CASE REPORT

Acute exacerbation of chronic tonsillitis

HEALTH SCIENCE PART - HEAD EAR NOSE THROAT MOUTH
Dr DR.SARDJITO

MEDICAL EDUCATION PROGRAM

FACULTY OF MEDICINE Gadjah Mada University
2014

IDENTITY PATIENT
Name : NRR

TTL : 18/09/2007
Age : 6 years 6 months 22 days
Gender: Female
Address : Bantren RT 01 / 02 Hamlet Bayat Klaten
Religion : Islam
RM Number : 814 725
BB : 20 Kg
History
Main complaints : Pain swallowing
Disease History Now :
Patients come to the poly ENT RSST Klaten complained of pain with
swallowing ( + ) since 2 days ago . Pain is felt gradually swallow and felt
more pain for 2 days . Swallow the pain felt like there are cuts in the base of
the mouth and feels hot . Become rather smelly breath and breath air into
heat . Swallow the pain is felt when swallowing food and drinks as well as
saliva . Pain is considered improved if swallowed drink lots of water and lots
of rest . Pain swallowing become heavy if the patient feels fatigue , lack of
sleep , drink ice , eating spicy and fried food . Patients not taking medicine
before.
In addition , the patient complained of a lump in the throat ( + ) along with
pain perceived swallow . Flavor prop felt since 2 days ago . The taste is felt
as a lump in the throat that no objects getting bigger . The taste was
advancing when the patient feels a lump fatigue , drink ice , eating spicy and
oily as well as improved if a lot of rest .
The patient also complained of a headache since 2 days ago . Front head felt
dizzy and become heavy if the afternoon until the evening . Felt dizzy at any
time and does not improve with rest . Patients also complained about the
heat since 2 days ago . Heat at night and felt a little down in the morning or
afternoon . Heat is felt throughout the body . Heat does not improve with rest
and become heavy at night and when the patient fatigue .

Past medical history : - Tonsillectomy ( + )

- History of recurrent sore throat ( + ) since 6 months ago
- History of previous cold ( + )
- History of previous fever ( + )
- History of previous dizziness ( + )
- History cough refuted
- History of allergic refuted
- History earache refuted
Family History of Disease : resume history
odynophagia ( + ) , prop throat ( + ) , headache ( + ) .
Differential Diagnosis :
- Chronic Tonsillitis acute exacerbation
- Tonsillitis diphtheria
- laryngitis?
- Pharyngitis
- Peritonsillar abscess
- Esophagitis erosiva
PHYSICAL EXAMINATION
EARS
TELINGA
Pemeriksaan Otoskopi

kanan kiri

Auricula

Normal

Normal

Planummastoidium Normal

Normal

Gld. Lymphatica

Normal

Normal

Can. Auditori Externa

Memb. Tympani

Normal

Normal

Normal

Normal

Discharge

Negatif

Positif

HIDUNG

kanan kiri

Discharge

Negatif

Concha

Normal

Normal

Septum

Normal

Normal

Negatif

Tumor Negatif

Negatif

Sinus paranasalis

Normal

Normal

NASOFARINGkanan kiri
Dinding Belakang
Choanae

Normal

Normal

Normal

Normal

Muara tub. Eustachi

Normal

Adenoid

Normal

Normal

Tumor Negatif

Normal

Negatif

OROFARING kanan kiri

Palatum

Normal

Normal

Uvula Normal
Tonsila Palatina

Normal
MembesarT3,

Detritus(+), Detritus(+)
kriptamembesar,
Tonsila Lingualis

Normal

Membesar T4
kripta membesar

Normal

Dinding Belakang

Normal

Normal

LARINGO FARING
Dinding Belakang
Parafaring

Normal

Normal

LARING
Epiglottis

Normal

Arytenoid

Normal

Plica vokalis Normal

Movement of plica vokalisNormal
Tumor

Negatif

Subglottis

Normal

Trachea

Normal

Investigations
- Not done
DIAGNOSIS
- Acute exacerbation of chronic tonsillitis
THERAPY
- Oral antibiotics group : Penicillin tab . 500 mg no.XV s.3.d.d tab. I
- Anti - Inflammatory Analgesics such as Na . Diclofenac tab . 25 mg no. XV
s.p.r.n.3.d.d tab 1
- Antipyretics like Paracetamol tab . 500 mg no.XV s.p.r.n.3.d.d tab 1/2

suggestion Therapy
- Surgery ( Tonsillectomy ) performed after the acute phase of recovery
EDUCATION
Maintaining oral hygiene
- Patients are reminded not to drink ice cold drinks aatau .
- Patients should not eat fried foods and spicy .
- Rest enough .

