MOKHTAR BASSIOUNI MD pharyngitis

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MOKHTAR BASSIOUNI MD pharyngitis Powered By Docstoc
					MOKHTAR BASSIOUNI, M. D.
PROFESSOR OF OTOLARYNGOLOGY

   UNIVERSITY OF ALEXANDRIA




         www.alexear.com
      Tonsillo-pharyngitis

    Clinical Aspects & Controversies




        Epidemiology
        E id i l
Prevalence:
•   N l all children experience at l t 1
    Nearly ll hild             i    t least
    episode of tonsillitis.
•   Adeno-tonsillectomy is one of the most
    common surgical procedures performed in
    children in the US today with an annual
    expenditure of $500 million.
          dit     f         illi
             Demographics

Age Occurrence:
• Tonsillitis is infrequent in the first 2
  years of life, and most common in
  school-age children.




               Microbiology
• Most cases of pharyngitis and tonsillitis
       i l        f h       ii i d l
  are viral: 90% of pharyngitis in adults
  and 60% to 75% in children are caused
  by viruses.
                Microbiology
 Viral Causes of Tonsillo-pharyngitis in Children
• Common:
• Adenoviruses, types 1, 2, 3, and 5.
  Less Common:
• L C
• Enteroviruses, Epstein-Barr virus, Herpes
   i l     i     I fl        i      P i fl
  simplex virus, Influenza viruses, Parainfluenza
  viruses Respiratory syncytial virus.
  Infrequent:
• I f
• Coronaviruses, Rhinoviruses.




                 Microbiology
                            Tonsillo-pharyngitis
     Bacterial Pathogens in Tonsillo pharyngitis
  Acute tonsillitis: the commonest is group A b-hemolytic
             i            ); i l d i 30-36.8% f hild
  streptococci (GABHS ) isolated in 30 36 8% of children.

  Recurrent tonsillitis:
     Aerobic: Streptococcus pneumoniae, Staphylococcus aureus, and
     Haemophilus influenzae.
                             fragilis.
     Anaerobic : Bacteroides fragilis

  Hypertrophic tonsils: H influenzae.

  Chronic tonsillitis: A polymicrobial bacterial population
  including: Staphylococcus aureus Moraxella catarrhalis, and
                            aureus,
  Hemophilus influenzae.
• In polymicrobial infections beta-lactamase
      d i         i                 G
  producing organisms can protect Group A
  strep from eradication with penicillins.




               Some Clinical
               Presentations
•   Acute Follicular Tonsillitis.
•   Chronic Tonsillitis.
•                         Hyperplasia
    Obstructive Tonsillar Hyperplasia.
•   Unilateral Tonsillar Enlargement.
•   Infectious Mononucleosis.
•   P it ill Abscess.
    Peritonsillar Ab
•   Thrush Tonsillitis.
         Acute Follicular Tonsillitis
 •   Signs and symptoms:


     –   Fever.
     –        throat.
         Sore throat
     –   Dysphagia.
     –   Enlarged tender cervical lymphadenopathy.
     –     y
         Erythematous tonsils with exudates.




  Chronic Tonsillitis
• Tonsils are unequal
   in size.
• Irregular cryptal pattern
• Malodorous breath.
• Peritonsillar erythema.
• Persistent enlarged firm cervical (JD)
  lymphadenopathy.
             Unilateral Tonsillar
                Enlargement

Non-neoplastic

Neoplastic




                 Peritonsillar Abscess
    Infectious
   mononucleosis
 White membrane covering
       both    il
one or b h tonsils

 Positive Paul-Bunnell blood
test

 Atypical mononuclear white
cells are increased on the
blood film.
bl d fil

 Huge CLNs
         Obstructive Tonsillar
             Hyperplasia

        g
• Snoring and Sleepp
  Apnoea (OSA).
• Muffled voice.
• Dysphagia.
• Kissing tonsils.




                        g g
          Beware of the gag reflex
Candidiasis
           Management of
          Pharyngo-tonsillitis
              y g
•   Investigations
•   Treatment of Acute attacks
•   Treatment of recurrent attacks
•   Prophylactic treatment
•   Surgery




           Investigations
•   ESR
•   ASOT
•   CRP
•   Throat swab / C&S.
 Treatment of Acute attacks

• Penicillin
• Amoxycillin

• Usually the causative organism is non- B
  lactamase-producing Streptococcus and will
     p            penicillins.
  respond well to p




 Treatment of Recurrent attacks

•Usually, Recurrent tonsillitis is a polymicrobial
infection,
infection in which beta-lactamase producing
organisms coexist and can protect Group A
                                      penicillins
streptococci from eradication with penicillins.

