Case of P.B.

Case of E.N.By Joel Josef Soller and Harold Nathan Tan 1ObjectivesAt the end of the presentation, the listener should be able to:Understand the anatomy of the tonsils and its functionKnow how to diagnose and manage common diseases affecting the tonsils, particularly hypertrophyIdentify indications for surgical management and properly manage the patient post-operativelyOutlineCase PresentationReview of Normal AnatomyInfections of the Tonsils and HypertrophyManagement of Patients with Hypertrophied TonsilsPrevention, Prognosis and Biopsychosocial AnalysisIdentifying InformationE.N. 44 year oldmarriedMaleDriverFilipino Roman CatholicTaguig City

Source: patient

Chief Complaint:

Pabalik-balik na masakit ang lalamunan (recurrent sore throat) 1st admission4History of Present IllnessSore throatkumikirot 4/10 severityintermittent

Associated symptomsUndocumented feverPain on swallowing

Consult Diagnosed: Acute tonsillitis, given unrecalled antibiotics, resolved

37 years prior to consult(at 7 years old)Other symptoms:No headacheNo rhinorrhea or nasal congestionNo hoarsenessNo difficulty breathingNo coughNo hemoptysisNo vomiting

Sought consult

5History of Present IllnessRecurrence of sore throatOne episode of tonsillitis/ yearGiven unrecalled antibiotics / episode, with resolution of symptoms

In the interimOther symptoms:No headacheNo hoarsenessNo difficulty breathingNo coughNo hemoptysisNo vomiting

Sought consult

6History of Present IllnessRecurrence of sore throatkumikirot4-5/10 severityIntermittent

Associated symptoms:Undocumented feverPain on swallowingDifficulty of breathing at night Snoring Sudden awakenings with sensation of gaspingDaytime sleepiness and fatigue

3 months prior to consultOther symptoms:No rhinoorhea or nasal congestionNo headacheNo hoarsenessNo difficulty breathingNo coughNo hemoptysisNo vomiting

ADMISSIONSought consult

7General. No weight changes.HEENT. No dizziness, no blurring of vision. No hearing changes. Cardiorespiratory. No chest pain. No palpitations. No cough. Gastrointestinal. No abdominal pain. No changes in bowel movement. No gastrointestinal bleeding.Urinary. No dysuria. No frequency. No hematuria. Neurologic. No motor weakness. No sensory loss. No seizures.Endocrine. No temperature intolerance. No excessive sweating. No polyuria, polydipsia or polyphagia.Review of SystemsPast Medical HistoryPulmonary tuberculosis (2006), completed 6 months of HRZEUreterolithotomy (1998) at East Avenue Medical CenteNo history of hypertension, diabetes mellitus, cancer, thyroid disease, cardiac disease, no asthmaNo history of trauma. No previous hospitalizations.No other past surgeries. No history of medication use. No known allergies to food or drugs. 9Family HistoryNo family history of hypertension, diabetes, asthma, thyroid diseases, myocardial infarction, cardiovascular disease, stroke, allergies, cancer Family of E.N.January 2013Son20

E.N.56Mother52Daughter18Son14Personal and Social HistoryHigh school graduateFamily driverSmoking: 50 pack year smokerAlcohol: 3-4 bottles of beer/occasion, 2 times/weekNo use of illicit drugsNo exposure to environmental toxins

Risk of SAH relatively increased in smokersHeavy alcohol use increases risk 11Stakeholder AnalysisStakeholderRoleStand on the IssueIntensity of StandDegree of InfluenceInsightWifePrimary caregiverAllyHighWife regularly checks up on the health status of the patient HighDecision making regarding patients health concerns is largely influenced by his wife.ModerateWife shows some awareness of the possible severity of the patients conditionChildrenEmotional SupportAlly

ModerateChildren occasionally checks up on the health status of the patient

LowChildren have low influence in decision making

LowChildren shlow awareness of the possible severity of the patients condition

Health TeamHealth ProviderAllyHighHealth team monitors and regularly checks patientHighHealth team provides options and guidance for patients treatmentHighHealth team is highly aware of the patients course Appearance Awake, alert, coherent, not In cardiorespiratory distress

Vital Signs HR: 80 bpm RR: 27 breaths per min BP: 120/80 Height: 169 cm Temperature 36.6 C. Weight: 83.7 kg Pain Scale: 0/10 BMI: 29.3Physical Examination13SkinNormal hair distribution. No rashes. Good skin turgor. Nails without clubbing nor cyanosis.

