Case Report

Chronic Tonsillitis

Moderator:

Presenter:

Group M.12.2

Jimmi Lihartanadi

Nurul Sardwiyanti

Zaki Horizon Islami

Hanifah Fajarisna Hayati

Maria Angela Stella Wijaya

Rony Trilaksono

Department of Otorhinolaryngology-Head and Neck Surgery

Faculty of MedicineGadjahMada University

DR Sardjito General HospitalYogyakarta

2012

CHAPTER I INTRODUCTION

The symptom of sore throat, depending on the age of the patient, maybe called tonsillitis or pharyngitis, but is usually treated in the same way. Lack of knowledge among clinicians, general practitioners, and hospital consultants about the conditions and diseases that affect the ear, nose, and throat may result in inappropriate treatment. For example, the majority of acute symptoms that develop in ENT are labelled as caused by an infection with the result that each such clinical scenario is treated by a course of an antibiotic (Paleri, 2010).

Complaints of sore throat, upper respiratory infection (URI), and associated ear disease account for the greatest number of patient visits in most primary care settings dealing with children. Recurrent and chronic infection and obstructive hyperplasia are the most common diseases affecting the tonsils and adenoids in the pediatric population. The recognition of sleep-disordered breathing, ranging from the full blown obstructive sleep apnea syndrome (OSAS) to the more recently recognized upper airway resistance syndrome is increasingly important as it relates to the physical, psychological, and cognitive well-being of both children and adults. Therefore the general practitioner and otolaryngologist plays a critical role in diagnosis and management of diseases of the tonsils and adenoids and their sequelae. Principles and practices of surgical management (preoperatively, intraoperatively, and postoperatively) are changing rapidly as new technology emerges. Precise clinical assessment is particularly important given the scope and nature of problems encountered in children, who are most often affected (Bailey, 2006).

CHAPTER II

LITERATURE REVIEW

II.1 Anatomy and PhysiologyThe body has a system of cells, the immune system, that has the ability to distinguish "self" (the organism's own molecules) from "nonself" (foreign substances). This system has the ability to neutralize or inactivate foreign molecules (such as soluble molecules as well as molecules present in viruses, bacteria, and parasites) and to destroy microorganisms or other cells (such as virus-infected cells, cells of transplanted organs, and cancer cells). The cells of the immune system (1) are distributed throughout the body in the blood, lymph, and epithelial and connective tissues; (2) are arranged in small spherical nodules called lymphoid nodules found in connective tissues and inside several organs; and (3) are organized as differently sized organs called lymphoid organs, the lymph nodes, the spleen, the thymus, and the bone marrow.

Lymphoid nodules and isolated cells of the immune system found in the mucosa of the digestive system (tonsils, Peyer's patches, and appendix), the respiratory system, the reproductive system, and the urinary system are collectively known as mucosa-associated lymphoid tissue (MALT) and may be considered a lymphoid organ. (Junquiera, 2005)

Waldeyer's ring is a circumpharyngeal ring of mucosa-associated lymphoid tissue which surrounds the openings into the digestive and respiratory tracts. It is consist of one pharyngeal tonsil (adenoid), two tuba tonsils, two palatine tonsils, and one lingual tonsil.

The two palatine tonsils are located in the lateral walls of the oral part of the pharynx. They are lined with a squamous stratified epithelium that often becomes so densely infiltrated by lymphocytes that it may be difficult to recognize. The lymphoid tissue in these tonsils forms a band that contains free lymphocytes and lymphoid nodules, generally with germinal centers. Each tonsil has 1020 epithelial invaginations that penetrate the tonsil deeply, forming crypts, whose lumens contain desquamated epithelial cells, live and dead lymphocytes, and bacteria. Crypts may appear as purulent spots in tonsillitis. Separating the lymphoid tissue from subjacent structures is a band of dense connective tissue, the capsule of the tonsil. This capsule usually acts as a barrier against spreading tonsillar infections.

