Ukkie - Lbm 4 Painful Swallowing Tht Sgd 19

8/12/2019 Ukkie - Lbm 4 Painful Swallowing Tht Sgd 19

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UKKIEmodul tht lbm 4 (tonsilitis) 2013

M a n g b e w o k . t k - @ s i m a n g b e w o k Page 1

LBM 4 PAINFUL SWALLOWING

STEP 1

Detritus : hasil eksudat yang berisi leukosit, bakteri, dan epitel yangterlepas di kanal berwarna bercak kuning.

Kripte : muara saluran limfoid yang dapat terlihat pada tonsil

STEP 2

1. Anatomi, fisiologi, dan histologi faring dan tonsil?2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada

tenggorokan?

3. Mengapa pasien demam dan mengalami penurunan nafsu makan?4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa

hiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan

mukosa hiperemis dan terdapat granul di posterior?

5. Causa detritus dan kripte (definisi, patofis)?6. Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangi

gejala?

7. Pemeriksaan penunjang untuk menegakkan diagnosis?8. Penatalaksanaan yang tepat untuk pasien tersebut?9. DD?10.Komplikasi yang dapat timbul dari diagnosis?

STEP 3

1. Anatomi, fisiologi, dan histologi faring dan tonsil?ANATOMI

Faring : berbentuk seperti corong, kurang lebih 15 cm, dibentuk oleh jarfibromuskular


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Nasofaring :Batas depan : choanae

Atas : basis crania

Belakang : vertebra cervical yg dipisahkan facia prevertebralis

Bawah : palatum mole

Lateral : dinding medial leher

Ada bangunanostium tuba eusthacii, adenoid, recessus faring

OROFARINGAtas : nasofaring

Depan : cavum oris dan uvula

Belakang : vertebra cervical II-III

Lateral : dinding medial leher

Bawah : tepi atas epiglottis

Bangunantonsila palatine, fossa supra tonsilaris, tonsila lingualis

LaringofaringAtas : orofaring

Depan : tepi blkg epiglottis

Belakang : dinding belakang orofaring

Bawah : porta esophagus

Ruang di sekitar faring:

Retrofaring : ada mukosa faring, fossa faringobulbolaris, seringtjd supurasi, jk pecahabses retrofaring

Parafaring : dibagi 2 ruangan oleh os. Stiloidpre dan poststiloid

Pre stiloid : gampang tjd supurasi

Post : banyak pemb darah

TONSILAda cincin waldeyer : tonsil palatine, tonsil faringeal, tonsil lingual, tonsil

tuba


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Tonsil palatine : ada di fossa tonsil, dibatasi pilar anterior : m.palatoglossus, posterior : m. palatofaringeus. Panjang 2-4 cm.

masing2 tonsil 10-30 kriptus. Lateral ; m. konstriktor faring superior,

anterior : m. palatoglossus, posterior : m. pakatofaringeus, superior :

palatum mole, inf : tonsil lingua.

Vaskularisasi : a. maksila eksterna, a. maksila interna, a. lingualis cab

a. lingua dorsal, a. faringeal ascenden

Tonsil faringeal ; di dinding belakang nasofaring, tidak mempunyaikripte

Tonsil lingual : di dasar lidah, dibagi 2 oleh lig. glossoepliglotikaHISTOLOGI

Pada nasofaring mukosanya bersilia dan epitel mengandung sel goblet, sedangkan

orofaring dan laringofaring mukosa tidak bersilia.

Pada faring banyak jar limfoid untuk proteksi.

Ada palut lender/mucous blanketdi bagian nasofaring, di atas cilia, berfungsi

untuk menangkap partikel dari udara, mengandung lisozim. Bergerak ke posterior.

Terdapat otot2 sirkuler dan longitudinal.

Sirkuler : m. konstriktor faring sup, media, infuntuk konstriksi Longitudinal : m. stiloideus dan m. palatofaringuntuk melebarkan faring

dan mengangkat faring. Dipersarafi n IX.