DISCUSSION
DEFINITION
Chronic tonsillitis is a condition where there is enlargement of the tonsils
accompanied by repeated attacks of infection. Tonsillitis is an inflammation
of the palatine tonsils that are part of the Waldeyer ring . Waldeyer ring
consists of lymph nodes that found in the oral cavity , namely : pharyngeal
tonsils ( adenoids ) , palatine tonsils ( faucial tonsils ) , the lingual tonsils
( tonsils base of the tongue ) , tonsils Eustachian tube ( lateral pharyngeal
wall band / Gerlach's tonsil ) . The spread of infection through the air (air
-borne droplets) , hands , and kisses . It can occur at any age , especially in
children .
Predisposing factors of chronic tonsillitis are chronic stimulation of
cigarettes ,fried foods , poor oral hygiene , the effects of weather , physical
exhaustion and treatment of acute tonsillitis inadequate .
Etiology
Microorganism that cause acute tonsillitis are Grup A Streptococcus beta
haemolyticus, pneumococci ,
S. viridans and S. piogenes . However, sometimes the bacteria can turn into
a group of gram-negative .
Pathogenesis

Chronic tonsillitis occurs due to recurrent inflammatory processes. This

process is not only result erosion of epithelial mucosa but also make the
lymphoid tissue is eroded, so that the healing process of lymphoid tissue is
replaced by scar tissue that will make shrinkage so the crypts widened.
These crypts clinically filled by detritus . Detritus are consists of
polimorphonuclear cells, epithelial cells and dead bacteria. The process runs
continuously so that it penetrate the tonsil capsule and eventually lead to
the attachment of the tissues around the fossa tonsilaris . In this process the
child is accompanied by enlargement of the submandibular lymph nodes .
SYMPTOMS AND SIGNS
Symptoms

Pain in the throat is sometimes severe and may last more than 48
hours, along with pain on swallowing.

Wedge and dry sensation in throat, and smelling breath .

Pain may be referred to the ears.

Small children may complain of abdominal pain.

Headache.

Loss of voice or changes in the voice.

Signs
On examination appeared enlarged tonsils with uneven surfaces,
widened crypts with some crypts filled with detritus

The throat is reddened, the tonsils are swollen and may be coated or
have white flecks of pus on them.

Possibly a high temperature.

Swollen regional lymph glands.

Classical streptococcal tonsillitis has an acute onset, headache,

abdominal pain and dysphagia.

Examination shows intense erythema of tonsils and pharynx, yellow

exudate and tender, enlarged anterior cervical glands.

Only about 20-30% of patients present with classical disease.

THERAPY
Local
Local therapy aimed at hygiene rinse mouth such as gurgling and sipping.
Tonsillectomy are performed when there is recurrent or chronic infections ,
symptoms of obstruction and suspicion neoplasms .
Absolute indications :

Enlarged tonsils that cause upper airway obstruction, severe

dysphagia, sleep disorders, and cardiopulmonary complications

Peritonsillar abscess that is unresponsive to medical

management and drainage documented by surgeon, unless
surgery is performed during acute stage

Tonsillitis resulting in febrile convulsion

Tonsils requiring biopsy to define tissue pathology

Relative indications :

Three or more tonsil infections per year despite adequate

medical therapy

Persistent foul taste or breath due to chronic tonsillitis that is not

responsive to medical therapy

Chronic or recurrent tonsillitis in a streptococcal carrier not

responding to beta-lactamase-resistent antibiotics

Unilateral tonsil hypertrophy that is presumed to be neoplastic

Drugs
1.Antipyretic analgesics such as paracetamol and ibuprofen are of value.
2.For most patients, antibiotics have little effect on the duration of the
condition or the severity of symptoms. The National Institute for Health and
Clinical Excellence (NICE) suggests that indications for antibiotics include:

Features of marked systemic upset secondary to the acute sore

throat.

Unilateral peritonsillitis.

A history of rheumatic fever.

An increased risk from acute infection (such as a child with

diabetes mellitus or immunodeficiency).
3.Corticosteroids may be helpful for tonsillitis due to infectious
mononucleosis, especially if severe.
Choice of antibiotic
Where antibiotic is thought to be necessary, Penicillin V is the drug of
choice (10-day course), as in bacterial infections the organism of concern is
the Lancefield's Group A beta-haemolytic streptococcus (GABS) which is still

