Tonsil ............... .
- 1. COMPLICATIONS OF TONSILLITIS INDICATIONS/ CONTRAINDICATIONS TO TONSILLECTOMY Dr.Usha MS,DLO
- 2. ANATOMY • Palatine tonsils are 2 in number and ovoid in shape • Situated in the Tonsillar fossa in lateral wall of oropharynx • Tonsillar fossa- composed of 3 muscles • Palatoglossus- anterior pillar • Palatopharyngeal muscle- posterior pillar • Superior constrictor muscle- laterally- forms larger part of tonsillar bed
- 3. • MEDIAL SURFACE Non keratinising stratified squamous epithelium 12-15 crypts Crypta Magna/ Intratonsillar cleft • LATERAL SURFACE Fibrous Capsule The tonsillar capsule is a specialized portion of the pharyngobasilar fascia and extends into it to form septa that conduct the nerves and vessels
- 6. • UPPER POLE: Extends into the soft palate Supratonsillar fossa- potential space enclosed in a semilunar fold, extending between anterior and posterior pillar Webers glands- tubular mucous glands located at the superior pole of the tonsil. The glands send a common duct to the tonsil and secrete saliva on to the surface of the tonsillar crypts. The glnds maybe left behind. Following a tonsillectomy and are therefore a potential source of Quincy after tonsillectomy
- 7. • LOWER POLE: Attached to the tongue Anterior tonsillar space- triangular fold of mucosa extends from anterior pillar to anteroinferior part of tonsil enclosing a potential space Separated from the tongue by Tonsillolingual sulcus (Maybe a seat of carcinoma)
- 9. • VENOUS DRAINAGE- Paratonsillar vein -> facial vein and pharyngeal venous plexus • LYMPHATIC DRAINAGE- Jugulodigastric Nodes • NERVE SUPPLY- Lesser palatine branches of Sphenopalatine Ganglion, Glossopharyngeal nerve Referred Otalgia
- 10. Waldeyers Ring
- 12. ACUTE TONSILLITIS • Acute infection and inflammation of palatine tonsils • More common in school going children
- 13. AETIOLOGY • BACTERIAL- Most common Group A beta hemolytic Streptococci Staphylococci Pneumococci H. Influenza • VIRAL- Influenza, Parainfluenza, Rhinovirus, Adenovirus, RSV, Echovirus
- 15. CLASSIFICATION • Acute catarrhal or superficial tonsillitis- When tonsils are inflamed as part of the generalized infection of the oropharyngeal mucosa
- 16. • Acute follicular tonsillitis- Infection spreads into the crypts which become filled with purulent material, presenting at the openings of crypts as yellowish spots
- 17. • Acute parenchymatous tonsillitis- When the whole tonsil is uniformly congested and swollen
- 18. • Acute membranous tonsillitis- Exudation from the crypts coalesces to form a membrane on the surface of tonsil.
- 21. Grade of tonsillar enlargement
- 25. DD of unilateral tonsillar enlargement • Tonsillar causes • Tonsillar malignancy • Peritonsillar abscess • Tonsillolith • Tonsillar cyst • Vincents angina • Extra Tonsillar Causes • Parapharyngeal abscess • Parapharyngeal tumors • Tumors of deep parotid lobe • ICA aneurysm • Cervical lymphadenopathy
- 26. Complications of tonsillitis 1. Chronic tonsillitis – • Due to recurrent attacks Types: • Chronic Follicular Tonsillitis- tonsillar crypts are full of infected material, seen as yellow spots on the surface • Chronic Parenchymatous Tonsillitis- Hyperplasia of lymphoid tissue. Tonsils are enlarged and may interfere with speech and deglutition. Sleep apnea may occur. Long standing cases develop cor pulmonale • Chronic Fibroid Tonsillitis- tonsils are small but infected, with h/o repeated sore throat
- 27. Clinical Features: • Recurrent attacks of sore throat • Chronic cough • Halitosis • Thick speech, difficulty swallowing 4 cardinal signs of Chronic Tonsillitis: • Flushing of anterior pillar • Enlarged tonsils • Irwin Moore sign • Non tender JD nodes
- 31. 2. Peritonsillar abscess: Collection of pus in the peritonsillar space (Between capsule and superior constrictor) Acute Tonsilltis Sealed infection of crypta magna Intratonsillar abscess Bursts through capsule Peritonsillitis Peritonsillar abscess
- 32. • Organisms- Strep pyogens, Staph aureus, Anaerobic organisms • Symptoms- Fever with chills and rigors Malaise, Headache, Nausea, Constipation Severe unilateral throat pain Odynophagia Hot potato voice Foul breath Ipsilatreal referred ear pain Trismus- Spasm of pterygoid