Di palatum mole ada 5 pasang otot :

M. levator veli palatinemenyempitkan isthmus faring, melebarkan tubaeusthacii. Dipersarafi n X

M. tensor veli palatinemengencangkan anterior palatum mole danmenyempitkan tuba eusthacii

M. palatoglossusmenyempitkan isthmus faring M. palatofaring


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M. azigos uvulamemperpendek dan menaikkan uvulaFISIOLOGI

Fungsi menelan3 fase :

ORALbolus di mulut berjalan ke faring, volunteer

FARINGEALtransfer bolus melewati faring, involunteer

ESOFAGEALbolus bergerak peristaltic dari esophagus keg aster,

involunteer

2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan padatenggorokan?

Invasi bakteripertahanan utama : tonsil , karena terdapat jaringan limfe

virulensi tinggiinflamasitonsil edemtonsil membentuk cincin ,

susah menelannutrisi berkurang , kelemahan . mengobstruksi tuba

eustacii jugakurang oendengaran .

Bias juga menyebar menjadi otitis.

Sensasi terbakarinflamasi tonsil dan mukosa di orofaring

Nafsu makanKarena ada nyeri di tenggorokan , nyeri telannafsu makan menurun

Derajat tonsil:

T0T4

Pada scenarioT4sehingga mengobstruksi makanan, nyeri telan

Jika kronistidak ada nyeri telan

3. Mengapa pasien demam dan mengalami penurunan nafsu makan?Di no 2

4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosahiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan



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Hiperemis mukosaada peradangan, dilatasi pemb darah Detritusadanya peradangan tonsilpenumpukan leukosit,

bakteri mati, epitel mati. Terlihat bercak kuning

Kriptusmuara sal limfoid terisi detritus lama kelamaan tjdpengerutan

Granulapembengkakan organ limfoid faringAda bakteri/virusmenginvasi mukosa faring, tjd inflamasi local,

kuman /bakteri mengikis epitel, jar. Limfoid bereaksi

pembendungan infiltrate leukosit PMN

Stadium awal : hiperemi, edema, sekresi banyak. Awal eksudat

serosa, menebal, kering menempel di dinding faring

Derajat tonsil

T0 : Tonsil sudah diambil

T1 : Normal

T2 : Pembesaran tonsil tidak sampai linea media

T3 : hipertrofi mencapai garis tengahsesak napas

T4 : pembesaran tonsil lebih dari linea media, mengganggu deglutio

Estidak bersihbanyak bakteriinflamasi pada tonsil

ChikiMSG jd Iritan di tonsil ..

5.

Causa detritus dan kripte (definisi, patofis)?Tonsil dibungkus oleh kapsul di fossa tonsil , di tonsil banyak jar limfe yg

disebut folikel, tiap folikel pny kanal yang bermuara pada perm tonsil.

Muara tersebut terlihat muara yaitu kripte.


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Folikel peradangantonsil membengkakmembentuk eksudat yang

mengalir dalam kanalkeluar ke kripteterlihat kotoran putih/ bercak

kuning (Detritus)

6. Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangigejala?

Hanya mengatasi simptomnya saja

Paracetamol, ibuprofen

Antibiotic

7. Pemeriksaan penunjang untuk menegakkan diagnosis? CT Scan MRI Biopsi Darah rutin : leukositosis, Hb turun Uji swabuntuk mengetahui bakteri

8. Penatalaksanaan yang tepat untuk pasien tersebut? Farmakologi : antibiotic cefadroxil 1 minggu, analgesic, antipiretik,

kortikosteroid

Non farma : edukasi, minum air putih, pengontrolan makananGOLONGAN ANTIBIOTIK ? GENERASI?SEDIAAN..

9. DD?TONSILITIS

Tonsillitis akuto Viral : haemophillus influenzaeo Bacterial : streptococcus beta hemoliticus

Tonsillitis membranaceao T. diphteriCorynebacterium diphteri


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Demam, nyeri kepala, nyeri telan, badan lemas

o T. septicstrep hemoliicuso T. angina plaut Vincentbakteri spirochaetao T. karena kelainan darahleukimiao Proses spesifik luas dan TB

Kronis Tonsilitis diphteri

Dari sal pernapasan atas, usia 10 th

Ada 3 gejala :

Local : membrane semu, pembesaran limfe / bull neck

Sistemik : Demam, nyeri kepala, nyeri telan, badan lemas

Eksotoksin : jantungmiokarditis

Diagnose : gejala local, px mikrobiologi

10.Komplikasi yang dapat timbul dari diagnosis?11.Batasan operasi pada anak2?


