CASE REPORT Chronic Tonsillitis with Acute Exacerbation
Moderator: dr. Ashadi Prasetyo M.Sc, Sp.THT-KL
Presented by: 1. Christina Dian Rinesti
11/323999/KU/14806
2. Harris C Kusumawardana Kusumawardana
12/335385/KU/15198
3. Luthfan Sumaryono
12/338756/KU/15340
4. Nea Amnelia
11/324002/KU/14807
5. Dwi Astuti
10/299282/KU/13913
6. Aghnia Amalia
12/328496/KU/14884
Department of Otorhinolaryngology-Head & Neck Surgery Faculty of Medicine Gadjah Mada University Dr. Sardjito General Hospital Yogyakarta 201
1
years old. This include cases where symptom
INTRODUCTION
last anywhere from 3 days to 2 weeks. Common
Tonsillitis is a inflammation of palatine
organisms causing this includes beta-hemolytic
tonsil which is a part from Waldeyer ring. The
streptococci
Waldeyer’s ring consists few lymph node inside
(most
common),
staphylococci,
pneumococci and H. Influenzae. Symptoms
the mouth cavity.1
include sore throat, difficulty in swallowing, On the recent study about the incidence
fever and earache. 1
of tonsillitis chronic in 7 provinces of Indonesia Inadequate treatment and management
are 3.8%. This data showed that the tonsillitis
of acute tonsillitis may leads to recurrent and
chronic incidences happen after the highest incidences of nasopharynx acute are 4.6 %.
chronic tonsillitis. Another etiology of chronic
2,3
tonsillitis consists of subclinical infection of According to Survei Kesehatan Rumah
tonsil and chronic sinusitis or dental sepsis.
Tangga (SKRT), the morbidity of tonsillitis
Types of chronic tonsillitis include chronic
chronic in children aged between 5-14 years old
fibroid tonsillitis where tonsils are small but
are 10,5 % for male and 13,7% for female. The
infected with history of repeated sore throat, and
result of examination in children and adult
chronic follicular tonsillitis, where tonsillar
showed that the total of incidences of ENT
crypts are full of ‘cheesy material’ resulting in
diseases is around 190-230 per 1000 population
yellow
and
parenchymatous tonsillitis is where the tonsils
38,4%
incidences.
included
of
tonsillitis
chronic
2,3
spots
on
the
surface.
Chronic
are very much enlarged almost touching each other and may interfere with speech, deglutition
Based on the recent study, Chronic tonsillitis was a disease that often
and respiration.1
happen in
ENT cases and it common happened to children
The pathophysiology of tonsillitis is
5-15 years old with prevalention of bacterial
started with the infiltration of germs to the
tonsillitis 15-30% in children with sore throat
epithelial
and 5-15% in adult with sore throat. This term
superficial lymphoid tissue will reacts. There is
because of children were easily got Upper
an inflammation damming with the infiltration
Respiratory Tract Infection (ISPA) and immune
of polymorphonuclear leukocytes. This process
system was still unstable. Tonsillitis classifications;
itself
acute
2,3
layer.
If
the
epithelial
eroded,
is clinically seen as corpus tonsil containing differs
tonsillitis,
into
yellow spots called detritus. Detritus is a
three
collection of leukocytes, bacteria and epithelium
recurrent
tonsillitis and chronic tonsillitis. Acute tonsillitis
that are released, an acute tonsillitis with a
mostly affects children in the age group of 5 - 15
detritus called lacunar tonsillitis, when detritus
2
spotting adjacent into one another, lacunar
years
tonsillitis will occur. When the detritus spot
effective to treat streptococcus. In this case, the
widens even more, a Pseudomembrane will be
clinician
formed, whereas in chronic tonsillitis occurs due
drug more effective for many cases as broad
to recurrent inflammatory process, the mucosal
spectrum drugs and cheaper than other drugs.
epithelium and lymphoid tissue eroded. So that
Amoxicillin will produce bactericidal effect that
in the healing process, lymphoid tissue will be
can inhibit mucopeptide form to synthesis el-
replaced by scar tissue. This network will shrink
microba wall. Beside antibiotic, the clinician
so that the space between the widened (cryptic)
give analgesic drugs such as paracetamol or
group will be filled by the detritus, this process
ibuprofen to reduce pain for this patient. 4
extends to penetrate the capsule and eventually
is
cephalosporin
give
because
more
amoxicillin drug because this
Tonsillectomy is the surgical removal of
arising fixtures with tissue around the tonsillar
tonsils. Indications include absolute indications
fossa. In children this process is accompanied by enlarged lymph nodes of submandibula.
