Acute Tonsillopharyngitis

1
Acute Tonsillopharyngitis

• Dr Rajesh
• 16/04/08

2
Definitions

• tonsillitis inflammation of pharyngeal tonsils
• tonsillopharyngitis inflammation extending from
  tonsils to the adenoids and lingual tonsils
• recurrent tonsillitis 7 episodes in 1 year, 5
  infections in 2 consecutive years, or 3
  infections each year for 3 years consecutively
  chronic tonsillitis chronic sore throat,
  halitosis, tonsillitis, and persistent tender
  cervical nodes for greater than 4 weeks
• quinsy Greek term used for inflammation of
  throat and tonsils, historically used for
  peritonsillar abscess

3
Epidemiology

• most cases occur in school-age children
• uncommon in the first 2 years of life
• 5-7 URIs per child per year
• GAS is found in 35 of children with pharyngitis
• 45,000 cases of PTA per year or 30 cases per
  100,000 people per year

4
Causes of Tonsillopharyngitis

•     Beta hemolytic streptococcal infection 22
  percent
•     Mycoplasma pneumoniae 9.4 percent
•     Chlamydia species strain TWAR 8.4 percent
•   Viruses 25.5 percent
• Huovinen, et al 1995

5
(No Transcript)
6
CLINICAL DIAGNOSIS

• The "classic" presentation of GAS
  tonsillopharyngitis is a sore throat associated
  with fever, tonsillopharyngeal erythema and
  exudate, swollen and tender anterior cervical
  adenopathy, and an elevated white blood cell
  (WBC) count without rhinorrhea or cough.
• However, even when this constellation of
  clinical symptoms is present, the likelihood of
  GAS infection does not exceed 60 to 70 percent in
  children, and 20 to 30 percent in adults.

7
Is it truly Group A beta hemolytic Streptoccal
tonsillopharyngitis?

• From many studies, it would appear that the
  presence or absence of a GAS pharyngitis cannot
  be accurately diagnosed with clinical examination
  alone in most patients.
• It is somewhat easier to identify a subset of
  children (approximately 20 percent of cases) and
  adults (approximately 67 percent of cases) who
  are unlikely to have GAS.
• These patients have sore throats with
  accompanying rhinorrhea, cough, and hoarseness.
  Fever is often absent. They have mild
  tonsillopharyngeal erythema without exudate, and
  slight or no cervical lymphadenitis.

8
Why antibiotics

• Treatment of GABHS pharyngitis is important
• To prevent complications of infection,
• particularly rheumatic fever
• suppurative complications
• To speed recovery
• To prevent spread of the infection

9
Treatment approach based on clinical findings
(Komarof, et al)

•     Empirically treat patients with the
  constellation of a tonsillar exudate, tender
  cervical adenopathy, and a temperature gt37.8º C.
•    Obtain throat cultures in patients with
  only one or two of the above findings and treat
  based upon those results.
•    Do not obtain cultures or treat patients
  with none of the above findings.

10
The nonsuppurative complications of GAS
tonsillopharyngitis

• Acute rheumatic fever
• Scarlet fever
• Streptococcal toxic shock syndrome
• Acute glomerulonephritis
• PANDAS (Pediatric Autoimmune Neuropsychiatric
  Disorder Associated with Group A Streptococci)

11
Suppurative complications

• Tonsillopharyngeal cellulitis or abscess
• Otitis media
• Sinusitis
• Necrotizing fasciitis

12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
Peritonsillar abscess
17
Mononucleosis epstein-barr virus (EBV

• indolent onset, gray tonsillar exudate, tender
  cervical, axillary and/or inguinal
  lymphadenopathy, low grade fever, weight loss,
  myalgias, fatigue, hepatosplenomegaly atypical
  lymphocytes in peripheral smear
• positive monospot or heterophil Ab test
• rash with penicillin
• illness lasts more than 7-10 days

18
Intraoral Ultrasound

• highly accurate ultrasound
• can exclude peritonsillar cellulitis, abscess and
  retropharyngeal abscess
• determination of abscess volume, location and
  relationship to carotid artery

19
CT neck with contrast

• indications
• spread to deep neck structures
• inferior pole abscess
• high risk for drainage procedures (coagulopathy)
• to guide drainage of PTA after unsuccessful
  surgical attempt
• patient unable to open mouth due to trismus

20
complicated PTA with rupture into carotid space
21
Airway Obstruction

• nasal airway
• humidified oxygen
• corticosteroids
• monitored observation
• intubation
• cricothyroidotomy
• tracheostomy

22
Recommendations on the Management of Acute and
Chronic Tonsillitis

• Adequate supportive care
• Use of analgesics, oral anesthetics, and
  antiseptics
• Antibiotics

23
Antibiotics

• Penicillins
• Cephalosporins
• Macrolides

24
(No Transcript)
25
Bacteriological cure
26
(No Transcript)
27
(No Transcript)
28