HairHair of average. Scalp without lesions.

EyesVisual acuity 20/20. Visual fields full by confrontation. Pink palpebral conjunctiva. Anicteric sclera. Pupils 3 mm constricting to 2 mm round, regular, equally reactive to light. Extraocular movements intact.

Physical ExaminationEarsNo tragal tenderness. Bilateral ear canals clear, no discharge., no masses. Tympanic membrane with good cone of light. Weber midline, AC> BC.

NoseMucosa pink. Septum midline. No nasal discharge/congestion. No sinus tenderness.

Oral CavityOral mucosa pink. Dentition good. Tongue midline. No oral ulcers. Grade 3 tonsils, non-hyperemic. Pharynx without exudates, nor tonsilloliths noted.

Physical ExaminationNoseSeptum midline. No nasal discharge.

Oral CavityMacroglossia. Grade 3 tonsils, non-erythematous, L>R. No exudates. No tonsiloliths.

Physical ExaminationNeck Neck supple. Trachea midline. No cervical lymphadenopathy. Non-palpable thyroid lobes.

PulmonaryNo retractions. Symmetric chest expansion. No crackles, no wheezes, no rhonchi.

Cardiovascular Adynamic precordium. Apex beat palpable at the 5th intercostal space left midclavicular line. Normal rate. Regular rhythm. No murmurs. Physical Examination17AbdomenFlat abdomenumbilicus midlineNormoactive bowel soundsLiver span: 7 cm, right midlavicular lineNo splenomegaly Tympanitic in all four quadrantsNo masses feltPhysical ExaminationExtremities:Full and equal pulses. CRT < 2 seconds. No cyanosis. Good skin turgor. Warm and without edema.

Physical Examination19Physical ExaminationNeurologic ExaminationPatient was awake, alert, coherent; GCS 15. CN 1 can smellCN2 2-3mm, round pupils, EBRTL, (-) RAPD . No papilledema.CN3, 4 and 6 intact EOMs CN 5 (+) corneal reflex, intact sensory (V1 V2 V3) functions CN 7 no facial asymmetry CN 8 Weber midline. CN9 and 10 can swallowCN 11 able to shrug shoulders, turn head side to side, good tone CN 12 tongue midline, no fasciculations

Physical ExaminationNeurologic ExaminationMotor: 5/5 strength on all extremitiesSensory: 100% on all extremitiesReflexes: 2+ on all extremities

Salient FeaturesSUBJECTIVEOBJECTIVE44 y/o, maleRecurrent acute tonsillopharyngitis (1 episode/year)Pain on swallowing, undocumented fever. Snoring episodes, awakens at night gasping for breath, daytime sleepiness50 pack year smokerNo heartburn, no weight loss

Stable vital signsMacroglossiaGrade 3 tonsilsNo cervical lymphadenopathySALIENT FEATURESSORE THROATACUTECHRONIC24SORE THROATACUTECHRONIC25Differential DiagnosisDifferential DiagnosesMore LikelyLess LikelyChronic Hypertrophic Tonsils Enlarged tonsils, snoring, difficulty breathing at nightGastroesophageal Reflux DiseaseCan present with sore throat as gastric acid irritates pharyngeal tissueNo regurgitation, no heartburn, no gastrointestinal painPostnasal drip Can present with sore throat (via chemical irritation and repeated drying)No nasal congestion, no rhinorrheaPulmonary tuberculosisCan present with sore throat (via irritation) No history of chronic cough, weight lossCHRONICSORE THROATPrimary Working Impression

Chronic Hypertrophic TonsilsObstructive Sleep ApneaObese Class I27Review of normal anatomyOral Cavity

Oral vestibuleOral cavity properLaterally and anteriorly: dental archesRoof: hard palatePosteriorly: communicates oropharynxFloor: tongueThe oral vestibule is the slit-like space between the teeth and gingivae (gums) and the lips and cheeks.Upper and lower dental arches

