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Anatomy of Tonsil and Acute Tonsillitis-Differential Diagnosis And Management PowerPoint Presentation

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Description : Check out this medical presentation on Ear, Nose, and Throat Facts, which is titled "Anatomy Of Tonsil & Acute Tonsillitis – Differential Diagnosis And Management", to know about the anatomy of tonsil and acute tonsillitis, and differential diagnosis and management.

Tags : Ear, Nose, Throat Facts, Anatomy, Tonsil, Acute Tonsillitis, Differential Diagnosis, Management

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Slide 1-

Dr.Nayana V G Anatomy Of Tonsil & Acute Tonsillitis – Differential Diagnosis And Management
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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
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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
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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
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MEDIAL SURFACE Non keratinising stratified squamous epithelium Dips into tonsils to form CRYPTS 12-15 crypts Largest – CRYPTA MAGNA or INTRATONSILLAR CLEFT Represent opening of second pharyngeal pouch
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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
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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
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TONSIL BED
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TONSIL – ARTERIAL SUPPLY
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VENOUS DRIANAGE Paratonsillar vein Common facial vein & pharyngeal plexus IJV
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LYMPHATIC DRAINAGE No afferent lypmhatic supply Jugulodiastric node below angle of mandible NERVE SUPPLY Lesser palatine br of sphenopalatine ganglion Glossopharyneal Nerve.
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Histology
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DEVELOPMENT EPITHELIUM DEVELOPS –VENTRAL PART OF SECOND PHARYNGEAL POUCH LYMPHOCYTES –MESODERMAL ORIGIN
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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
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NORMAL FLORA - GABHS - Hemophilus - Staph. aureus - Alpha hemolytic streptococci - Moraxella - Mycoplasma - Chlamydia - Anaerobes - Respiratory viruses
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DISORDERS Infection / inflammation Hypertrophy - U/L or B/L Tumors - benign / malignant
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ACUTE TONSILLITIS PRE DISPOSING FACTORS Fatigue Extremes of climate Pre-existing URTI Metabolic or immune disorder
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EPIDEMIOLOGY Affects both sexes All age groups are affected; increased in children Autumn and winter Rare in infants and age more then 50 years
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CLASSIFICATION a/c catarrhal a/c follicular a/c membranous a/c parenchymatous
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A/c CATARRHAL A/c superficial / congestive Initiated by viral infection As a part of pharyngitis Mainly local symptoms
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A/c FOLLICULAR Suppurative Follow superficial tonsillitis/reactivation of subclinical infections Inflammation of mouth of crypts Presents with both local and systemic symptoms
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A/C MEMBRANOUS Stage ahead of follicular Exudates at the crypts coalesce to form a membrane Local and constitutional symptoms
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A/C PARENCHYMATOUS Tonsillar substance is affected Uniformly enlarged and congested More obstructive symptoms
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AETIOLOGY GABHS Staphylococci Pneumococci Hemophilus Anaerobic Secondary to viral infection
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FEATURES Fever with chills and rigor Sorethroat Odynophagia Dysphagia Voice changes Pain neck Cervical lymphadenopathy Earache Abdominal pain
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OROPHARYNX
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Grading the Size of Tonsils BRODSKY;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%
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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 tonsillar areas Rapid antigen testing (RAT) for GABHS
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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
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COMPLICATIONS LOCAL Quinsy Intratonsillar abscess Parapharyngeal abscess Retropharyngael abscess Suppurative jugulodigastric lymphadenitis Lemierre’s syndrome SYSTEMIC a/c glomerulonephritis SABE Exacerbation of psoriasis Acute rheumatic fever
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1.QUINSY Collection of pus between tonsillar capsule and bed Follows recurrent tonsillitis/inadequately treated c/c tonsillitis Theories- 1] pus tracking into the supratonsillar fossa 2] infection of peritonsillar salivary gland-Webers gland
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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
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SIGNS Uvula is deviated away from the abscess Tonsil pillars and soft palate congested u/l peritonsillar bulge Cervical LNE Torticollis; Signs of dehydration
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MANAGEMENT Routine investigations Supportive measures Parenteral antibiotics Early cellulitis can be managed conservatively If frank abscess ;incision and drainage
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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
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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
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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 Necrotising fascitis Perichondritis of thyroid cartilage Spontaneous hemorrhage from carotid or IJV
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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
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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
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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
