Tonsil is an ovoid shaped, subepithelial aggregate of lymphoid tissue situated in lateral wall of oropharynx between anterior and posterior pillar. It forms a part of Waldeyer’s ring that acts as a barrier to bacterial invasion. The tonsil contains deep tortuous crypts and has exceptionally good blood supply.
Acute Tonsillitis
It is acute inflammation of tonsil commonly seen in children and young adults.
Causes
Bacterial infection: Hemolytic streptococci, staphy-lococci, pneumococci.
Viral infection: Infectious mononucleosis
Clinical features: The patient presents with sore throat, malaise, fever, dysphagia and sometimes referred ear-ache. On examination, the tonsils are swollen and erythematous. Yellow or white pustules are seen covering the crypt, hence named follicular tonsillitis.
A throat swab should be taken at the time of examination and bacteriological examination helps to rule out diphtheria.
Treatment
• Warm saline gargles to wash away the purulent secretions.
• Analgesics and antipyretics to relieve pain and fever.
• Phenoxymethyl penicillin (penicillin V) is given initially and most patients respond well. In case of no response, antibiotics are changed according to swab culture and sensitivity report.
• Most of the cases resolve in 5-7 days.
Complications See Box 14.2.
Box 14.2: Complications of acute tonsillitis
• Chronic tonsillitis
• Subacute bacterial endocarditis
• Acute glomerulonephritis Chronic Tonsillitis
It usually results from repeated attacks of acute tonsillitis.
The tonsils become indurated and adherent due to fibrosis. It provides a reservoir for infective organisms leading to recurrent infection.
The patient presents with recurrent sore throat, fever and dysphagia. On examination, the tonsils are small
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Textbook of Surgery for Dental Studentsbut contain pus and debris. The tonsillar lymph nodes are enlarged.
Treatment
Conservative in form of nutrition, maintaining oral hygiene and course of antibiotics and analgesics.
If condition recurs or persists, treatment is tonsillectomy.
Tonsillectomy Indications
One of the important indications is enlarged tonsils causing chronic upper respiratory tract obstruction and sleep apnea. The diagnosis is made after hospitalization and performing sleep studies in the patient to establish the exact site and extent of the problem. Various indications of tonsillectomy are given in Box 14.3A.
Box 14.3A: Indications of tonsillectomy Absolute
• Chronic upper respiratory obstruction causing sleep apnea.
• Suspected tonsillar malignancy.
Relative
• Chronic tonsillitis.
• Recurrent acute tonsillitis.
• Systemic disease due to recurrent tonsillitis, e.g.
rheumatic fever, glomerulonephritis.
• Peritonsillar abscess.
Tonsillectomy should not be done when tonsils are acutely inflamed.
Steps
It is done under general anesthesia. Patient lies supine with head extended. The mucosa is incised over anterior faucial pillar and tonsil separated from its bed by blunt dissection till its pedicle is defined. Then pedicle is severed using a wire snare. A swab is placed in tonsillar bed to apply pressure for a few minutes so as to control bleeding. The swab is removed and bleeding points identified and controlled with suture ligation or bipolar cautery.
Complications See Box 14.3B.
Box 14.3B: Complications of tonsillectomy
• Hemorrhage
• Pain (dysphagia, otalgia)
• Airway obstruction
• Infection
• Aspiration pneumonia
Peritonsillar Abscess (Quinsy)
There is formation of abscess in peritonsillar region between capsule of tonsil and superior constrictor muscle. It mostly occurs as a complication of acute tonsillitis and associated with streptococcal infection. It is commonly seen in adult males.
Clinical Features
There is severe pain in tonsillar region radiating to the ear and side of the neck. The patient has severe trismus and foul smelling breath. General symptoms include high grade fever with malaise. The patient presents to the clinician with his head held forward and upwards with a handkerchief. He talks as if he has ‘hot potato’
in his mouth. For examination, installation of local anesthetic may be required in posterior nasal cavity so that trismus is relieved and patient can open his mouth.
On examination, there is diffuse swelling of the soft palate just above the involved tonsil and uvula is displaced to the opposite side. There may be pus pointing at the summit of the swelling.