29TonsilsWaldeyer Tonsillar RingPalatine tonsilsAdenoids/pharyngeal tonsilsLingual tonsilsFunctionInduction of secretory immunityRegulating immunoglobulin productionMost active from ages 4 to 10 involute after pubertyWaldeyer tonsillar ring and its design allow direct exposure of the immunologically active cells to foreign antigens entering the upper aerodigestive tract, which maximizes the development of immunologic memory30Palatine TonsilsLargest component of the ringLymphoid tissue: more compact with clearly identifiably cryptsvery adherent to the capsuleLoose connective tissue- between the capsule and the muscles of the tonsillar fossa

With the inflammation resulting from either acute or chronic infection, which is limited by this capsule, tonsillar tissue swelling usually extends medially into the oropharyngeal airway. The potential space between the tonsil and the pharyngeal muscles is the usual site of a peritonsillar abscess.31HistologyB- Cell lymphocytesT cell lymphocytesFew mature plasma cellsOrganization: specialized endothelium-covered channels that facilitate antigen uptake directly into the tissue

maximize the exposure of tissue to surface antigen, they can also harbor debris and bacteria and may be the reason that tonsils are so commonly infected

others: Lymphoid tissue covered by a specialized, pseudostratified, ciliated columnar epithelium that forms redundant surface folds to maximize the surface area of the tissue32Palatine TonsilsTonsillar FossaPalatoglossus muscle- anterior tonsillar pillarPalatopharyngeus muscle- posterior tonsillar pillarPharyngeal constrictors: base (superior constrictor)Below the constrictors: glossorpharyngeal nerve and neurovascular structures of the carotid sheath33Palatine TonsilsBlood Supply Inferior PoleTonsillar branch of the dorsal lingual arteryAscending branch of the palatine arteryTonsillar branch of the fascial arterySuperior PoleAscending pharyngeal arteryLesser palatine artery (anteriorly)

Tonsillar LN is behind the angle of the mandible34Palatine TonsilsDraininageVenous: peritonsillar plexus lingual and pharyngeal veins Internal jugular veinLymphatic: tonsillar lymph node or jugulodigastroc or upper cervical LNsInnervation:Tonsillar branch of the glossophrayngeal nerveContributions from the descending branches of the lesser palatine nerveGPN- has tympanic branch referred pain to the ear35Diseases of the tonsilsApproach to Sore ThroatHistory:AllergyIrritation: dry heat, mouth-breathing, regurgitation, industrial pollutants, chemicals, tobacco smoke, alcohol, spicy foods, voice strainTumors

InfectionsAcute Streptococcal TonsillopharyngitisGroup A beta-hemolytic- most common bacterialFever + sore throat + CLAD + dysphagia + odynophagia; Erythematous, exudative tonsilsOther causesViruses: adenovirus, EBV, HSV, RSV influenzaVincent angina: Treponema vincentii and Spirochaeta denticulata

Viral: URTI symptoms; viral= all agesASTP: more common in childrenVincent: young adults

38InfectionsRecurrent Acute TonsillitisEpisodes of acute tonsillitis with complete recovery between episodesChronic TonsillitisPersistent sore throat, anorexia, dysphagia, pharyngotonsillar erythemaMixed aerobic and anaerobic, predominance of streptococciInfectionsPeritonsillar AbscessExtension of infection beyond the capsuleBetween capsule and surrounding pharyngeal muscle bedHigh risk in recurrent infectionsmalaise + trismus + odynophagiaasymmetrically enlarged tonsilsTonsillolithsStagnation of food and secretions in cryptsBacterial overgrowthHard white material

Complications of AdenotonsillitisScarlet Fever- fever + severe dysphagia, exudative tonsillopharyngitis + diffuse erythematous rashAcute Rheumatic Fever- when throat culture is no longer positive, cross-reactive antibodies- heart damage; ~18 days after throat infectionPoststreptococcal GN- acute nephritic syndrome ~ 10 days after throat infectionChronic Adenotonsillar Hypertrophy Chronic Tonsillar HypertrophyResponse to colonization with normal floraClinical Presentation:Adenoid hypertrophy: Nasal obstruction, Rhinorrhea, Hyponasal voiceTonsillar enlargement: snoring, dysphagia, either hypernasal or muffled voiceUpper airway obstruction- loud snoring, chronic mouth breathing, secondary enuresis

