Tonsillitis扁桃体炎

AnatomyAnatomy

HistologyHistology• Specialized squamous epithelium (E) • hemi-capsule (Cap)• 10-30 Crypts• Lymphoid follicles (F)

Grade of Tonsil Size

Grade % 0 in fossa–1 <25–2 25-50–3 51-75–4 >75

1. Acute Tonsillitis

2. Chronic Tonsillitis

(Recurrent Acute Tonsillitis)

3. Obstructive Tonsillar Hyperplasia

Clinical classification

Acute tonsillitis

Etiology (Etiology (病原学病原学))

• BLPO (beta-lactamase-producing )

• Anaerobic BLPO

• GABHS (GroupA beta-hemolytic streptococcus):

most important pathogen because of potential

sequelae

signs and symptomssigns and symptoms

•High fever, malaise, headache, and vomiting

•Sore throat and Odynophagia

•Dysphagia

•Tender cervical lymphadenopathy

•Erythematous/exudative tonsils

•Purulent exudate from the crypts

•A white membrane

•Viral–Lower grade fever–Lower WBC, Lymphocytic shift–Less tonsillar exudate

•Bacterial–Higher WBC, Granulocytic shift–More exudative

Clinical EvaluationClinical Evaluation

Acute Tonsillitis

•Evidence of inflammation of the tonsils

PLUS

•pyrexia of at least 38.50C, measured orally.

•enlarged, tender, anterior cervical lymph nodes.

•documentation of GABHS infection by throat swab (antigen detection or culture).

DiagnosisDiagnosis

•Infectious mononucleosis•Vincent's angina•Malignancy: lymphoma, leukemia, carcinoma•Diphtheria•Scarlet fever•Agranulocytosis

Differential diagnosisDifferential diagnosis (AT鉴别诊断)

Complications Complications

•Peritonsillar abscess

•Cervical adenitis

•Acute myocarditis

•Acute glomerulonephritis

•Rheumatic fever

PeritonsillarPeritonsillar CellulitisCellulitisAnd Abscess And Abscess

aspiration or incision

Medical ManagementMedical Management

•Bed rest. •PCN is first line, even if throat culture

is negative for GABHS.•Local treatment:Gargle, spray.

Recurrent Acute Tonsillitis

•Seven episodes in a single year

•Five or more episodes in 2 years

•Three or more episodes in 3 years

Recurrent Acute Tonsillitis

Treatment:

1. PCN injection if concerned about

noncompliance or antibiotics aimed

against BLPO and anaerobes.

2. Tonsillectomy

Chronic Tonsillitis

•No true consensus on the definition.

•Symptoms greater than 4 weeks

DEFINITIONS:

MicrobiologyMicrobiology(CT)

Most common organisms cultured from patients with chronic tonsillar disease

•Streptococcus pyogenes (GABHS)•H. influenza•S. aureus•Streptococcus pneumoniae

SymptomsSymptoms

•Low grade intermittent sore throat

•Halitosis

SignsSigns

•Enlarged, mildly red tonsils that are scarred with large pits

•Crypts tend to become impacted with white foul-smelling (especially to the owner) debris.

•Slightly enlarged lymph nodes that are not usually tender

DiagnosisDiagnosis

•Histories of recurrent throat infections is the most important.

•Examinations–The size of tonsil is not correlative with

the degree of inflammation.

Differential Diagnosis Differential Diagnosis

•Infectious Mononucleosis–EBV

•Scarlet Fever•Corynebacterium diptheriae•Malignancy

ICA AneurysmICA Aneurysm

PleomorphicPleomorphic AdenomaAdenoma

Other Other TonsillarTonsillar PathologyPathology

Hyperkeratosis Hyperkeratosis ((角化症角化症))

CandidiasisCandidiasis((念珠菌病念珠菌病))

Syphilis Syphilis 梅毒

Retention CystsRetention Cysts潴留囊肿

SupratonsillarSupratonsillar CleftCleft

Complications of CTComplications of CT

•Myocarditis

•Glomerulonephritis

•Rheumatic fever

•Fever

Medical TherapyMedical Therapy

•First Line–Penicillin/Cephalosporin for 10 days–Injectable forms for noncompliance

• BLPO, co pathogens

•Macrolides–Penicillin allergy–Erythromycin/Clarithromycin 10 days–Azithromycin (12mg/kg/day) 5 days

Medical TherapyMedical Therapy

•Patients with recurrent otitis media history have higher bacterial concentrations with BLPO.–Initial treatment with anti-BLP antibiotic.

•Adenotonsillar size may respond to a one month course of antibiotic therapy.

•Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid.

Surgical IndicationsSurgical Indications

•Absolute–Obstructive airway with cor pulmonale

–Severe dysphagia

–Failure to thrive

•Relative–Recurrent acute tonsillitisepisodes/year for 2 years or 3 episodes/year for 3 years–Chronic tonsillitis–Obstructive Sleep Apnea–Peritonsillar Abscess–Halitosis–Suspected Neoplasia/ Tonsillar hyperplasia

Surgical IndicationsSurgical IndicationsSurgical IndicationsSurgical Indications

Innovative Surgical TechniquesInnovative Surgical Techniques

•Cold Dissection•Electrosurgery•Intracapsular partial tonsillectomy•Harmonic Scalpel•Radiofrequency tonsillar ablation and

coblation.

Complications

Mortality rate is 1 in 16000-35000•Postoperative Bleeding•Anesthetic complications•Eustachian tube injury•Nasopharyngeal stenosis•Pulmonary Edema•Atlantoaxial subluxation