The tonsils are part of secondary immune system. There are no afferent lymphatics to tonsils. Exposed to ingested or inspired antigens passed through the epithelial layer. Immunologic structure is divided into 4 compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle. Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle. Antigen is presented to T-helper cells. T-helper cells induce B cells in germinal center to produce antibody. Secretory IgA is primary antibody produced. It also involved in local immunity.The arterial blood supply and innervation of the tonsil is from inferior pole and superior pole, primarily based at the inferior pole. The inferior pole is consist of the tonsillar branch of the dorsal lingual artery, the ascending branch of the palatine artery and the tonsillar branch of the facial artery. The superior pole is consist of the ascending pharyngeal artery and, anteriorly, from the lesser palatine artery. Venous drainage is more diffuse, with a venous peritonsillar plexus about the capsule. This plexus drains into the lingual and pharyngeal veins, which feed into the internal jugular vein. Lymphatic drainage is usually to the tonsillar lymph node (just behind the angle of the mandible), or to the jugulodigastric or other upper cervical lymph nodes. No afferent lymphatics for tonsils. (Moore, K.L., et al., 2006)

The nerve supply of the tonsil is primarily from the tonsillar branch of the glossopharyngeal nerve, but also has contributions from the descending branches of the lesser palatine nerve. Because the glossopharyngeal nerve also has a tympanic branch, severe tonsillitis frequently presents with referred pain to the ear. (Moore, K.L., et al., 2006)

II.2 Definition

Tonsillitis is inflammation of the tonsils most commonly caused by a viral or bacterial infection. The tonsils are a lymphoid organ in the throat and is therefore susceptible to infection by pathogenic organisms that enter the mouth. Tonsillitis is characterized by swollen tonsils, swollen lymph nodes, fatigue, a fever (in acute cases) and sore throat (Bailey, 2006)..

Acute tonsillitis is an infection of the tonsils caused by one of several possible types of bacteria or viruses. Acute tonsillitis is characterized by either the sudden or gradual onset of a sore throat which is usually associated with fever. The surface of the tonsil may be bright red or have a grayish-white coating (exudate).

Recurrent acute infection has been variably defined as from four to seven episodes of acute tonsillitis in 1 year, five episodes for 2 consecutive years, or three episodes per year for 3 consecutive years (Bailey, 2006).

Chronic tonsillitis is a persistent infection of the tonsils which is usually caused by bacterial infection. Recurrent tonsillar infections sometimes lead to enlargement of the tonsils which is often chronic. It can cause tiny stone (tonsilloliths) formation or even cause small pockets (crypts) formation which shelters bacteria.II.3 Etiology

Chronic tonsillitis may be a complication of acute tonsilitis. Group A b-hemolytic streptococcal (GABHS) is the most commonly infecting organism. Other causes of infection may be Streptococcus pyogenes, Streptococcus viridian, Neisseria gonorrhea, Corynebacterium diphtheria, Pneumococci, Staphylocci and H. influenzae. These bacteria may primarily infect the tonsil or may be secondary to a viral infection. Tonsillitis can also be caused by fungi or parasites, but these causes are rare in people who have healthy immune systems (Dhingra, 2009).

There are several predispositing factors for chronic tonsillitis: smoking, some irritating foods (salty, hot and fried food), poor oral hygiene, seasonal change, physical stress and inadequate treatment of acute tonsillitis (Soepardi, 2007). II.4 Pathophysiologys

A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species having been identified. A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes. H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids (Shah, 2012).

Local immunologic mechanisms are important in chronic tonsillitis. The distribution of dendritic cells and antigen-presenting cells is altered during disease, with fewer dendritic cells on the surface epithelium and more in the crypts and extrafollicular areas. Study of immunologic markers may permit differentiation between recurrent and chronic tonsillitis. Such markers in one study indicated that children more often experience recurrent tonsillitis, whereas adults requiring tonsillectomy more often experience chronic tonsillitis.Radiation exposure may relate to the development of chronic tonsillitis. (Shah, 2012).

Like infections confined to the tonsillar crypts, recurrent inflammations of the tonsil and peritonsillar tissue can lead to permanent structural changes with scarring. Bacteria that grow on cellular debris in poorly drained crypts can perpetuate a smoldering inflammation, chronic tonsillitis. In this condition the palatine tonsil provide a focus that can sustain a variety of diseases in other parts of the body (rheumatic fever, glomerulonephritis, iritis, psoriasis, inflammatory heart disease, pustulosis palmaris and plantaris, erythema nodosum) (Bailey et al, 2006)Inflammation and loss of integrity of the crypt epithelium result in chronic cryptitis and crypt obstruction, leading to stasis of crypt debris and persistence of antigen. Bacteria even infrequently found in normal tonsils crypts may multiply and eventually establish chronic infection. The role of mechanical trauma to the lymphocytes by excessive upper airway vibration as seen in snoring needs further investigation (Bailey et al, 2006).