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5.SPONTANEOUS HAEMORRHAGE Occasionally spontaneous haemorrhage from 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
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SYSTEMIC COMPLICATIONS a/c rheumatic fever } immune a/c PSGN } complex Exacerbation of psoriasis (guttate variety) Scarlet fever SABE
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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
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RECURRENT TONSILLITIS H.influenza and Staph.aureus 7 or more episodes of a/c tonsillitis in one year 5 episodes for 2 consecutive years 3 episodes for 3 consecutive years
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CHRONIC TONSILLITIS Persistent inflammation of tonsils as a result of recurrent a/c or subclinical infections Usually adults; gram positive organisms Predisposing - c/c infection in sinuses /teeth c/f -recurrent sore throats; cervical LNE; halitosis; thick speech; increased episodes of URTI
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D/D OF ADENOTONSILLAR INFLAMMATION / INFECTION
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INFECTIOUS MONONUCLEOSIS Caused by EBV Young adult Dirty grey membrane over tonsils not responding to antibiotics, sore throat, dysphagia and odynophagia Other manifestations include liver damage, generalised LNE, skin rash, splenomegaly
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Upper airway obstruction can occur due to severely enlarged tonsils which can be life threatening Petechiae at the junction of hard & soft palate Method of transmission – Oral contact
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Diagnosis DC– 50% lymphocytosis with 10% atypical lymphocytes Monospot & Paul Bunnell test Management: Symptomatic Recovery takes weeks Antibiotics for 2o bacterial infection Ampicillin should be avoided If severe respiratory obstruction – high dose steroid therapy If not relieved – either an adenotonsillectomy or a tracheostomy
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DIPHTHERIA Exudative pharyngotonsillitis Suspected in a very toxic child Dirty grey membrane over tonsils extending to pillars, palate and posterior pharyngeal wall
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DIPHTHERIA Lethal exotoxins Removal of membrane causes bleeding. Firm leathery membrane Bull neck due to LNE – even in mild cases Condition of the patient deteriorates secondary to airway obstruction
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Diagnosis Fluorescent antibody studies Gram staining – Klebs-Loffler bacillus Culture TREATMENT Adequate hydration Antibiotics – Pencillin – in high doses-benzyl pn-600mg 6hrly for 7 days/erythromycin Antitoxin – within first 48hrs Airway obstruction - tracheostomy
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VINCENT’S ANGINA Borrelia vincenti and Bacillus fusiformis M.C.in over crowded conditions Fever, headache, sore throat, cervical lymphadenopathy Membrane over the tonsil and on removal  an ulcer remain confined to the surrounding tissue & usually heals in 7-10 days Rx – Penicillin, local hygiene
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SCARLET FEVER Thick membranous tonsillitis with marked erythema of oropharyngeal mucosa Strawberry tongue with prominent lingual papillae and characteristic scarlatine rash Due to endotoxin produced by streptococcus Diagnosis : Bacteria in throat cultures, Immune testing – Dick’s test or Schultz – Charlton blanching phenomenon
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AGRANULOCYTOSIS Ulcerative necrotic lesion over tonsil and oropharynx Patient severly ill. TLC <2000 cu.mm upto 50 cu.mm and PMN <5%
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LEUKEMIA C/F –fatigue,headache,sorethroat,f/o acute tonsillitis,stomatitis,bleeding from mucous membrane Bone marrow- blat cells
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APHTHOUS ULCER Involve any part of oral cavity and oropharynx Tonsil and pillars Solitary,painful Small or large
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MALIGNANCY TONSIL Persisitent sore throat,,difficulty in swallowing,pain in the ear,lump in the neck Biopsy
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TRAUMATIC ULCER Accidental trauma Heals by memebrane formation Within 24 hrs
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OTHER MISCELLANEOUS CONDITIONS Fungal infection – Candida – immunocompromised removal of membrane – raw bleeding surface Leukoplakia Pemphigus Granulomatous diseases like T.B,Syphilis Leishmaniasis Neisseria gonorrhoea – M.C.in homosexual males as a part of gonococcal pharyngitis Crohn’s disease – serpigenous ulcers over tonsil
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DIAGNOSIS OF ULCERO-MEMBRANEOUS LESION OF TONSIL HISTORY Physical Examination TLC and DC (Agranulocytosis,leukemia,IMN) Blood smear(for atypical cells) Bone marrow aspirations and needle biopsy
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Throat swab and culture( pyogenic bacteria,vincents angina ad candidal infections) Special tests: paul bunnel / monospot test(IMN) Biopsy of lesion(malignancy)
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MISCELLANEOUS CONDITIONS OF TONSILS Tangier disease – A yellow orange hypertrophy of the tonsil, a consequence of -lipoprotein deficiency Hyperkeratosis of the tonsils (Keratosis Pharyngeus) White projection on the lymphoid tissues of the pharynx as well as on the tonsils and adenoids Young adults and debilitated Initially thought to be due to Leptothrix buccalis (fungus) or due to some metabolic disturbances
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CLINICAL FEATURES Vague symptoms – FB sensation, recurrent cough O/E: White minute projections from tonsillar crypts or other pharyngeal lymphoid tissues Rx: Primarily supportive Removal by curette or Electrocoagulation
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3)TONSILLOLITHS (Calculi) More frequently in adults Repeated episodes of inflammation -> fibrosis at the openings of the tonsillar crypts ->Bacterial and epithelial debris, then accumulate within these crypts -> retention cyst forms ->Calcification later occurs.
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Certain calculi form from keratohyaline accumulation in the crypts with 2o deposits of salts C/F: Non specific c/c sorethroat and otalgia, foreign body sensation throat. O/E: Stones in the tonsil Rx: Supportive, local excision, tonsillectomy
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