Tonsillitis Flashcards
Generally when talking about the tonsils, what are we referring to?
The palatine tonsils
Other than the palatine tonsils, what other tonsils are there?
Adenoids - pharyngeal
Lingual
Tubal
What do the tonsils contain?
Macrophages
B cells
T cells
What is the role of the the tonsils?
Leading and building up immune response
Important in early years - cells in tonsils exposed to many antigens
By what age do the tonsils tend to shrink?
12
The palatine tonsils have a strong blood supply from how many different vessels?
5
Tonsillitis is usually accompanied by what…
Pharyngitis
So a better term would pharyngotonsillitis
Are the majority of cases of tonsillitis viral or bacterial?
Viral
What viruses typically cause tonsillitis?
EBV Adenovirus Rhinovirus Influenza Respiratory syncytial virus CMV Herpes simplex
If tonsillitis is caused by a bacterial infection, what is the most common type?
Group A beta haemolytic streptococcus (streptococcus pyogenes)
Also called strep throat
Other than group A beta haemolytic strep, what other bacteria cause tonsillitis?
Staphylococcus aureus
Strep pneumoniae
Mycoplasma pneumoniae
Chlamydia pneumoniae
EBV is usually asymptomatic. If it produces symptoms it can be part of a condition called…
Infectious mononucleosis (glandular fever)
How does infectious mononucleosis usually begin?
Insidiously
Fatigue
Malaise
What symptoms are associated with infectious mononucleosis?
Fatigue Malaise Sore throat Headache Fever Abdominal pains with nausea and vomiting sometimes occurs
What signs are associated with infectious mononucleosis?
Hepatomegaly Spenomegaly Swollen posterior cervical lymph nodes Enlarged tonsils with exudate (similar to that seen in strep throat) Petechiae on roof of mouth
What viral family is EBV part of?
Herpes
How is EBV transmitted?
Via saliva
“The kissing disease”
What investigations for infectious mononucleosis can be done?
FBC -lymphocytosis, thrombocytopenia
U&E
LFT
CRP
Mono spot test - looks for heterophile antibodies (produced by B cells infected by EBV)
EBV specific antibodies
Throat swab to look for differential diagnosis
What is the management for infectious mononucleosis?
Conservative:
Analgaesia - paracetamol and ibuprofen
Fluids
Rest
How long do symptoms usually last in infectious mononucleosis?
2-4 weeks
However, fatigue and malaise may last for months
What can happen if given amoxicillin or ampicillin when patient has infectious mononucleosis?
A generalised, itchy maculopapular rash can develop
What age group does infectious mononucleosis typically affect?
15 to 24
What complications of infectious mononucleosis can occur?
Upper airway obstruction Splenic rupture Burkitt’s lymphoma Lymphoproliferative disorders Leukoplakia
Is it difficult or easy to distinguish between viral and bacterial tonsillitis?
Difficult
How is step pyogenes transmitted?
Saliva
Nasal secretions
Is group A streptococcus a common commensal organism?
Yes
What is the incubation period of streptococcus pyogenes?
2-5 days (without symptoms)
What symptoms are associated with strep throat?
Acute, sudden onset sore throat Dysphagia Odonophagia Headache Nausea and vomiting Halitosis
What signs are associated with strep throat?
Tonsillitis - red, enlarged, purulent exudate
Pharyngitis - red
Soft palate petichiae
Tender, cervical lymphadenopathy
Why are throat swabs not very useful?
Group A strep are commensal organisms in many patients
What investigations can be done for strep throat?
Throat swab and culture or rapid antigen test
FBC - neutrophilia
Why is early recognition and management of strep throat important?
Prevent complications
How do you decide if antibiotics are required?
CENTOR criteria or fever pain score
What is the fever pain score?
Fever in last 24 hours Purulence Attends rapidly in under 3 days Inflamed tonsils No cough or coryza
Total = 5
Describe the scoring system in the fever pain score
0-1 = no antibiotics
2-3 = consider 3 day delay before antibiotics
4 or more = antibiotics if severe, if not 48 hour delay prescription
If antibiotics are required, what should be prescribed?
Penicillin V 500 mg QDS for 10 days (phenoxymethylpenicillin)
Or
Clarithromycin 500 mg BD for 5 days
What are the specific indications for tonsillectomy?
The episodes are disabling and prevent normal functioning
Seven or more well documented, clinically significant, adequately treated sore throats in preceding year
OR
5 or more episodes in each of preceding 2 years
OR
3 or more episodes in each of preceding 3 years
Suspected malignancy
Sleep apnoea
Peritonsillar abscess formation
Describe the centor criteria
Absence of cough
Tender anterior cervical lymphadenopathy
Temperature > 38
Tonsillar exudate
Max of 4
In terms of fever pain score, what score is likely to benefit from antibiotics?
Score of 4 or 5
In terms of the centor score, what score is likely to benefit from antibiotics?
3 or 4
Patients with EBV should avoid what for 3 months?
Contact sports
What supportive measures can be done?
Increase fluid intake
Analgaesia
Salt water gargle
Avoid hot drinks
What safety net advise should be given?
Seek urgent help if:
Breathing difficulties
Severe abdominal pain
Reduced urine output
For most patients, are antibiotics necessary?
No - have little effect on duration or severity of symptoms
When should amoxicillin be avoided?
If possibility of infectious mononucleosis
What complications can occur?
Guttate psoriasis - occurs weeks after infection with strep throat Acute otitis media Retropharyngeal abscess Rheumatic fever Post strep GN Quinsy - peritonsillar abscess
What can be given to reduce tonsillar swelling ?
Steroids e.g IV dexamethasone 10 mg
What differential may cause stridor and increased work of breathing?
Epiglottitis - requires immediate admission
What risk factors are associated with tonsillectomy?
Pain - may increase for up to 6 days following tonsillectomy
Haemorrhage - all should be assessed by ENT
Primary or reactionary haemorrhage most commonly occurs in first 6-8 hours following surgery. Managed by immediate return to theatre
Secondary haemorrhage - occurs between 5 and 10 days after surgery and often associated with wound infection - admit and antibiotics
What is haemorrhage 5-10 days post tonsillectomy commonly associated with?
A wound infection - should be treated with IV antibiotics
Referred to as a secondary haemorrhage
Secondary haemorrhage occurs in around what percentage of all tonsillectomies?
1-2%