• in the AHA guidelines, prevention of
• rheumatic fever as a poststreptococcal
  complication depends on eradication of GABHS
  bacteria from the pharynx
• prevention of rheumatic fever and other
  nonsuppurative complications of GABHS pharyngitis
  still occurs when antibacterial therapy is
  postponed by as many as 9 days after the onset of
  pharyngitis symptoms

29
Factors influencing antibiotic choice

• ability to eradicate GABHS bacteria from the
  pharynx
• Ability to resolve signs and symptoms of the
  infection (bacteriologic and clinical efficacy)
• adherence (frequency of daily administration,
  duration of therapy, and palatability),
• Antibacterial spectrum (narrow versus broad
  activity),
• potential treatment-related side effects
• cost.

30
Cephalosporins
31
(No Transcript)
32
Changing pattern of penicillin sensitivity
33
(No Transcript)
34
(No Transcript)
35
Clinical cure
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Short course therapy of AT

• Cephalopsorin
• Azithromycin

40
(No Transcript)
41
(No Transcript)
42
Penicillin Resistance Mechanism

• It is important to note that no strains of GABHS
  resistant to penicillin or cephalosporin have
  ever been reported.
• Copathogenicity is the most likely explanation
  for the increasing rate of penicillin treatment
  failures
• GABHS susceptible to penicillin are protected by
  other in vivo, colocalized bacteria that lack the
  same susceptibility due to beta-lactamase
  production
• beta-lactamase producing organisms is more likely
  to inactivate penicillin

43
Recurrence risk

• Symptomatic bacteriologic recurrence within 30
  days of initial diagnosis occurred in
• 37 of patients treated with penicillin V,
• 25 of patients treated with amoxicillin,
• 18 of patients treated with cephalexin or
  cefadroxil,
• 7 of patients treated with amoxicillin-clavulanat
  e or a second-generation or third-generation
  cephalosporin

44
Children Less Than Three-Years-OldWith
PharyngitisAre Group A Streptococci Really That
UncommonClinical pediatrice , 1986

• During a 15-month period, 148 infants and
  children less than 3-years-old who presented with
• signs and/or symptoms of pharyngitis were
  monitored in a private pediatric practice.
  Clinical
• signs included fever (95 or 64), tonsillar
  exudate (16 or 11), and cervical adenopathy (5
  or 3).
• Beta-hemolytic streptococci (BHS) from group A
  were isolated from throat swabs in 37 (25)
• instances. These isolations were more common
  among children 25-35 months old than among
• children less than 2 years old (35 vs. 19, p lt
  0.05), and were significantly more likely when
• overnight anaerobic culture techniques were used
  rather than conventional aerobic methods (23
• vs. 11, p lt 0.01).

45
Recurrent tonsillitis

• Recurrent tonsillitis is diagnosed when an
  individual has 7 episodes in 1 year, 5 infections
  in 2 consecutive years, or 3 infections each year
  for 3 years consecutively.

46
Microbiology of recurrent tonsillitis

• A polymicrobial flora consisting of both aerobic
  and anaerobic bacteria is observed in core
  tonsillar cultures from cases of recurrent
  pharyngitis.
• Streptococcus pneumoniae, Staphylococcus aureus,
  and Haemophilus influenzae are the most common
  bacteria isolated in recurrent tonsillitis.
• Bacteroides fragilis is the most common anaerobic
  bacterium isolated in recurrent tonsillitis.
• 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
  identified.
• One study, based on bacteriology of the tonsillar
  surface and core in 30 children undergoing
  tonsillectomy, suggests that antibiotics
  prescribed 6 months before surgery do not alter
  the tonsillar bacteriology at the time of
  tonsillectomy.7
• 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 is not significantly different
  from the microbiology of tonsils removed from
  patients with tonsillar hypertrophy.

47
Treatment for recurent / chronic tonsillitis

• Clindamycin 20-30 mg/kg PO divided tid for 10 d
  not to exceed 300 mg/dose Rifampin 10
  mg/kg/dose bid for 4 days
• Amoxy-clav for 4-6 weeks

48
Prophylaxis (5 strep infections in 6 months)

• Penicillin V Potassium (Kaypen)40 mg/kg/day PO
  bid, max 3 gm/day

49
Tonsillectomy Absolute Indications

• Tonsillar hypertrophy causing obstruction to
  respiration or deglutition
• Obstructive sleep apnea

50
Relative Indications

• Chronic tonsillitis
• Tonsillitis resulting in febrile convulsions
• Peritonsillar abscess
• Diphteria carrier
• Suspected tonsillar malignancy
• Hypertrophy causing malocclusion
• Failure to thrive
• Systemic disease secondary to Beta hemolytic
  streptococcal infection
• Chronic halitosis