- 33. • Signs: Tonsillar pillars, tonsil, soft palate- congestion Uvula- swollen, pushed to opposite side Bugging soft palate Mucous covering tonsillar region Cervical lymphadenopathy Torticollis
- 34. Treatment • Hospitalization • Iv fluids • I’ve antibiotics • Analgesics • Incision and Drainage • Interval tonsillectomy • Hot tonsillectomy
- 35. 3. Parapharyngeal abscess • Also known as abscess of pharyngomaxillary or lateral pharyngeal space • Due to acute/ chronic tonsillitis or peritonsillar abscess • Severe trismus • Possibility of airway compression
- 39. • USG/ CT neck • Treatment- IV antibiotics, Hydration, Analgesics, External drainage
- 41. 4. Retropharyngeal abscess: • Mainly in infants/ young children • Infection tracks to lymphoid tissue between posterior pharyngeal and prevertebral fascia • Systemically ill/ Airway compromise
- 44. • Investigations- X ray neck, USG, CT neck • Treatment- High dose antibiotics Urgent I&D, with airway protection Usually drained per orally, but external drainage can be done Tracheostomy maybe required
- 47. 5. Cervical Abscess Due to suppuration of JD node 6. Lemierre’s Syndrome Rare, potentially fatal Septic thrombophlebitis of IJV Organism- Fusiform Bacillus Severe neck pain, Septicemia Investigations- USG neck- thrombus in neck veins Treatment- Prolonged antibiotics (6 weeks), Anticoagulants
- 48. 7. Immune complex disorders • Acute Rheumatic fever- Joint pain, rashes, jerky body movement • Acute Glomerulonephritis • Subacute Bacterial Endocarditis- in patients with valvular heart disease. Due to Strep viridans. 8. Grisels Syndrome- Subluxation of atlantoaxial joint from inflammatory ligamentous laxity following an infectious process 9. Acute Otitis Media 10. Exacerbation of Psoriasis
- 49. 12. Sleep Apnea- Walls of the throat relax during sleep which causes breathing difficulties and poor sleep 13. Scarlet Fever Causes distinctive pink red skin rash
- 51. DD for white patch over tonsil • Membranous tonsillitis • Faucial diphtheria • Infectious mononucleosis • Candidiasis • Vincents angina • Leukemia • Agranulocytosis • Traumatic ulcer
- 52. Tonsillar Cyst • Due to blockage of a tonsillar crypt • Appears as a yellowish swelling over the tonsil • Symptomless • It can be easily drained
- 54. TONSILLECTOMY SCOTTISH INTERCOLLEGIATE GUIDANCE NETWORK CRITERIA Patient should meet all the criteria • Sore throat due to Tonsilltis • 5 or more episodes per year • Symptoms for at least a year • Episodes of disabling throat pain which prevents normal functioning
- 55. AMERICAN ACADEMY OF OTORHINOLARYNGOLOGISTS- HEAD AND NECK SURGEONS (AAO HNS) GUIDELINES • Tonsillectomy should be considered in all children with 3 or more infections of tonsillitis/ adenoiditis per year despite adequate medical therapy
- 57. Absolute Indications • Recurrent infections of throat (Paradise Criteria) • Peritonsillar abscess- 4-6 weeks after abscess is treated 2nd attack is an absolute indication • Tonsillitis which causes febrile seizures
- 58. • Hypertrophy of tonsils causing Airway obstruction Difficulty in deglutition Interference with speech • Suspicion of Malignancy- Unilateral enlarged tonsil maybe lymphoma in children or epidermoid carcinoma in adults
- 59. Relative Indications • Diphtheria carriers not responding to antibiotics • Streptococcal carriers • Chronic Tonsilltis with bad taste/ halitosis unresponsive to medical management • Recurrent Streptococcal tonsillitis in patients with valvular disease
- 60. As a Part of Another Operation • Palatopharyngoplasty- done for sleep apnea • Glossopharyngeal Neurectomy • Removal of styloid process
- 61. CONTRAINDICATIONS • Hb level less than 10g% • Presence of acute respiratory tract infection- Higher risk of bleeding • Children under 3 year of age • Overt or submucous cleft palate
- 62. • Bleeding disorder- Von Willebrand disease, Lymphoma, Purpura, Aplastic aneamia, Hemophilia, Sickle cell disease • Epidemic of polio • Uncontrolled systemic disease • During period of menses
- 63. Thank you …