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STEP 7

1. Anatomi, fisiologi, dan histologi faring dan tonsil?

Nasopharynx

The upper portion of the pharynx, the nasopharynx, extends from the base of the skull to

the upper surface of the soft palate. It includes the space between the internal nares and

the soft palate and lies above the oral cavity. The adenoids, also known as the pharyngeal

tonsils, are lymphoid tissue structures located in the posterior wall of the nasopharynx.

The nasopharynx, oropharynx, and laryngopharynx or larynx can be seen clearly in this

sagittal section of the head and neck.

Polyps or mucus can obstruct the nasopharynx, as can congestion due to an upper

respiratory infection. The eustachian tubes, which connect the middle ear to the pharynx,

open into the nasopharynx. The opening and closing of the eustachian tubes serves to

equalize the barometric pressure in the middle ear with that of the ambient atmosphere.

The anterior aspect of the nasopharynx communicates through the choanae with the nasal

cavities. On its lateral walls are the pharyngeal ostia of the auditory tube, somewhat

triangular in shape, and bounded behind by a firm prominence, the torus tubarius or

cushion, caused by the medial end of the cartilage of the tube that elevates the mucous

membrane. Two folds arise from the cartilaginous opening:


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the salpingopharyngeal fold, a vertical fold of mucous membrane extending from the

inferior part of the torus and containing the salpingopharyngeus muscle

the salpingopalatine fold, a smaller fold extending from the superior part of the torus to

the palate and containing the levator veli palatini muscle. The tensor veli palatini is lateralto the levator and does not contribute the fold, since the origin is deep to the cartilaginous

opening.

Behind the opening of the auditory tube is a deep recess, the pharyngeal recess (also

referred to as the fossa of Rosenmller). On the posterior wall is a prominence, best

marked in childhood, produced by a mass of lymphoid tissue, which is known as the

pharyngeal tonsil. Superior to the pharyngeal tonsil, in the midline, an irregular flask-

shaped depression of the mucous membrane sometimes extends up as far as the basilar

process of the occipital bone, this is known as the pharyngeal bursa.

Oropharynx

The oropharynx lies behind the oral cavity, extending from the uvula to the level of the

hyoid bone. It opens anteriorly, through the isthmus faucium, into the mouth, while in its

lateral wall, between the Palatoglossal arch and the Palatopharyngeal arch, is the palatine

tonsil. The anterior wall consists of the base of the tongue and the epiglottic vallecula; the

lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars; the

superior wall consists of the inferior surface of the soft palate and the uvula. Because both

food and air pass through the pharynx, a flap of connective tissue called the epiglottis

closes over the glottis when food is swallowed to prevent aspiration. The oropharynx is

lined by non-keratinised squamous stratified epithelium.

Laryngopharynx

The laryngopharynx, (Latin: pars laryngea pharyngis), is the caudal part of the pharynx; it is

the part of the throat that connects to the esophagus. It lies inferior to the epiglottis and

extends to the location where this common pathway diverges into the respiratory (larynx)

and digestive (esophagus) pathways. At that point, the laryngopharynx is continuous with

the esophagus posteriorly. The esophagus conducts food and fluids to the stomach; air

enters the larynx anteriorly. During swallowing, food has the "right of way", and air passage

temporarily stops. Corresponding roughly to the area located between the 4th and 6th

cervical vertebrae, the superior boundary of the laryngopharynx is at the level of the hyoid

bone. The laryngopharynx includes three major sites: the pyriform sinus, postcricoid area,

and the posterior pharyngeal wall. Like the oropharynx above it, the laryngopharynx serves

as a passageway for food and air and is lined with a stratified squamous epithelium. It is

innervated by the pharyngeal plexus.