•Streptococcus pneumoniae, Staphylococcus aureus,
 Streptococcus pneumoniae                      aureus
and Haemophilus influenzae are the most common
bacteria isolated in recurrent tonsillitis. These are
       ll           i        h           d     b
generally more resistant pathogens and are better
faced with Beta-Lactamase stable antibiotics .
 Treatment of Recurrent attacks
•Combinations
Ampicillin-sulbactam
Amoxicillin-clavulanate
A   i illi l     l   t
•Second-generation cephalosporins
Cefdinir (Cefdin)
Cefprozil
 Third generation
•Third-generation cephalosporins
Cefixime
Ceftriaxone
•Macrolide/azalide
Azithromycin
Clarithromycin




           Vaccination
• Pneumococcal conjugate vaccine
• H influenzae vaccine
• Flu vaccine
• Oral bacterial vaccine (Buccaline, bronchovaxom)
• Immune-stimulant: (Echinacea)
           Indications for
           Tonsillectomy
AAO-HNS / Guidelines for Tonsillectomy1995 :
• 3 or more episodes/year
• Hypertrophy causing dental malocclusion.
• Hypertrophy causing upper airway obstruction, severe
  d sphagia sleep disorder, cardiopulmonary
  dysphagia,        disorder cardiop lmonar
  complications
• One attack of quinsy.
• Halitosis, not responsive to medical therapy
       ,    p               g
• UTE, suspicious for malignancy  y
• Chronic or recurrent tonsillitis associated with
  streptococcal carrier state .
• Individual considerations




        Other Indications
        for Tonsillectomy
Marshall’s syndrome or PFAPA syndrome
            fever, aphthous stomatitis
(periodic fever                   stomatitis,
  pharyngitis, cervical adenitis)
 Tonsillectomy and Allergy




                    y potentiates the severity
• Does tonsillectomy p                       y
  of bronchial asthma?




• Does bronchial asthma constitute an
  absolute/relative/or no contraindication to
  tonsillectomy?
  t ill t       ?
      •In a non-asthmatic atopic patient, does
      tonsillectomy increases the p ob b y o
       o s ec o y c e ses e probability of
      developing asthma?




                   [T ill         i
                   [Tonsillectomy in recent
                         references]
                            f       ]


                y       g                    q
• Tonsillectomy has no general immune consequences.
• Pre-existing allergy or asthma is not a
  contraindication to tonsillectomy.
• Tonsillectomy doesn’t have a deleterious impact on
           children
  allergic children.
• Any role for ASOT in dictating indications
                  y
  for tonsillectomy?




             y g       ,                y
• Does a very high ASOT, necessitates any
  treatment at all?
  Titre



450
400
350
300
250
200                                ASOT
150
100
 50
  0
               n


                   1


                       2


                           3


                               4


                                     5


                                          6


                                              7


                                                  8


                                                      9


                                                              10
              io
           ct
           e
        nf
    o fI
 et




                                                          Month
 ns
O




          Does a positive f il hi
        • D                                f h      i heart
                     i i family history of rheumatic h
          disease affects your decision about performing a
          tonsillectomy?
                              Is a throat swab a
                               good diagnostic
                                     test?
                                     t t?
• The throat swab is currently recommended as a diagnostic
  aid in patients with sore throat.The quoted sensitivity is
  (26-30%) and specificity (73-80%)
• This low predictive value of throat swabs is probably due
  to a high symptomless carriage rate of group A ß
           y        p         ( g g
  haemolytic streptococcus (ranging from 6% to 40% ).    )
• In approximately one-third of patients with pharyngitis or
  tonsillitis, even with elaborate culture techniques no
                                  detected.
  microbiologic etiology can be detected
• Furthermore, non-pathogenic resident flora frequently
  contaminate the microbiological specimen, making the
  results laboratory culture                doubtful
  res lts of laborator c lt re reports of do btf l clinical
  value




           Indications for
           Tonsillectomy
AAO-HNS:
• 3 or more episodes/year
• Hypertrophy causing dental malocclusion.
• Hypertrophy causing upper airway obstruction,
         dysphagia, l       disorder, di
  severe d h i sleep di d cardiopulmonary     l
  complications
                 quinsy
• One attack of quinsy.
• Halitosis, not responsive to medical therapy
  UTE,
• UTE suspicious for malignancy
• Chronic or recurrent tonsillitis associated with
  streptococcal carrier state .
      p
• Individual considerations
• Does prophylactic antibiotics have a role in the
  management of tonsillo-pharyngitis?




        Potential Indications of
        Prophylactic Antibiotics
           p y
• Recurrent tonsillo-pharyngitis.
• High ASOT.
  Hi h ASOT
• Rheumatic fever.
• Conservative trial to preserve the tonsils
  before surgery is stated.
• Adeno-tonsillar hyperplasia may
  respond to one month of therapy with
  beta-lactamase resistant antibiotics
  Prophylactic Antibiotics
• Long-acting penicillin
• Amoxycillin (20 mg/kg/day given either
          g
  as a single dose )
• Azithromycin (10 mg/kg given weekly)
• Trimethoprim/sulfamethoxazole (6.8/34
    g g y                        y      )
  mg/kg/day divided into two daily doses)




              Case Study
• A 3 y boy presents to your office whose
                l i h he            loudly d
  parents complain that h snores l dl and
  stops breathing sometimes while sleeping.
  The child’s pediatrician told the parents that
                    big
  his tonsils were “big” and that the child is
  under weight for his age
  • Also has dysphagia and daytime
    somnolence
  • Apneic spells last >10 seconds
  • PMH:
    – otherwise healthy
    – Tonsillitis: Seldom

  • No allergies




• PE:
  – Dark circles under eyes
  – Breathing with mouth open
  – Small amount of clear
    rhinorrhea
  – Tonsils are almost touching
    in the midline
       Diagnosis
• Adenotonsillar hypertrophy.
• OSA.




    Management
• Any role for conservative therapy?
     Surgical choice
•   Tonsillectomy
•   Ad          ill
    Adeno-tonsillectomy
•                          y
    Unilateral tonsillectomy
•   Tonsillotomy

				
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posted:1/20/2011
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