II.5 Classification

1. Acute TonsillitisSore throat is a common condition in primary care. As many as 1 in 10 people suffer recurrent episodes of tonsillitis. Acute tonsillitis is a common condition often seen in children aged 510 and young adults aged 1525. It is defined as inflammation of the tonsils but may also involve pharyngeal lymphoid tissue. Acute tonsillitis may be either bacterial or viral and is spread by respiratory droplets with an incubation period of 24 days. It is most common in children under 9 years of age. Acute tonsillitis is most commonly viral in origin and can be caused by adenovirus, influenza virus, EpsteinBarr virus (EBV), herpes simplex virus and cytomegalovirus. Bacterial acute tonsillitis is most frequently caused by group A beta haemolytic streptococcus. Symptoms may vary between patients but most will present with one or more localized symptoms such as sore throat, pain on swallowing, enlarged painful cervical lymph glands and earache. In addition, there may be generalized symptoms of malaise, fever and lethargy (Isaacs, 2009).2. Recurrent Acute Tonsillitis

Recurrent acute infection has been variably defined as from four to seven episodes of acute tonsillitis in 1 year, five episodes for 2 consecutive years, or three episodes per year for 3 consecutive years (Bailey et al, 2006)3. Chronic (Persistent) Tonsillitis

Chronic tonsillitis is a common disease, it is not as acute inflammation of the oncoming danger, the symptoms are not severe, because its symptoms are mild, many people think that small problems and paid little attention. In fact a common cause of acute exacerbation of chronic tonsillitis. The sign and symptoms are chronic sore throat, malodorous breath, excessive tonsillar debris (tonsilloliths), peritonsillar erythema, and persistent, tender cervical adenopathy (Knott, 2010)

4. Obstructive Tonsillar Hyperplasia

Enlarged tonsils can cause snoring, with obstructive disturbances (asleep and awake), dysphagia, changes in the craniofacial skeleton, and voice changes (muffling or hypernasality). Enlarged tonsils, by themselves, in the absence of identifiable symptoms that affect health and well-being, need not be removed automatically. (Bailey et al., 2006).A standardized grading classification is proposed based on the ratio of the tonsils to the oropharynx (in the medial to lateral plane) as measured between anterior pillars.

0: tonsil in fossa;

+1: < 25% of tonsils occupy oropharynx;

+2: 25% - 50%;

+3: 50% - 75%;

+4: >75%The narrowest portion of the airway should be used, and the anatomic location of this point should be noted as described in Figure. The contribution of tongue size and position and the shape and size of the hard and soft palate is also not factored in to this grading system (Bailey et al., 2006).

I. Risk Factor

Risk factors for tonsillitis include:

1. Young age: Tonsillitis is most common from the preschool years to the mid-teenage years.

2. Frequent exposure to germs: School-age children are in close contact with their peers and frequently exposed to viruses or bacteria that can cause tonsillitis.

3. Chronic stimulation of the cigarette

4. Poor oral hygiene (from what literature?)II. Diagnosis

a. Sign and Symptoms

Common signs and symptoms of tonsillitis include: Red, swollen tonsils, White or yellow coating or patches on the tonsils, Sore throat, Difficult or painful swallowing, Fever, Enlarged, tender glands (lymph nodes) in the neck, A scratchy, muffled or throaty voice, Bad breath, Stomachache, particularly in younger children, Stiff neck, Headache

In young children, signs of tonsillitis may include: Drooling due to difficult or painful swallowing, Refusal to eat, Unusual fussinessb. Physical ExaminationPhysical examination of tonsillitis :

1. Using a lighted instrument to look at your child's throat and likely his or her ears and nose, which may also be sites of infection

2. Checking for a rash known as scarlatina, which is associated with some cases of strep throat

3. Gently feeling (palpating) child's neck to check for swollen glands (lymph nodes)

4. Listening to his or her breathing with a stethoscope

5. Checking for enlargement of the spleen (for consideration of mononucleosis which also inflames the tonsils)

c. Laboratory Examination

For laboratory examination that suggested for diagnose tonsillitis include:

1. Throat swab With this simple test, the doctor rubs a sterile swab over the back of your child's throat to get a sample of secretions. The sample will be checked in a lab for streptococcal bacteria. Many clinics are equipped with a lab that can get a test result within a few minutes. However, a second more reliable test is usually sent out to a lab that can return results within 24 to 48 hours.

