TONSILLITIS or PERITONSILLAR ABSCESS.

TONSILLITIS OR PERITONSILLAR ABSCESS



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Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. Most cases of bacterial tonsillitis are caused by group A beta-hemolytic Streptococcus pyogenes (GABHS).

Signs and Symptoms 

Individuals with acute tonsillitis present with the following:

Fever

Sore throat 

Foul breath 

Dysphagia 

Odynophagia

Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnea.

Peri tonsillar abscess 

Individuals with peritonsillar abscess (PTA) present with the following:

Severe throat pain 

Fever

Drooling 

Foul breath 

Trismus ( difficult to open the mouth)

Altered voice quality (the hot potato voice)

Physical examination of a PTA almost always reveals unilateral bulging above and lateral to one of the tonsils.

Diagnosis

Tonsillitis and PTA are clinical diagnoses. Testing is indicated when GABHS infection is suspected. Throat cultures are the criterion standard for detecting GABHS. For patients in whom acute tonsillitis is suspected to have spread to deep neck structures (ie, beyond the fascial planes of the oropharynx), radiologic imaging using plain films of the lateral neck or computed tomography (CT) scanning with contrast is warranted. In cases of PTA, CT scanning with contrast is indicated.

Treatment and management 

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever.

Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin may be helpful. GABHS infection obligates antibiotic coverage.

Tonsillectomy is indicated for the individuals who have experienced the following:

More than 6 episodes of streptococcus pharyngitis confirmed positive culture during  one year 

5 episodes of streptococcus Pharyngitis 2 consecutive years 

Three or more infections of the tonsils and or adenoids per year for 3 years in a row despite adequate medical therapy.

Chronic or recurrent tonsillitis associated with the streptococcus carrier state that has not responded to beta-lactamase-resistant antibiotics.

Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and because minimal additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform an adenoidectomy if adenoids are present and inflamed at the time of tonsillectomy.

However, this point remains controversial.

Treatment of PTA includes aspiration and incision and drainage (I&D). Antibiotics, either orally or intravenously, are required to treat PTA medically, although the condition is usually refractory to antibiotic therapy alone.

In the first century AD, Celsus described tonsillectomy performed with sharp tools and followed by rinses with vinegar and other medicinals. Since that time, physicians have been documenting management of tonsillitis.

 HISTORY 

Tonsillitis gained additional attention as a medical concern in the late 19th century. The consideration of quinsy in the differential diagnosis of George Washington's death and the discussion of tonsillitis in Kean's Domestic Medical Lectures, a home medical companion book published in the late 19th century, reflect the rise of tonsillitis as a medical concern.

Pathophysiology and etiologie 

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Overcrowded conditions and malnourishment promote tonsillitis. Most episodes of acute pharyngitis and acute tonsillitis are caused by viruses such as the following:

Herpes simplex virus

Epstein-barr-virus (EBV)

Cytomegalovirus

Herpes Virus

Adenovirus

Measles 

Bacteria cause 15-30% of cases of pharyngotonsillitis. Anaerobic bacteria play an important role in tonsillar disease. Most cases of bacterial tonsillitis are caused by group A beta-hemolytic Streptococcus pyogenes (GABHS). S pyogenes adheres to adhesion receptors that are located on the tonsillar epithelium. Immunoglobulin coating of pathogens may be important in the initial induction of bacterial tonsillitis.

Mycoplasma pneumoniae, Corynebacterium diphtheriae, and Chlamydia pneumoniae rarely cause acute pharyngitis. Neisseria gonorrhea may cause pharyngitis in sexually active persons. Arcanobacterium haemolyticum is an important cause of pharyngitis in Scandinavia and the United Kingdom but is not recognized as such in the United States. A rash similar to that of scarlet fever accompanies A haemolyticum pharyngitis.

RECURRENT TONSILLITIS 

A polymicrobial flora consisting of both aerobic and anaerobic bacteria has been observed in core tonsillar cultures in cases of recurrent pharyngitis, and children with recurrent GABHS tonsillitis have different bacterial populations than children who have not had as many infections. Other competing bacteria are reduced, offering less interference to GABHS infection. Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae are the most common bacteria isolated in recurrent tonsillitis, and Bacteroides fragilis is the most common anaerobic bacterium isolated in recurrent tonsillitis.

The microbiologies of recurrent tonsillitis in children and adults are different; adults show more bacterial isolates, with a higher recovery rate of Prevotella species, Porphyromonas species, and B fragilis organisms , whereas children show more GABHS. Also, adults more often have bacteria that produce beta-lactamase.

A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species having been identified. A study that was based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy suggested that antibiotics prescribed 6 months before surgery did not alter the tonsillar bacteriology at the time of tonsillectomy.

A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes. H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids. With regard to penicillin resistance or beta-lactamase production, the microbiology of tonsils removed from patients with recurrent GABHS pharyngitis has not been shown to be significantly different from the microbiology of tonsils removed from patients with tonsillar hypertrophy.

Local immunologic mechanisms are important in chronic tonsillitis. The distribution of dendritic cells and antigen-presenting cells is altered during disease, with fewer dendritic cells on the surface epithelium and more in the crypts and extrafollicular areas. Study of immunologic markers may permit differentiation between recurrent and chronic tonsillitis. Such markers in one study indicated that children more often experience recurrent tonsillitis, whereas adults requiring tonsillectomy more often experience chronic tonsillitis.

PERITONSILLAR ABSCESS

A polymicrobial flora is isolated from peritonsillar abscesses (PTAs). Predominant organisms are the anaerobes Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species. Major aerobic organisms are GABHS, S aureus, and H influenzae.

Uhler et al, in an analysis of data from 460 patients with PTA, found a higher incidence of the condition in smokers than in nonsmokers.

EPIDEMIOLOGY

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than 2 years. Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years, while viral tonsillitis is more common in younger children. Peritonsillar abscess (PTA) usually occurs in teens or young adults but may present earlier.

PROGNOSIS

Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including death, are rare.[12] Historically, scarlet fever was a major killer at the beginning of the 20th century, and rheumatic fever was a major cause of cardiac disease and mortality. Although the incidence of rheumatic fever has declined significantly, cases that occurred in the 1980s and early 1990s support concern over a resurgence of this condition.