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The vascular supply to the hypopharynx includes the superior thyroid artery, the lingual

artery and the ascending pharyngeal artery. The primary neural supply is from both the

vagus and glossopharyngeal nerves. The vagus nerve provides a branch termed "Arnolds

Nerve" which also supplies the external auditory canal, thus hypophayrngeal cancer canresult in referred otalgia. This nerve is also responsible for the ear-cough reflex in which

stimulation of the ear canal results in a person coughing.

Pharyngeal lymphatic ring(waldeyer lymphatic ring):1. inner ring2. outer ring

Applied anatomy of pharynx, Wang Peihua, Department of Otorhinolaryngology,9th peoples hospital, School of medicine, Shanghai Jiaotong University.

Tonsils are lymphoepithelial organs at the opening of the upper aerodigestive tract.

From above downwards, they can be divided into

1. pharyngeal tonsil, adenoid, which lies on the roof and posterior wall of the

nasopharynx

2. tubal tonsil which lies around the eustachain tube

3. palatine tonsil which lies between the anterior and posterior faucial pillars

4. lingual tonsil which lies at the base of the tongueThese lymphoid organs developed from the epithelium of the primitive oronasal cavity,

the mesenchymal stroma and lymphoid cells then infiltrate these areas. Although the

tonsils are present at embryonal stage, they only acquire their typical structure in

thepostnatal period. They begin increasing rapidly in size between the first and third year

of life, with peaks in the third and seventh year. They involute slowly at early puberty. In

contrast to other lymphoid aggregates, tonsils do not filter lymph.


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The palatine tonsil is supplied by the facial artery, ascending pharyngeal artery, lingual

artery and the maxillary artery. Venous drainage is by the lingual and pharyngeal veins.

2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan padatenggorokan?

Bacteria and virus enter the body through the nose

and mouth

Bateria and viruses are filtered

in the tonsils

tonsils work by surrounding bacteria and

virus with white blood cells

Precipitating factors

Age Sex Race Unhealthy Lifestyle Environment

Predisposing Factors

Cold loss of sleep constipation

infection and inflammation causes

enlarge tonsils

Signs

Red and swollen tonsils and uvula Redness of throat Presence of purulent materials Tenderness on the jugulodiagastric

lymph nodes

Gray furry tongue

Symptoms

Sore throat Dysphagia Fever Earache Loss of appetite Constitutional symptoms


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emedicine.medscape.com

3. Mengapa pasien demam dan mengalami penurunan nafsu makan?Virus; Bacteria; Group A beta hemolytic streptococcusActivation of macrophages by

IFN- production of endogenous pyrogen IL-1, IL-4, IL-6, TNF-endogenous pyrogens

enter the systemic circulation and penetrate hematoencephalic barrier reacts to the

hypothalamusEffects of endogenous pyrogen on hypothalamic cytokines causethe

production of arachidonic acidand prostaglandins Prostaglandins stimulate the cerebral

cortex (behavioral response) leptin causes stimulation of the

hypothalamussuppressed appetite.

ACUTE TONSILLO PHARYNGITIS EXUDATIVE, CAPITOL MEDICAL CENTER COLLEGES INC.,

CORRAL, Priscilla Chantal M.

4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosahiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan



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Standardized tonsillar hypertrophy grading scale. (0) Tonsils are entirely within the tonsillar

fossa. (1+) Tonsils occupy less than 25 percent of the lateral dimension of the oropharynx

as measured between the anterior tonsillar pillars. (2+) Tonsils occupy less than 50 percent

of the lateral dimension of the oropharynx. (3+) Tonsils occupy less than 75 percent of the

lateral dimension of the oropharynx. (4+) Tonsils occupy 75 percent or more of the lateraldimension of the oropharynx.

Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in

pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg. 1998;118:6973.

Widen crypt:

The human palatine tonsils (PT) are covered by stratified squamous epithelium that

extends into deep and partly branched tonsillar crypts, of which there are about 10 to 30.

The crypts greatly increase the contact surface between environmental influences and

lymphoid tissue.