If the rapid in-clinic test comes back positive, then the patient almost certainly has a bacterial infection. If the test comes back negative, then the patient likely has a viral infection. The doctor will wait, however, for the more reliable out-of-clinic lab test to determine the cause of the infection.

2. Complete blood cell count (CBC) The doctor may order a CBC with a small sample of patients blood. The result of this test, which can often be completed in a clinic, produces a count of the different types of blood cells. The profile of what's elevated, what's normal or what's below normal can indicate whether an infection is more likely caused by a bacterial or viral agent. A CBC is not often needed to diagnose strep throat. However, if the strep throat lab test is negative, the CBC may be needed to help determine the cause of tonsillitis.

III. Management:

Definitive treatment for chronic tonsillitis is tonsillectomy. Tonsillectomy used in cases when conservative management fail to ease patients symptoms. Conservative management for chronic tonsillitis include:

1. Usage of antibiotics which are effective against beta-lactamase producing bacteria (e.g: amoxicillin-clavulanate acid; clindamycin) for 3-6 weeks

2. Daily throat irrigation

3. Cleaning of tonsils crypts with tools for oral/teeth irrigation

Tonsillectomy indication may include:

Absolute indication:

Cor pulmonale caused by chronic airway obstruction

Tonsils or adenoid hypertrophy with sleep apnea syndrome

Tonsils hypertrophy which causes dysphagia with weight loss

Excision biopsy result suspect of malignancy

Recurrent peritonsillar abscess

Relative indication:

Recurrent episode of Streptococcus Beta-Hemolytic Group A infection

Recurrent/chronic tonsillitis despite of adequate medication

Tonsils hyperplasia with functional obstruction (e.g: dysphagia)

Permanent tonsils hyperplasia or obstruction in 6 months after mononucleosis infection

History of rheumatic fever with heart dysfunction related with tonsillitis

Tonsils hypertrophy related with abnormality of orofacial anatomy which causes upper airway obstruction

IV. Complication

Complication of chronic tonsillitis: (Chronic tonsillitis act as a focus which can activate other chronic inflammation disease caused by bacterial spread)

Peritonsillar, retropharyngeal, parapharyngeal abscess

Obstructive sleep apnea

Deep neck infectionV. PrognosisA study found that tonsillectomy for recurrent and chronic tonsillitis, can make a large improvements in disease-specific and global quality of life which contain of a reduction in number and frequency of symptoms, days of work missed, doctor visits, antibiotic usage and also, indirectly, on long-term financial savings through avoidance of the aforementioned circumstances.CHAPTER III

CASE REPORTPatient IdentityName

: An. R.U

Age

: 13 years-old

Gender

: Female

Religion: Islam

Occupation: Student (JHS)

Address: Kalibagor, Banyumas

Date of visit: September 25, 2012

ANAMNESIS

Main Complaint : Difficulty in swallowing

History of Present Illness :

A 13 years-old girl came with her mother to ENT policlinic in RSU Banyumas, with complaints of difficulty in swallowing since 3 months ago. Her condition was exacerbated after drinking cold beverage. She did not complain pain during swallowing. She eats in small proportion but quite often. She prefers liquid meals such as soup or porridge.

Her mother reported that her daughter has snoring during sleeping. The patient told she has enough sleep and never feels sleepy during the day. She did not complain any fever, cough, ear pain, ear discharge

History of Past Illness :

2 years ago, patient had similar symptom and diagnosed as tonsillitis by the doctor. She got medication and her symptoms were improved. Her mother reported that her daughter has food allergy (seafood), allergy to dust, and history of asthma attack.