Grading of Tonsils Based on Size

Obstructive Sleep ApneaClinical PresentationApneic episodeshypersomnolence or hyperactivityfrequent nighttime awakeningspoor school performancegeneral failure to thriveLong term effects: Pulmonary hypertensionCor pulmonareAlveolar hypoventilation- chronic CO2 retention

ManagementDiagnosticsASO TiterAntistreptolysin O antibodies in blood plasmaOxygen-labile hemolytic toxin hemolysis of RBCsPositive: >200IUFound in groups A, C, and G streptococciRADTThroat Culture- gold standardCBC, Coagulation Factors, BT, CTSleep StudiesELISA

46Therapeutic GoalsImprove Quality of LifePrevent recurrence of infectionPrevent long-term complicationsMedical ManagementAntibioticsPenicillin and derivativesAmoxiclav/Claunvunamic AcidCephalosporinsClindamycinSupportive MedicationsAnti-pyreticsPain relievers

Modified Centor Scoring

SURGICAL: TonsillectomyParadise CriteriaFrequency: At least 7 episodes in the previous yearAt least 5 episodes in each of the 2 previous yrsAt least 3 episodes in each of the 3 previous yrsClinical features:sore throat+ at least oneT>38.3oCCLAD (tender lymph nodes/ size > 2cm)Tonsillar exudateCulture (+) for A B-hemolytic StrepTreatment: antibiotics given in conventional dosageDocumentation: on medical recordsAAO-HNS Guidelines for Tonsillectomy in Children and Adolescents. 2011. http://www.aafp.org/afp/2011/0901/p566.htmlSurgical Indications for Tonsillectomy and AdenoidectomyInfectious DiseasesRecurrent, acute tonsillitisPhilippine Guidelines: 4x/yearScottish Guidelines: 5/yearAO-ENT: 3/yearParadise CriteriaRecurrent, acute tonsillitis, with recurrent febrile seizures or cardiac valvular diseaseChronic tonsillitis, unresponsive to medical therapy or local measuresPeritonsillar abscess with history of tonsillar infectionsSurgical Indications for Tonsillectomy and AdenoidectomyObstructive DiseaseSnoring with chronic mouth breathingObstructive sleep apnea or sleep disturbancesAdenotonsillar hypertrophy with dysphagia or speech abdnormalitiesAdenotonsillar hypertrophy with craniofacial growth or occlusive abnormalitiesMononucleoisis with obstructive tonsillar hypertrophy, unresponsive to steroidsSurgical Indications for Tonsillectomy and AdenoidectomyNeoplastic DiseaseAsymmetric growth or tonsillar lesion suspicious for neoplasmSurgical IndicationsSTRONGRELATIVECor-pulmonale due to hypertrophied tonsilsUpper airway obstructionOSAComplications: RF, PSGNDysphagia due to hypertrophied tonsilsPeritonsillar abscenssUnilateral tonsillar hypertrophyRecurrent tonsillitis Chronic tonsillitis with halitosis or sore throatTonsillar hypertrophy with speech distortion or snoring

OperationSubcapsular dissection and total removal of the tonsilsIncision of mucosa adjacent to the tonsil to find the capsuleCauterization of blood vesselsTonsillar bed is examined for bleedersSuturing is avoidedPost-OperationPost-op changesOdynophagia, change of diet, decreased activityRecovery:Children 4 days-1 weekAdults- up to 2 weeksComplications: hemorrhageMedications: high-dose steroids, antibiotics, local anestheticsMay lead to dehydration57Post-Operative PlanDiet:First 4-7 days: soft, cold diet5th-8th day onwards: regular food as long as swallowing is comfortableActivityAvoid strenuous activities, rest at homeAvoid exposure to extreme temperatures, void people with cough and coldsTake multivitaminsAvoid smoking and drinking alcoholWatch out ForPersistence of painFever, malaise, dysphagiaVomiting occurs after discharge, with gross blood or dark materialClinical Practice GuidelinesAcute and Chronic Tonsillopharyngitis and Obstructive Adenoidal Hypertrophy