The tonsillar crypts often provide such an inviting environment to bacteria that bacterial

colonies may form solidified "plugs" or "stones" within the crypts. In particular, sufferers of

chronic sinusitis or post-nasal drip frequently suffer from these overgrowths of bacteria in

the tonsillar crypts.[medical citation needed] these small whitish plugs, termed

"tonsilloliths" and sometimes known as "tonsil stones".


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Barnes, Leon (2000). Surgical Pathology of the Head and Neck (2nd ed. ed.). CRC Press. p.

404.

Detritus:

Infiltration of bacteria on the epithelial tissue lining the tonsils will cause an inflammatoryreaction in the form of the release of polymorphonuclear leukocytes to form detritus. This

detritus is a collection of leukocytes, dead bacteria and epithelial apart. Clinically this

detritus filling kripte tonsils and appear as yellowish spots.

Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok

Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.

Granule in the posterior wall:

Acute pharyngitis Looks at mucosal thickening and hypertrophy of the lymph nodes

underneath and behind the posterior pharyngeal arch (lateral band). The existence of the

uneven mucosa of the posterior wall of the so-called granular.

Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok

Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.

5. Causa detritus dan kripte (definisi, patofis)?6.

Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangigejala?

7. Pemeriksaan penunjang untuk menegakkan diagnosis?Diagnosis of tonsillitis is based on a medical history and a physical exam of the throat.

An accurate medical history is needed to find out whether tonsillitis is recurrent, which

may affect treatment choices.

If your symptoms suggest strep throat, your doctor may want to confirm this diagnosis

by doing a throat culture. Strep throat is more likely if 3 or 4 of the following signs or

symptoms are present:Fever

White or yellow spots or coating on the throat and/or tonsils (tonsillar exudates)

Swollen or tender lymph nodes on the neck

Absence of coughing or sneezing


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If a strep infection is suspected, your doctor may do a rapid strep test or a throat

culture or both. Both of these tests can be done in a doctor's office. You may want to

discuss the advantages and disadvantages of each test to see which test is appropriate.

The results of these tests will determine whether antibiotic treatment is needed. These

results combined with an accurate medical history will be considered in deciding whethersurgery to remove the tonsils (tonsillectomy) is recommended.

If the Epstein-Barr virus, which can cause mononucleosis, is suspected as a cause for the

tonsillitis, a test for mononucleosismay be done.

http://www.emedicinehealth.com/tonsillitis-health/page6_em.htm

8. Penatalaksanaan yang tepat untuk pasien tersebut?

http://www.nzdl.org/

9. DD?
http://www.emedicinehealth.com/tonsillitis-health/page6_em.htmhttp://www.emedicinehealth.com/tonsillitis-health/page6_em.htmhttp://www.nzdl.org/http://www.nzdl.org/http://www.nzdl.org/http://www.emedicinehealth.com/tonsillitis-health/page6_em.htm


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Tonsilitis

The most active phase of tonsils is between age 3 to 10 years and after that involutionbegins. Although hyperplasia of tonsils is not a disease, these organs are found to have a

higher incidence of pathogenic bacteria around the poorly-drained tonsillar crypts resulting

in tonsillitis. Majority of childhood tonsillitis are caused by group A ]-haemolytic

streptococcus (GABHS). Its frequency and serious consequences such as acute rheumatic

fever and glomerulonephritis make this an important infection. Viral causes are also

common including coxsackievirus, herpesvirus and Epstein-Barr virus. However, it was

found that with recurrent attacks of tonsillitis, the type and number of organisms changes

from a commensal to greater varieties of bacteria and thus requiring different broad-

spectrum antibiotics. Therefore the use of throat culture to arrive at the diagnosis isinaccurate.

Clinically, the patients presented with sorethroat, fever and malaise. Physical

examination may nor may not show enlarged tonsils, but exudates, erythema are seen.

Cervical lymph nodes may be enlarged and tender.

Definition of recurrent acute tonsillitis is varible. We take more than 4 episodes in one

year or 7 episodes in 1 year, 5 episodes per year for 2 years or 3 episodes per year for 3

years .