old
where there is recurrent infection of throat,
4
peritonsillar abscess, tonsillitis causing febrile
Clinical features of chronic tonsillitis
seizures,
hypertrophy
irritation
halitosis,
Relative indications include diphtheria carriers,
dysphagia, odynophagia and hoarseness of the
streptococcal carriers, chronic tonsillitis with
voice. In physical examination, tonsil may show
halitosis and recurrent streptococcal tonsillitis in
varying degree of enlargement depending on the
a patient with valvular heart disease. 5
with
cough,
type. Where tonsils are small but pressure on the
However
anterior pillar expresses pus or cheesy material
there
malignancy.
are
also
contraindications to this procedure. In situation
may be seen mainly in fibroid type. Appearance
where Hb level less than 10, in children under 3
of yellowish beads of pus on the medial surface
years old, overt or submucous cleft palate,
of tonsils may be seen in chronic follicular type.
bleeding disorders such as aplastic anaemia and
There might be also flushing of the anterior
haemophilia,
pillar compared to the rest of the pharyngeal
uncontrolled systemic disease
such as diabetes or asthma, tonsillectomy is not
mucosa, and enlargement of the jugulodigastric node and where it is soft and non tenderness.
of
causing
obstruction
throat
suspicion
tonsils
include recurrent attacks of sore throat, chronic in
and
of
recommended. 1
1
Conditions such as acute otitis media, Management include conservative and
peri-tonsillar abscess, obstructive sleep apnoea,
surgical treatment or tonsillectomy. Based on
tonsilith,
recent study, the choice of antibiotic drug that
acute
rheumatic
fever,
subacute
bacterial endocarditis and glomerulonephritis
can we given to this patient with age below 12
might happen if not treated well. 6
3
From
history
taking
and
physical
examination, the patient was diagnosed with
CASE REPORT
A 7 years old female patient came to the
chronic tonsillitis with acute exacerbation.
ENT clinic in a hospital in Klaten with the chief
Patient
was
given
antibiotic
and
complaint of pain on swallowing since 3 days
analgesic, Amoxicillin, 250 mg every 8 hour for
ago. One day before coming to the ENT clinic,
10 days and paracetamol, 250 mg if needed. And
the patient came to primary health care with the
patient is advised to bed rest, maintain oral
same complaint, and then was referred to the
hygiene always brush the tooth twice a day.
hospital.
Avoid irritating foods, Complete antibiotic
Since one year ago, patient has on and
therapy, Suggested to undergo tonsillectomy
off complaints about her throat. The complaints
after the infection resolves. The patient was
had recurred approximately 8 times. Until now,
given follow up were planned 1 week after
the patient is still having the same complaints.
starting treatment.Patient was asked to come to
History of allergy, urticaria, asthma and same
the hospital again after antibiotic therapy is
complaint from the patient and family also
completed
denied.
determine whether tonsillectomy was needed or The patient's general condition at the
for
follow
up
examination
to
not.
day of examination was good and awareness was
The conclusion of this case is a 7 years
compos mentis. Patient’s vital signs: blood
old female patient suffering from swallowing
pressure was 115/80 mmHg, respiratory rate was
pain for 3 days, physical examination shows
22 times per minutes, heart rate was 82 times per
enlarged tonsils and the complaints have been
minutes, and axial temperature was 36.7° C.
repeated 8 times since last year. The patient was
On
physical
examination,
ear
diagnosed with chronic tonsillitis with acute
examination and nose examination are within
exacerbation. The main problem in this case is
normal limits.
the etiology of the current exacerbation.
From throat examination we find that there are no erythema and stomatitis found in the
DISCUSSION
lips. The teeth and gingiva have no caries, the
Tonsillitis is an inflammation of the
tongue has no erythema. There is hyperemia in
waldeyer ring caused by infection (viral or
the uvula, and in the tonsil we found that there is
bacterial) and inflammation of the tonsils. The
tonsil enlargement of both left and right tonsil
function of the waldeyer ring is as a bulwark for
(T2-T2), detritus and enlarge crypta is shown.
the food channel as well as the airway to the
And also the posterior wall of pharynx show
attack of germs that come in with food / drink
hyperemia.