Philippine Society of Otolaryngology-Head and Neck SurgeryDefinitionsAcute TonsillopharyngitisErythematous and/or exudative tonsils with any one of the ff: sore throat, dysphagia, odynophagia, fever and accompanying tender, enlarged cervical lymph nodes

Viral tonsillopharyngitisInflammatory condition of tonsils caused by respiratory viruses (adenovirus, influenza, parainfluenza, RSV)

Bacterial tonsillopharyngitisInflammatory conditionof pharynx and/or tonsils caused by GABHS, H. influenzae, and Moraxhella catarrhalis.Streptococcal tonsillopharyngitisInflammatory condition of pharynx and/or tonsils caused by GABHSStrep pharyngitis increased risk for acute rheumatic fever (1%), - glomerulonephritis and RHD

60DefinitionsChronic TonsillopharyngitisTonsillar inflammation resulting from recurrent clinically documented attacks of acute tonsillitis occurring 4 times per year.

Obstructive Tonsillar HypertrophyPresence of enlarged tonsils enough to cause symptoms of functional obstruction of the air and food passages such as snoring and dysphagia.

Obstructive adenoidal hypertrophyPresence of enlarged adenoids enough to cause symptoms of chronic mouth breathing, snoring, hyponasal speech and Eustachian tube dysfunction

Obstructive Tonsillar Hypertrophy- degree of obstruction may be expressed in terms of Clinically Assessed Size (CAS) scale in which the distance between the tonsils and the distance between the anterior tonsillar pillars are measured while the tongue is gently depressed. The ratio between the two is a measure of tonsillar encroachment on oropharyngeal space

Hyponasal soeech: lack of change in voice nosality whether the nose is pinched or not. Use test words: mama, mana, nina, nganga61Epidemiology PGH Outpatient Department ORL Clinic (From Jan-May 2005)10 consults for Acute Tonsillitis4 consults for Acute Pharyngitis21 consults for Acute Tonsillopharyngitis76 consults for Chronic Hypertrophic Tonsils

Prevalence rate: 56 out of 1000 patients seen in PGH have Chronic Hypertrophic Tonsils Obstructive Tonsillar Hypertrophy- degree of obstruction may be expressed in terms of Clinically Assessed Size (CAS) scale in which the distance between the tonsils and the distance between the anterior tonsillar pillars are measured while the tongue is gently depressed. The ratio between the two is a measure of tonsillar encroachment on oropharyngeal space

Hyponasal soeech: lack of change in voice nosality whether the nose is pinched or not. Use test words: mama, mana, nina, nganga62Recommendations on DiagnosisDiagnosis of acute tonsillopharyngitis may be made clinically for both children and adults (grade B)Differentiate whether infection is viral or bacterial in etiologyDiagnosis of chronic tonsillitis can be made by a history of medically documented episodes of acute tonsillitis for at least 4 times a year (grade C).Diagnosis of obstructive adenoidal hypertrophy should be made on the basis of enlarged adenoids and a persistent difficulty in breathing and/or swallowing (grade C)Symptomatic treatment is an integral part in the management of children and adults with sore throat. This includes maintaining adequate fluid intake, warm saline gargle, bed rest, use of analgesics and antipyretics and maintaining good oral hygiene (grade B)

30-60% viral etiology, only 5-10% are caused by bacteria

Bacteria- sudden onset , sore throat, dysphagia, fever, petechiae, haeadache, nasusea. Vomiting, abdominal pain, patchy discret exudates, tender LNViral connctivitis, coryza, cough, hoarseness, diarrhea

Rapid antigen detection test- specificity of 95% and sensitivity of 89.1%

Throat culture: gold standard for diagnosis of streptococcal pharyngitis. (grade B)Suspect on clinical grounds and support with lab test (rapid antigen detection test)

Either a positive throat culture or RADT provides adequate confirmation of GABHS in the pharynx, but a negative RADT result should be confirmed with a throat culture (grade C)