Recurrent acute tonsillitis and chronic tonsillitis can give rise to peritonsillar abscess.

Further spread of the infection beyond the peritonsillar space and lateral aspect of tonsillarfossa can lead to parapharyngeal space abscess. In addition, children under age 3 with

tonsillitis are more susceptible to retropharyngeal space infection. Affected children will

present as irritability, fever, difficulty in breathing and torticollis.

The most common drug used to treat tonsillitis is amoxicillin. But with increasing

resistance, the use of beta-lactamase inhibitor i.e. augmentin or unasyn may be needed.

Only 32% responds to medical treatment with 6 months prophylaxis or a prolonged course

of 30-days antibiotics.

Decision for surgical intervention in patients with recurrent tonsillitis should be

individualized. When treating paediatric patients, surgeon should have good

communication with parents and provide full explanation of the procedure. Always ask for

family history of bleeding tendency and other medical problems. Cervical XR should be

done for children with Down's syndrome.




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10.Komplikasi yang dapat timbul dari diagnosis?


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Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the

following problems: repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive

sleep apnea;

repeated attacks of purulent otitis media; suspected hearing loss due to serous otitis media that has occurred in association with

enlarged tonsils and adenoids;

and some other conditions, such as an exacerbation of asthma or rheumatic fever.emedicine.medscape.com

1. Infection:

Recurrent, acute tonsillitis (>6 episodes per year or 3 episodes per year >2 years)

Recurrent acute tonsillitis associated with other conditions

Cardiac valvular disease associated with recurrent streptococcal tonsillitis

Recurrent febrile seizures

Chronic tonsillitis that is unresponsive to medical therapy associated with

Halitosis

Persistent sore throat

Tender cervical adenitis

Streptococcal carrier state unresponsive to medical therapy

Peritonsillitis abscess

Tonsillitis associated with abscessed cervical nodes

Mononucleosis with severely obstructing tonsils that is unresponsive to medical therapy

2. Obstruction:

Excessive snoring and chronic mouth breathing

Obstructive sleep apnoea or sleep disturbances

Adenotonsillar hypertrophy associated with

Cor pulmonale

Failure to thrive

Dysphagia

Speech abnormalities

Craniofacial growth abnormalities

Occlusion abnormalities

3. Other:


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Suspected neoplasia-asymmetric tonsillar hypertrophy

There are different methods of tonsillectomy including the use of a cold knife, hot knife,

diathermy, laser and harmonic scalpel. The operation lasts for about one hour. Postop,

the patients recover rapidly and can resume tonsillar diet immediately. Most important

is to look out for post-op bleeding. Postoperative haemorrhage ranges from 0.5-2%. Nosignificant immunological consequence has ever been documented. Changes in speech

or velopharyngeal insufficiency are mainly temporary. In general, nearly all our patients

can be discharged safely from hospital three days after the operation.



Tonsillectomy Complications:

Peritonsillar abscess. Acute otitis media. Lancefield's GABS can cause rheumatic fever, Sydenham's chorea, glomerulonephritis

and scarlet fever.

Streptococcal infection may cause a flare-up of guttate psoriasis. Enlarged and chronically infected tonsils interfere with children's sleep. Complications of tonsillectomy include otitis media and haemorrhage which can be

very difficult, especially where there is an undiagnosed bleeding tendency such as

haemophilia. Altered taste sensation has been reported.

Patients who have had tonsillectomy are more susceptible to bulbar poliomyelitis.Smithard A, Cullen C, Thirlwall AS, et al; Tonsillectomy may cause altered tongue

sensation in adult patients. J Laryngol Otol. 2009 May;123(5):545-9. Epub 2008 Jul 30.

BACTERIA vs VIRAL

These symptoms are generally mild in viral infection and very severe in bacterial infection.


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ACUTE TONSILLO PHARYNGITIS EXUDATIVE, CAPITOL MEDICAL CENTER COLLEGES INC.,CORRAL, Priscilla Chantal M.

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Ukkie - Lbm 4 Painful Swallowing Tht Sgd 19