100% susceptible to penicillin. A recent meta-analysis confirmed that a 10day course was superior to shorter courses in terms of bacterial eradication.
Macrolides including erythromycin and azithromycin can be used where
there is allergy, and a course need be only 5 days. They can also be used
for treatment failures, which do occur with penicillin. Between 5% and 35%
of patients do not have bacteriological eradication. [9] This may be due to
commensal infection with bacteria that produce beta lactamase.
COMPLICATIONS
Chronic inflammation of the tonsils can cause complications to the
surrounding areas such as chronic rhinitis , sinusitis or otitis media
perkontinuitatum . Complications occur much hematogenous or limfogen and
can arise endocarditis , arthritis , myositis , nephritis , uveitis , iridocyclitis ,
dermatitis , pruritus , urticaria and furunculosis .
Acute tonsillitis
DEFINITION
Acute tonsillitis is an inflammation of the palatine tonsils . Acute tonsillitis is
often caused by the bacteria streptococcus group A -haemolytic , but
various types of other organisms can also be a cause . In some cases it can
also be caused by a virus .

Etiology
Acute tonsillitis can be caused by bacteria , virus and even fungi . Most often
caused by the -haemolytic streptococcus group A ( GABHS ) ,
pneumococci , staphylococci , Haemophilus influenzae and also viral
pathogens may be involved . Sometimes non -haemolytic streptococci or
Streptococcus viridans was found in the culture , usually in severe cases .
The virus can be a precursor to the mucosal inflammation , crypt
obstruction , and ulcerations that cause secondary bacterial invasion .
Epstein - Barr virus ( EBV ) can cause serious acute tonsilofaringitis .
Pathogenesis
Pathogenesis of infection and inflammation of the tonsils based on the tonsils
function as immune organs , managing infectious materials and other
antigens , and then became the focus of infection or inflammation. Viral
infection with secondary bacterial infection may be a mechanism that

initiates chronic disease , but the effects of the environment , host factors ,
the widespread use of antibiotics , ecological considerations , and diet , can
all play a role .
Recent studies have revealed that inflammation and loss of integrity of the
epithelial crypt produces chronic inflammation and obstruction crypt ,
increase the accumulation of debris and antigens .

Clinical Symptoms
The patient complained of sore throat , pain on swallowing , malaise , fever
( usually high temperature , can be up to 40 C ) , and breath odor . There
may be otalgia in the form of referred pain . There is tenderness along the
cervical adenopathy .
Trere are enlargement and inflammation of tonsils . Tonsils are usually
spotted and sometimes covered by exudate . This exudate may be a grayish
or yellowish . This exudate can get together and form a membrane , and in
some cases local tissue necrosis can occur .
Not all signs and symptoms appear in all patients, many clinicians rely on the
positive results of the throat culture or rapid strep antigen test for GABHS as
the sole criteria for the diagnosis of acute tonsillitis . This is still under debate
whether the throat culture is needed when there are definite signs of
infection. In the patients who are ill with inflammation of the tonsils caused
by bacterial infections or EBV ( infectious mononucleosis ) need to be
considered and treated .
DIAGNOSIS
Diagnosis based on anamnesis , clinical examination and investigations
( Rapid strep test and throat swab culture ) .
MANAGEMENT
In general , patients with acute tonsillitis and fever should be bed rest ,
adequate fluid administration , and a light diet . Local applications such as
drug throat , is considered to have a relatively minor significance . Oral
analgesics are effective in controlling bad taste . Antibiotic therapy was
associated with proper culture and sensitivity . Penicillin is still the drug of

choice , except the organism is resistant or penicillin-sensitive patients . In

such cases , erythromycin or antibiotics that are effective against specific
organisms should be used . Treatment should be continued for the entire
clinical course , between 5 to 10 days . If beta -haemolytic streptococcus
group A positive culture results , it is important to maintain adequate
antibiotic therapy for 10 days to reduce the possibility of complications such
as non supurative rheumatic heart disease and nephritis . Certain patients
still showed positive culture results after adequate treatment with penicillin .
Experiment with clindamisin recommended to eradicate these resistant
organisms . Acute tonsillitis can cause increased morbidity in patients and
their families ; however , serious complications rarely obtained . This
includes acute cervical adenitis with abscess , PTA , poststreptococcal
glomerulonephritis ,and rheumatic fever .
Penicillin group continues to be a first-line antibiotic use in acute tonsillitis
due to GABHS . Even though the negative results of the throat culture for
GABHS , antibiotic therapy appears to be effective for reducing the
symptoms . A trial of antibiotic treatment effective against - lactamase
-producing microorganisms or encapsulated anaerobic bacteria ( such as
amoxicillin - clavulanate or clindamycin ) for 3-6 weeks can be beneficial and
negate the need for tonsillectomy in about 15 % of children . Acetylsalicylic
acid or acetaminophen from 0.3 to 0.9 g every 3-4 hours can reduce the
complaints .

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