History of Illness in Family :

Similar complaints (-). History of tonsillitis or tonsillectomy in family (-).PHYSICAL EXAMINATION

General Status : well, compos mentis, adequately nourishedVital Sign :

BP = 110/70 mmHg (not measured)??HR= 84 x/minute

RR=24x/minute

T =36.8C

BW= 30 kg

Ear Nose Throat Examination

Ear ( just write ear examination within normal limit, don't need to describe all)AURIS DEXTRAAURIS SINISTRA

InspectionDeformity (-), otorrhea (-), lesion (-)Deformity (-), otorrhea (-), lesion (-)

PalpationTragus pain (-), tenderness in mastoid area (-), palpable lnn. retroauricular (-), lnn. preauricular (-)Tragus pain (-), tenderness in mastoid area (-), palpable lnn. retroauricular (-), lnn. preauricular (-)

OtoscopyDischarge (-), oedema canal (-), erythem (-), cone of light (+) in 5 oclock positionDischarge (-), oedema canal (-), erythem (-), cone of light (+) in 7 oclock position

Turning ForkNot done

within normal limit

Nose ( just write rhinoscopy ant within normal limit, don't need to describe all)RightLeft

Inspection Simmetry (+), deformity (-), discharge (-), deviation (-)Simmetry (+), deformity (-), discharge (-), deviation (-)

PalpationTenderness (-) in nose and sinuses, crepitation (-)Tenderness (-) in nose and sinuses, crepitation (-)

Anterior rhinoscopyHyperemis mucosa (-), oedema conchae (-), septum deviation (-), discharge (-)Hyperemis mucosa (-), oedema conchae (-), septum deviation (-), discharge (-)

Posterior rhinoscopyNot done

within normal limit

not carried outThroatAnatomical StructureFindings

LipsRedness (-), stomatitis (-)

Tooth-GinggivaCaries (-)

TongueRedness (-), tonsila lingua normal

UvulaDeviation (-)

Palatine TonsilEnlargement of right (T3) and left (T3) palatine tonsils, non smooth surface, detritus (-), hyperemis (-), crypt enlargement (+)

PharynxRedness (-)

Not carried out

Not carried outLymphnode = Lnn Submentalis, Lnn Submandibularis are not palpable

DIAGNOSIS

Chronic Tonsillitis

TREATMENT

Management :Tonsilectomy

Education :

1. Proper Diet post operation2. Avoid food that can iritate throat for example oily food, spicy food, cold drink, etc ??3. Keep the mouth hygiene, use mouthwash ??4. Control to doctor 1 week after operationCHAPTER IV

DISCUSSION

Recurrent and chronic infection and obstructive hyperplasia are the most common diseases affecting the tonsils and adenoids in the pediatric population. Diagnosis of chronic tonsillitis is best established on the base of anamnesis and physical examination. Complaints of sore throat, lump sensation in the throat, dysphagia, cough, flu, subfebrile, stridor, and awakening night sleep are often found in patients with chronic tonsillitis. From the physical examination of the patient, enlargement of both palatine tonsils, enlargement of crypts, and present of detritus further reinforce the diagnosis of chronic tonsillitis.

In this patient we could find dysphagia and snoring. Most children with airway obstruction related to adenotonsillar hypertrophy have a history of significant snoring at night. Excessive snoring in itself may be a significant indicator of obstructive sleep apnea, even without a history of witnessed apnea. Descriptions parents may use in cases of significant obstruction include the child snoring like an adult or that they can hear the child snoring outside of the child's bedroom.

However, in this patient, no other supporting examinations were carried out. Chronic tonsillitis is clinical diagnoses. A blood test may be needed to find the type of virus, especially if the infection does not clear up in about two weeks. Throat cultures are the criterion standard for detecting beta-hemolyticStreptococcus pyogenes GABHS.

Tonsillectomy is carried out to this patient because dysphagia is the absolute indication for tonsillectomy. Another absolute indication for tonsillectomy are cor pulmonale, tonsil hypertrophy with apnea, malignancy suspicion, recurrent abscess peritonsilaris. Meanwhile, some relative indications for tonsillectomy are failure of conservative medication, oral temperature is 38.3C, tonsilar exudates, positive culture of GABHS, and recurrent otitis media.

CHAPTER V

CONCLUSIONA 13 year old female patient diagnosed with chronic tonsillitis has been reported. Chronic tonsillitis was determined by complaints of dysphagia and snoring accompanied by physical examinations that shows non erythem enlargement of both palatine tonsils with non smooth surface. Diagnosis of chronic tonsillitis is best established on the base of anamnesis and physical examination. Tonsillectomy was carried out to this patient.

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Soepardi E.A., Ikandar,N., Bashiruddin,J., Restuti,R.D.,2007. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala dan Leher. Edisi ke-6. Balai Penerbit FKUI, Jakarta.Tonsil Hypertrophy

Rough surface

Detritus

Crypt enlargement

T333

T333

1