis (sore throat is present for at least 3 months with tonsillar inflammation)

Peritonsillar abscess (several days after the onset of tonsillitis)

Parapharyngeal abscess Retropharyngeal abscess Otitis media

Sinusitis Laryngitis Bronchitis

ComplicationsSystemic

Sequel of streptococcal tonsillitis – rarely, a delayed type antigen-antibody reaction can give rise to poststreptococcal diseases: acute glomerulonephritis (1 to 2 weeks after infection) acute rheumatic fever (1 to 4 weeks) rheumatic endocarditis

Clinical Case

A 5-year-old boy presented to his general practitioner with a 36-h history of acute malaise, shivering and vague pains in his legs. For 12h he had complained of a dry, sore throat and had vomited twice. He was febrile (temperature 40.2°C) with a tachycardia of 140/min and tender, bilateral, cervical lymphadenopathy. His pharynx, tonsils and buccal mucosa were red and inflamed and his tonsils were studded with white areas of exudate. He was diagnosed as having acute bacterial tonsillitis.

Clinical case

• He was treated with penicillin for 5 days. A throat swab taken before starting antibiotics grew beta-haemolytic streptococci (Group A). After 3 days of treatment, his temperature had returned to normal and he made an uneventful recovery.

• Haemolytic streptococcal infections illustrate an important point about bacterial infection - that immune defenses together with antibiotics cope satisfactorily with most bacterial infections in most people.

1. Which clinical form of an acute tonsillitis is showed in the picture?a)Acute catarrhal/superficial b)Acute follicularc)Acute membranousd)Acute parenchymatous

1. Which form of an acute tonsillitis is showed in the picture?a)Acute catarrhal/superficial b)Acute follicularc)Acute membranousd)Acute parenchymatous

2. Which is the most common bacterial pathogen causing tonsillitis?

2. Which is the most common bacterial pathogen causing tonsillitis?Answer: group A beta-hemolytic streptococci

3. Which one of these complications isn’t caused by acute tonsillitis? a)rheumatic endocarditisb)laryngitisc)agranulocytosisd)retropharyngeal abscess

3. Which one of these complications isn’t caused by acute tonsillitis? a)rheumatic endocarditisb)laryngitisc)agranulocytosisd)retropharyngeal abscess

Sources1. Basic Otorhinolaryngology A Step-by –Step- Learning Guide. R.Probst,

G.Grevers, H.Iro Themie 2006, p. 430 2. Otolaryngology : head & neck surgery : clinical reference guide. Raza

Pasha, Justin S. Golub. — 4th edition, 2014, p. 7573. Otolaryngology: Basic Science and Clinical Review Authors: Van de

Water, Thomas R., Staecker, Hinrich Publisher: New York: Themie, 2006, eBook

4. http://the-family-doctor.com/the-family-doctor/t/tonsil.htm5. http://www.uspharmacist.com/continuing_education/ceviewtest/

lessonid/109176/6. http://epomedicine.com/medical-students/applied-anatomy-of-

palatine-tonsils/7. http://www.immunologyclinic.com/case.asp?chap=02&case=3

THANK YOU FOR YOUR ATTENTION!