63Recommendations on ManagementSurgical treatment (tonsillectomy with or without adenoidectomy) tonsillectomy may be recommended in patients with the following conditions: Tonsillar hyperplasia accompanied by any of the following: upper airway obstruction, dysphagia, speech impairment or halitosisRecurrent or chronic tonsillitis (4 episodes of tonsillitis within a year) Peritonsillar abscess occurring in the background of chronic tonsillitis

Patients with obstructive adenoidal hypertrophy may benefit from adenoidectomyNew surgical modalities for tonsillectomy may be available but are not recommended as routine procedures because of unproven effectiveness and higher expense (radiofrequency, ultrasonic harmonic scalpel

Paracetamol or ibuprofen effective intreatment (in first 48 hrs) of sore throat

Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis based on clinical and epidemiological findings with/without support by lab examinations

Penicillin drug of choice for streptococcal pharyngitis, proven efficacy and safety , narrow spectrum of activity and low cost (amoxicillin 50 mg/kg/day in 3 divided doses. Adult dose: 250-500 mg/cap, q 8 hours Penicillin V (pediatric dose: 50-100 mg/kg/day in 3-4 divided doses, adult dose: 1-4 g / day in 3-4 divided doses as oral therapy for children

Likelihood of bacteriologic and cllinical cure of GABHS tonsillopharyngitis in children is significantly higher after 10 days of oral cephalosporin therapy with cephalexin, cefadroxil, cefuroxime, cefpodoxime, cefprozil, cefixime, ceftibuten, or cefdinir than after 10 days of oral penicillin

For those allergic to penicillin who manifest hypersensitivity to beta lactam antibiotics, may give erythromycin (pediatric dose: 30-50 mg/kg/day in 4 divided doses, adult dose: 1-2 g/day in 4 divided doses)

Cases with high ASO (indicative factor for tonsillectomy)

64COURSE IN THE WARDS65Course in the WardsAdmitted to the 6th Floor of TMCMonitor vital signs every 4 hours Monitor input and urine output every 4 hoursDiet as tolerated and appropriate for ageDiagnostics:Creatinine: 94 umol/L (N)PT: 13 seconds (N)aPTT: 29 seconds (N)Chest xray: Residual fibrosis, right upper lobePatient is scheduled for tonsillectomy

(1818 mg/day)

66DAY 1 of Hospitalization67Operative TechniquePlaced on general anesthesiaPatient placed in Rose positionAsepsis and antisepsis. Sterile drapes placedMouth gag positioned.Right tonsil grasped with Allis forceps.Mucosa of the superior tonsillar pillar infiltrated with 1:100,000 lidocaine + epinephrine solutionMucosa of the superior tonsillar pillar was incised sing Blade 12Blunt dissection done at the superior pole going to the inferior pole using unipolar cautery to separate the capsule of the tonsil from its fossa.(1818 mg/day)

68Operative TechniqueRight tonsil removed.Bleeders controlled using unipolar cautery and Chromic 3-0 suture.Same procedure was done on the left tonsil.Patient tolerated the procedure well.

Operative findings:(+) Grade 3 tonsils without tonsilloliths, no exudatesNo reportable events(1818 mg/day)

69ComplicationsBlockage of airway from swollen tonsilsDehydration from difficulty swallowing fluidsPeritonsillar abscess formationFor tonsillectomy: hemorrhage(1818 mg/day)

70PrognosisGood prognosis with prompt treatment and monitoring of patients conditionIn patients who have undergone tonsillectomy, studies have shown that it produces a positive an durable increase in health related quality of life measures.(1818 mg/day)

71PreventionAdequate hydrationLifestyle changes (refrain from smoking)Avoidance of contact with individuals who are ill or patients who are immunocompromised is useful.(1818 mg/day)

72Biopsychosocial PerspectiveMedicationsPsychosocial supportSurgical ManagementPATIENTHEALTH CARE TEAMFAMILY AND FRIENDSSupport from family members and friends is vitalNeed for an environment that helps patient improve his coping mechanisms to adverse life situationsNeed a proactive health team that coordinates with the family

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