and air respiration. 7 In addition, lymphoid
4
organs in the waldeyer ring produce antibodies
viral infections, with most viruses being Epstein
and lymphocytes.8
Barr Virus.9
In
chronic
tonsillitis,
repeated
In this case, the patient is a 7-year-old
inflammatory processes will result in the erosion
girl diagnosed with Acute Exacerbations of
of the mucosal epithelium and lymphoid tissue,
Chronic Tonsillitis through anamnesis, clinical
resulting in the healing process of lymphoid
manifestation and the result of examination.
tissue replaced by scar tissue that will contract
Based on the incidence, in children most of the
so that the crypts widen. Clinically, crypts are
cause of tonsillitis is virus. 9 But, because the
filled by detritus. The process runs continuously
patient is already have repeated complaints in
so that it penetrates the capsule of the tonsils and
the past year, it indicates that the infection has
eventually gives attachment to the tissues around
not been eradicated yet. So the use of broad
the tonsillar fossa. In children this process is
spectrum antibiotics are considered. 10,11
accompanied by enlarged submandibular lymph
Broad spectrum antibiotics is shown to
nodes.1
be effective against a wide range of infections of Tonsillitis
membranous
and
is
divided
chronic
into
acute,
Gram positive and Gram negative bacteria.
tonsillitis.
Acute
Amoxicilin is one of the broad spectrum
tonsillitis consists of viral tonsillitis with the
antibiotics.
most frequent cause is Epstein Barr virus, and
introduced in the early 1970’s for oral use in
bacterial tonsillitis is caused by Group A germs
U.K., has found a gradually regular place as
Streptococcus
broad
tonsillitis,
a
β
Hemolyticus.
disease
Membranous
belonging
to
Amoxicillin
though
spectrum antibacterial
to
originally
treat
the
infections of various diseases. 11,12
the
membranous tonsillitis are diphtheria tonsillitis,
Amoxicillin
is
bactericidal
septic tonsillitis, Vincent's Angina Paut and
susceptible
diseases of blood disorders. Chronic tonsillitis,
inhibition
the same cause of bacteria with acute tonsillitis
mucopeptide during bacterial multiplication. It
but occasionally turns into a Gram-negative
acts by binding to penicillin binding protein 1A
germ.1
(PBP-1A) located inside the bacterial cell well. Based on the incidence, both acute and
The
micro‐organisms
against
of
biosynthesis
penicillins
through of
(amoxicillin),
cell
acylate
wall
the
chronic tonsillitis is more common in children
penicillin-sensitive
than adults.8 This is due to children susceptible
domain by opening the lactam ring causing
to acute respiratory infections and generally
inactivation
children who suffer tonsillitis have viral
formation
infections.9 From a study by Modena et al
peptidoglycan strands, inhibiting the third and
(2009) on 121 children with tonsillitis, 118 had
last stage of bacterial cell wall synthesis, which
5
of of
transpeptidase
the
the a
enzyme,
cross-link
C-terminal
prevents of
two
the linear
is necessary for cell division and cell shape and
are estimated may reduce sore throat symptoms
other essential processes; and thus, the lethality
approximately 25%-31% in children. 13
of penicillin for bacteria involves both lytic and
CONCLUSION
non-lytic
mechanisms.
Cell
lysis
is
A
mediated
by
cell
wall
autolytic
Exacerbations of Chronic Tonsillitis with the
enzymes such as autolysins; it is possible that
chief complaint of pain on swallowing. This
amoxicillin
autolysin
patient has on and off complaints about her
inhibitor. Amoxicillin is more effective against
throat since one year ago. The complaints had
gram
negative
recurred approximately 8 times. From throat
microorganisms and it demonstrates greater
examination we find that there is hyperemia in
efficacy
and
the uvula, and in the tonsil we found that there is
comparable to other antibiotics, e.g. ampicillin,
tonsil enlargement of both left and right tonsil
azithromycin clarithromycin, cefuroxime and
(T2-T2), detritus and enlarge crypta is shown.
doxycycline in treatment of various infections/
And also the posterior wall of pharynx show
diseases. 12
hyperemia. Based on the symptoms shown by
bacterial
interferes
positive
to
with
than
penicillin,
an
gram
penicillin
V
than
7-year-old
girl
diagnosed
with
Acute
According to a study by Regioli et al,
the patient, the Centor Score for this patient is 2,
amoxicillin is the drug of choice and the
which means there is a probability of 1-17% the
duration of treatment is 10 days. But a new trend
patient suffer from GABHS infection. Because
has developed, they shorten the course of
this patient is most likely has bacterial infection,
treatment to 3-6 days, in order to increase
antibiotics is indicated to eliminate the bacteria
compliance. Also amoxicillin is an antibiotic
causing this infection. The appropriate treatment
with low risk of side effect. Cephalosporin has
for this patient should be antibiotic treatment
been considered to be drug of choice, if the
administration such as amoxicillin and then we
patient are allergic to penicillin.
