Tonsillitis and Peritonsillar

Abscess
Dr Niranjan
 Epidemiology: Tonsillitis/Pharyngitis
• Mostly Viral
– Rhino, influenza virus, parainfluenza virus,
adenovirus, coxsackievirus,echovirus, EBR,
reovirus,RSV, cytomegalovirus,Measles,rubella
• Bacterial:
GABHS,H. influenzae, S.pneumonae, S.aureus
– Adults-5-10%
– Children-30-40%
Anatomy
 Acute tonsillitis
• Viral:
– cough, rhinorrhea, hoarseness and
oral ulcers
– Absence of severe sore throat or
odynophagia
• Bacterial:GABHS
– Centor criteria
• Hx of fever more than 38.3oC or 101F
• Cervical lymphadenopathy(tender or
enlarged)
• Pharyngeal or Tonsillar exudate
• Absence of cough
 Types of Acute Tonsillitis
1. acute catarrhal or superficial tonsillitis
2. acute follicular tonsillitis
3. acute parenchymatous tonsillitis
4. acute membranous tonsillitis
Acute catarrhal or superficial tonsillitis
Acute follicular tonsillitis
. Acute parenchymatous tonsillitis
 Acute membranous tonsillitis

D/D:
– Diphtheria
– Vincents angina
– Infectious
mononucleosis
– Agranulocytosis
– Leukaemia
– Traumatic ulcer
– Aphthous ulcer
– Malignancy
– Candidiasis
Infectious mononucleosis
 Symptoms
• sore throat
• difficulty in swallowing + pain
• fever (can be accompanied by rigors and chills)
• Associated with:
– malaise, dysphagia, otalgia, headache, nausea,
and abdominal pain
 Signs
 hyperaemia of the pillars, tonsil+/- exudates
 enlarged and tender jugulodigastric lymph
nodes
 foetid breath and coated tongue
 Management
• 1.Supportive:
– Adequate Hydration
– Analgesics: Paracetamol, NSAIDS
• 2.Specific treatment: Antibiotic Therapy Indication
– 1. No signs of improvement after 48-72hrs of supportive
t/t
– OR. Strong clinical suspicion of bacterial tonsillitis
– OR.Throat swab or bacteriological culture or RAT positive
(not routinely performed)
 Antibiotics

• Penicillin is first line treatment  oral medication

preferable (penicillin V) 10days

• Other choices:

– Amoxicillin 10 days

– Cephalosporin 10days

– Macrolides: Azithromycin 5days

 Antibiotics

• Recurrent or unresponsive infections require

treatment with beta-lactamase resistant
antibiotics such as
– Clindamycin
– Amoxicillin plus clavulanic acid
 Complications of Acute tonsillitis
• Noninfective/ Immune complex disorder:
– ARF
– PIGN
– SABE
• Infective:
– Peritonsillar abscess(Quinsy)
– Retropharyngeal abscess
– Parapharyngeal abscess
– Cervical Abscess
– AOM
– Lemierre’s Syndrome
– Septicemia
– Scarlet fever
– Chronic tonsillitis/ Recurrent tonsillitis
 Chronic Tonsillitis
• Duration: ≥3months
• Cause:
– complication of acute
tonsillitis
– chronic infection of
sinuses/teeth
• Types:
– chronic follicular
– chronic parechymatous &
– chronic fibroid tonsillitis
 Chronic Tonsillitis
• Triad:
1.Flushing/erythema of ant tonsillar pillars
2.Irwin moore sign+( cheezy material
expressed on sqeezing tonsil)
3.Nontender enlarged cervical LN(tender
during acute episodes)
Other c/f: Halitosis,chronic irritation of throat,
T/t: 1.Conservative: T/T of cause
2. Surgery
 Peritonsillar Abscess(quinsy)

• Abscess formation between tonsillar

capsule and superior constrictor muscle
• Signs and symptoms:
– Fever
– Sore throat/severe pain
– Dysphagia/odynophagia
– Hot potato voice(muffled and thick voice)
– Drooling
– Ipsilateral earache
– Trismus
– Unilateral swelling of soft palate/pharynx
with uvula deviation to opposite side
• Rare in children
 Peritonsillar Abscess(quinsy)
• Aetiology:
– Complication of tonsllitis
• One of the crypts of tonsil gets infected and sealed
off….abscess in tonsil..breaks through capsule into
peritonsillar space)
– De novo infection of weber gland in superior
tonsillar space
– Idiopathic
 Treatment
1. Hospitalisation
2. IV fluids
3. Antibiotis/analgesics/Stat steroid
4. Needle aspiration followed by
Incision and drainage under LA
 Tonsillectomy : Indications
• 1. Recurrent tosillitis
– Paradise criteria: 7or more episodes of sore throat
in 1 year;5 or more in preceding 2 years ; 3 or
more in preceding 3 years
• 2. After 2nd episode of peritonsillar abscess
• 3.Tumor of tonsil
• 4.Assymetrical enlargement of tonsil
suspicious of malignancy
• 4.Obstructive sleep apnea syndrome(OSAS)
 Tonsillectomy : Indications
• Severe hemorrhagic tonsillitis
• Severe infectious mononucleosis with upper airway obstruction
• Long term Mx of IgA nephropathy
• Large symptomatic tonsillolith
• Tonsillitis with
– Febrile convulsion
– Streptococcal or diphtheria carrier
• As a part of other surgeries:
– UVPP
– Styloid process excision
– Glossopharyngeal neurectomy
 Methods of tonsillectomy
• 1. Dissection Method
– Cold dissection technique with hemostasis with ties or
cautery
– Diathermy or electrocautery method(Mono/Bipolar)
– Radiofrequency ablation: Coblation,Argon plasma
– Harmonic scalpel( ultrasonic) tonsillectomy
– Laser tonsillectomy
• 2.Nondissection method:
– Gulliotone
– Intracapsular partial tonsillectomy
 Complications of tonsillectomy
• 1. Immediate:
– Primary/ reactionary hemorrhage
– N,V, Excessive pain, post op fever
– Airway fires
– Dental injuries, TMJ dislocation, SC emphysema
– Hypoglycemia, hypovolemia, hyponatremia
• 2.Intermediate
– Secondary hemorrhage
– Grisel’s syndrome( atlantoaxial subluxation)
– Peritonsillar abscess,pneumonia, Pulmonary embolism/oedema,
pneumomediastinum,SABE,Pain
• 3. Late: Tonsil remnant, pharyngeal stenosis, scarring
Velopharyngeal insufficiency, taste distortion, IX CN paresis
Thank You