Adenoidal Enlargement & Tonsilitis Flashcards
What is the Waldayer’s ring and list the components.
It is a collection of lymphatic tissues located within the pharynx. It is also known as tonsils arranged in a ringed form.
COMPONENTS
1) nasopharyngeal tonsils (adenoids)
2) tubal tonsils (x2)
3) palatine tonsils (x2)
4) lingual tonsils
What is the greatest complication of tonsillectomy?
Hemorrhage (due to its proximity to the paratonsilar vein)
At what age does adenoids start enlarging in children?
2 years
The adenoids is largest at what age?
7 years
At what age do you expect the adenoids to almost disappear?
13 years
What are the symptoms of adenoidal enlargement?
•Symptoms
•Snoring
•Mouth Breathing
•Hyponasal speech
•Obstructive sleep apnoea syndrome
•Day-time hypersomnolence
•Aproxesia (inability to fix and sustain attention mainly due to nasal disorders)
•Recurrent nasal discharge
•Cough
•Aural fullness/ Hearing difficulty
•Recurrent ear discharge
The palatine tonsils are bounded anteriorly and posteriorly by
Anteriorly — Anterior tonsilar pillar
Posteriorly — Posterior tonsilar pillar
What are the signs of adenoidal enlargement
Dull tympanic membrane
Ear discharge
Reduced nasal patency
Nasal discharge + engorged turbinate
Adenoidal facies
What are the features of adenoidal facies?
- Pinched nose
- Open mouth
- Dull expression
- Elongated face
- Prominent and crowded upper central teeth
- High arched palate
- Hitched-up upper lip
What is the management protocol for adenoidal enlargement
- Detailed history
- Physical examination
- Investigations (post nasal space x-ray, chest x-ray, FBC, E/U/Cr, ECG, Echo)
- Treatment
Treatment options for adenoidal enlargement
Conservative
•Infection and Allergy control
•Broad-spectrum antibiotics (Cephalosporins, Penicillin-based)
•Antihistamines (Systemic/ local)
•Nasal steroids (Fluticasone, Betamethasone)
•Decongestants (Xylometazoline, Pseudoephedrine)
Surgery
What are the indications for surgery in adenoidal enlargement?
•Failure of medical treatment
•Obstructive sleep apnoea symptoms
•Associated Otitis media (with effusion)
•Associated speech and swallowing defects
•Recurrent rhinosinusitis
What are the complications of adenoidal enlargement?
•Failure to thrive
•Poor school performance and social integration
•Gnathopathy
•Pulmonary hypertension
•Cor-pulmonale (Rt side heart failure)
What is tonsillitis
This is the inflammation of the palatine tonsils
What is the aetiology of tonsillitis?
Infectious
•Viral (Rhinovirus, corona, Adeno, parainfluenza, Measles, EBV, HIV)
•Bacterial (GABHS pyogenes, C. diphtheriae, S. aureus, H. Influenza, T. pallidum, Fusobacterium)
•Fungal (C. albicans)
•Protozoan (T. gondii)
Non-Infectious
•Laryngo-pharyngeal reflux
•Trauma
•Foreign body
•Others (Sarcoidosis, Crohn’s, SJ syndrome etc.)
Discuss the aetio-pathogenesis of tonsillitis
- Presence of inciting factor (infectious or non-infectious)
- Inflammatory response — obstructive symptoms
- Complications arise if not addressed
What is the natural history of tonsillitis?
1) Catarrhal
2) Parenchymatous
3) Follicular
4) Membranous
CPFM
What are the symptoms of tonsillitis
•Sore throat
•Odynophagia (difficulty swallowing)
•Dysphagia (painful swallowing)
•Fever
•Otalgia
What are the investigations done for tonsillitis
NB:- Diagnosis is clinical thus investigations are to determine the causative infection (bacteria, viral, fungal) and direct drug therapy after sensitivity. Also for monitoring complications.
- Throat swab with m/c/s
- FBC (with differentials) to know if it’s bacterial and to rule out differentials
- FBS to rule out DM and possible immunocompromised state
- E/U/Cr for kidney dx (AGN from GABHSp), acute renal failure (from dehydration)
- LVS (lenti viral screening) to rule out HIV that can cause immune suppression
- ECG and Echo to rule out rheumatic heart disease from GABHSp
What are the treatment options for tonsillitis
Non surgical
•Warm saline gargles
•Broad-spectrum antibiotics (Penicillin-based, Macrolides, Cephalosporins± anaerobe cover)
•Anti-inflammatory (NSAIDS, Short-dose steroids)
•Analgesics/ Antipyretics
Surgery
What are the indications for tonsillectomy
1) Failure of non-operative management (Acute Recurrent Tonsillitis) which is determined by
• ≥7 episodes in previous year or
• ≥5 episodes in previous 2
consecutive years or
• ≥3 episodes in the previous 3
consecutive years
Each characterized by:
●Fever ≥ 38.3°C
●Pain in the throat
●Tonsillar exudates with positive culture of GABHS
●Tender cervical lymphadenopathy
2) Less frequent episodes but severe symptoms affecting school, work and daily activities
3) Chronic Tonsillitis
4) Peritonsillar abscess
What is the modified CENTOR’s criteria and what is it used for?
Since most of the causes of acute tonsillitis are viral which is in turn self limiting, the centor’s criteria is used to know when it’s bacterial so as not to prescribe antibiotics unnecessarily.
•Cough (Absence +1, Presence -1)
•Exudates (Absence -1, Presence +1)
•Nodes (Swollen/tender +1, Absence-1)
•Temperature (>38 +1, Absence -1)
•Old OR Young (under 15years +1, over 44years -1). NB:- 15 - 44 years = 0
• -1 to +1: No antibiotics or throat swab required
•2 to 3: Throat swab required, with antibiotics given if positive for β-Hemolytic strep
• 4-5: Empiric antibiotic Rx/ Rapid antigen testing for β-Hemolytic strep and/or culture and antibiotics subsequently
What are the complications of tonsillitis
•Peritonsillar abscess
•Parapharyngeal abscess
•Deep neck space abscesses
•Rheumatic fever
•Acute Glomerulonephritis