11
observe the progress of patient’s condition.
The patient was also given paracetamol
Beside antibiotic, the doctor may give analgesic
for symptoms relief. Even though tonsillitis is a
and antipyretic drugs such as paracetamol.
self limiting illness, it is the symptoms of the illness that compel a person with tonsillitis to attend
to
a
doctor.
Analgesics
such
REFERENCES
as
1. Rusmarjono
dan
Soepardi,
EA.
paracetamol and ibuprofen seems to be very
Faringitis, Tonsilitis, dan Hipertrofi
effective in relieving sore throat in pediatric
Adenoid.
patients.12 In a trial conducted by Schaltel et al ,
Arsyad,
the administration of ibuprofen or paracetamol
Kesehatan Telinga, Hidung, Tenggorok,
Dalam et
al.,
Soepardi, Buku
Ajar
Efiaty Ilmu
Kepala & Leher. ed 6. Jakarta. FKUI,
6
2009: p. 199-208 2. Farokah,
9. Modena JL, Fabianan CP, Marcos GJ,
2007, Hubungan Tonsilitis
Guilherme PB, Tamara HS, Lucia L,et
Kronik dengan Prestasi Belajar pada
al. High rates of detection of respiratory
Siswa Kelas II Sekolah Dasar di Kota
viruses in tonsillar tissue from children
Semarang ,
Kesehatan
with
chronic
Kedokteran
BMJ
Publishing
Bagian
THT-KL
Ilmu
Fakultas
Universitas
Diponegoro,
SMF
adenotonsillar Group
disease.
Ltd.
2009;
10:503.
Kesehatan THT-KL Rumah Sakit Dr.
10. Furuncuoglu Y, Saglam F, Kutluhan A.
Kariadi Semarang, Indonesia, Cermin
Acute exudative tonsillitis in adults: the
Dunia Kedokteran No. 155 Hal: 87-92.
use of the Centor score and some
3. Nadhilla NF, Sari MI. Tonsilitis Kronik
laboratory tests. Turkish Journal of
Eksaserbasi Akut pada Pasien Dewasa J
Medical
Sciences.
Medula Unila. 2005;(1):107-112.
20;46(6):1755-9.
2016
Dec
4. Thomas M, Del Mar C, Glasziou P.
11. Regoli, M., Chiappini, E., Bonsignori,
How effective are treatments other than
F., Galli, L. and de Martino, M., 2011.
antibiotics for acute sore throat? The
Update on the management of acute
British Journal of General Practice.
pharyngitis in children. Italian journal
2000;50(459):817-820
of pediatrics, 37 (1), p.10.
5. Stelter K. Tonsillitis and sore throat in children.
GMS
current
topics
12. Kaur
in
SP,
Rao
Amoxicillin:
a
R,
Nanda
broad
SA.
spectrum
otorhinolaryngology, head and neck
antibiotic. Int J Pharm Pharm Sci.
surgery. 2014;13.
2011;3(3):30-7.
6. Campisi P, Tewfik PL. Tonsillitis and Its
Complications.
The
13. Schachtel BP, Thoden WR. A placebo-
Canadian
controlled model for assaying. systemic
Journal of Diagnosis. 2003: 99-105. 7. Herawati Faring.
S,
Rukmini
Dalam:
Anatomi
14. Drake Amelia F. (2015, October 25)
Penyakit Telinga Hidung Tenggorokan.
Tonsillectomy. Retrieved June 1,2017
Jakarta:
from
Buku
Ajar
Ther 1993; 53: 593-601.
Ilmu
Penerbit
Buku
S.
analgesics in children. Clin Pharmacol
Kedokteran
ECG; 2004.
:
reference.medscape.com/article/872119-
8. Health Technology Assessment (HTA) Departemen
Medscape
Kesehatan
overview
Republik
15. Epocrates.
Tonsillitis
epidemiology.
Indonesia Tahun 2004. Tonsilektomi
AnAthenahealth Service. 2015 [disitasi
pada anak dan dewasa. Jakarta; 2004.
tanggal 1 mei 2016]
7
16. Lipton A.J., Gozal D. Treatment of obstructive sleep apnea in children: do we really know how?. Sleep Med Rev. 2003 Feb;7(1):61-80.
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