Treatment
Patient is hospitalized and intravenous fluids are given.
Parenteral analgesics and antibiotics may resolve the lesion during early phase. If condition persists, treatment is trans-oral incision and drainage of the pus. Interval tonsillectomy should be done after 4-6 weeks.
Parapharyngeal Abscess
• It is very similar to quinsy except that abscess occupies lateral pharyngeal space.
• There is maximum swelling behind the posterior faucial pillar.
• There is little or no edema of the palate.
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• There can be diffuse swelling in the neck behind angle of the jaw and parotid region.
• Treatment is transoral incision and drainage of the pus using a blunt instrument.
Retropharyngeal Abscess It can be acute or chronic.
Acute Retropharyngeal Abscess
There is formation of abscess in retropharyngeal space lying between pharynx in front and prevertebral fascia behind. This space is completely divided in the midline by a strong fascial septum into a right and left compartment. Hence, abscess always occurs on one side of the midline.
Etiology: Most commonly seen in children less than 1 year of age due to suppuration of retropharyngeal lymph nodes. The infection starts from tonsils, oropharynx or nasopharynx. In adults, it is rare and is caused due to injury of posterior pharyngeal wall by a foreign body, e.g. fish bone.
Clinical features: Generalized malaise, neck rigidity, dysphagia, dribbling saliva and marked dyspnea.
The apex of abscess is opposite the glottis and interferes with deglutition and breathing. Hence, child is seen characteristically holding his head in full extension with mouth open for maintaining adequate airway. On examination, inspection of posterior pharyrngeal wall shows gross swelling with pointing abscess. On palpation, cushion like projection is felt on posterior pharyngeal wall.
Treatment:
• Hospitalization and intravenous fluids
• Antibiotics and analgesics
• Incision and drainage of the abscess. During drainage of abscess, airway should be protected by placing the child in head down position.
Chronic Retropharyngeal Abscess
• It is mostly tubercular in nature and rarely seen these days.
• It is due to anterior extension of tuberculosis of cervical spine. Since the abscess lies behind the prevertebral fascia, consequently it occupies the midline.
• Another cause is tuberculosis of retropharyngeal lymph nodes. In this situation, abscess is in front of prevertebral fascia in the retropharyngeal space and hence, gives swelling on one side of the midline (c/f acute retropharyngeal abscess).
• Unlike acute retropharyngeal abscess, this condition is solely seen in adults and there is no dysphagia or dyspnea.
• Apart from retropharyngeal swelling seen through oral cavity, the abscess extends in the neck and patient presents with fullness behind sternomastoid muscle on one side of the neck.
• The cervical spine is unstable and its manipulation may lead to neurological deficit.
• X-ray cervical spine shows evidence of bone destruction.
Treatment:
• Antitubercular drugs.
• If abscess persists, it is drained through cervical incision anterior to sternomastoid muscle.
• The abscess should not be drained through trans-oral route otherwise it may lead to secondary infection.
• Sometimes surgery is required for decompression of spinal cord to prevent progressive neurological deficit.
Infectious Mononucleosis (Glandular Fever) It is a viral infection caused by Epstein-Barr virus.
However, similar clinical features can be due to toxoplasmosis or cytomegalovirus.
Clinical Features
• Commonly seen in young adults.
• High grade fever with malaise.
• Throat pain and dysphagia.
• Hypersalivation.
• Difficulty in breathing.
• On examination, the tonsils are enlarged, edematous with a creamy-gray exudate.
• The tonsils are symmetrically enlarged and may appear to meet in the midline.
• There is generalized lymphadenopathy with hepatosplenomegaly.
Diagnosis: It is confirmed with serological test showing positive Paul-Bunnell test.
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Textbook of Surgery for Dental StudentsTreatment
• Hydration.
• Analgesics and antipyretic drugs.
• Patient may need hospitalization in case of respiratory obstruction.
• Steroids may help in relieving respiratory obstruction.
• If airway obstruction persists, elective tracheostomy should be done.
• Antibiotics are of no value since it is viral infection.
• Emergency tonsillectomy is contraindicated.
NEOPLASTIC LESIONS OF ORAL CAVITY