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 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
INTRODUCTION
Tonsillitis is a inflammation of palatine
tonsil which is a part from Waldeyer ring. The
Waldeyers ring consists few lymph node inside
the mouth cavity.1
On the recent study about the incidence
of tonsillitis chronic in 7 provinces of Indonesia
are 3.8%. This data showed that the tonsillitis
chronic incidences happen after the highest
incidences of nasopharynx acute are 4.6 %. 2,3
According to Survei Kesehatan Rumah
Tangga (SKRT), the morbidity of tonsillitis
chronic in children aged between 5-14 years old
are 10,5 % for male and 13,7% for female. The
result of examination in children and adult
showed that the total of incidences of ENT
diseases is around 190-230 per 1000 population
and 38,4% included of tonsillitis chronic
2,3
incidences.
Based on the recent study, Chronic
tonsillitis was a disease that often happen in
ENT cases and it common happened to children
5-15 years old with prevalention of bacterial
tonsillitis 15-30% in children with sore throat
and 5-15% in adult with sore throat. This term
because of children were easily got Upper
Respiratory Tract Infection (ISPA) and immune
2,3
system was still unstable.
Tonsillitis itself differs into
classifications; acute tonsillitis, recurrent
tonsillitis and chronic tonsillitis. Acute tonsillitis
mostly affects children in the age group of 5 - 15
years old. This include cases where symptom
last anywhere from 3 days to 2 weeks. Common
organisms causing this includes beta-hemolytic
streptococci (most common), staphylococci,
pneumococci and H. Influenzae. Symptoms
include sore throat, difficulty in swallowing,
fever and earache.1
Inadequate treatment and management
of acute tonsillitis may leads to recurrent and
chronic tonsillitis. Another etiology of chronic
tonsillitis consists of subclinical infection of
tonsil and chronic sinusitis or dental sepsis.
Types of chronic tonsillitis include chronic
fibroid tonsillitis where tonsils are small but
infected with history of repeated sore throat, and
chronic follicular tonsillitis, where tonsillar
crypts are full of cheesy material resulting in
yellow spots on the surface. Chronic
parenchymatous tonsillitis is where the tonsils
are very much enlarged almost touching each
other and may interfere with speech, deglutition
and respiration.1
The pathophysiology of tonsillitis is
started with the infiltration of germs to the
epithelial layer. If the epithelial eroded,
superficial lymphoid tissue will reacts. There is
an inflammation damming with the infiltration
of polymorphonuclear leukocytes. This process
is clinically seen as corpus tonsil containing
three yellow spots called detritus. Detritus is a
collection of leukocytes, bacteria and epithelium
that are released, an acute tonsillitis with a
detritus called lacunar tonsillitis, when detritus
2
spotting adjacent into one another, lacunar
tonsillitis will occur. When the detritus spot
widens even more, a Pseudomembrane will be
formed, whereas in chronic tonsillitis occurs due
to recurrent inflammatory process, the mucosal
epithelium and lymphoid tissue eroded. So that
in the healing process, lymphoid tissue will be
replaced by scar tissue. This network will shrink
so that the space between the widened (cryptic)
group will be filled by the detritus, this process
extends to penetrate the capsule and eventually
arising fixtures with tissue around the tonsillar
fossa. In children this process is accompanied by
enlarged lymph nodes of submandibula.4
Clinical features of chronic tonsillitis
include recurrent attacks of sore throat, chronic
irritation in throat with cough, halitosis,
dysphagia, odynophagia and hoarseness of the
voice. In physical examination, tonsil may show
varying degree of enlargement depending on the
type. Where tonsils are small but pressure on the
anterior pillar expresses pus or cheesy material
may be seen mainly in fibroid type. Appearance
of yellowish beads of pus on the medial surface
of tonsils may be seen in chronic follicular type.
There might be also flushing of the anterior
pillar compared to the rest of the pharyngeal
mucosa, and enlargement of the jugulodigastric
1
node and where it is soft and non tenderness.
Management include conservative and
surgical treatment or tonsillectomy. Based on
recent study, the choice of antibiotic drug that
can we given to this patient with age below 12
3
years old is cephalosporin because more
effective to treat streptococcus. In this case, the
clinician give amoxicillin drug because this
drug more effective for many cases as broad
spectrum drugs and cheaper than other drugs.
Amoxicillin will produce bactericidal effect that
can inhibit mucopeptide form to synthesis el-
microba wall. Beside antibiotic, the clinician
give analgesic drugs such as paracetamol or
ibuprofen to reduce pain for this patient.4
Tonsillectomy is the surgical removal of
tonsils. Indications include absolute indications
where there is recurrent infection of throat,
peritonsillar abscess, tonsillitis causing febrile
seizures, hypertrophy of tonsils causing
obstruction and suspicion of malignancy.
Relative indications include diphtheria carriers,
streptococcal carriers, chronic tonsillitis with
halitosis and recurrent streptococcal tonsillitis in
a patient with valvular heart disease.5
However there are also
contraindications to this procedure. In situation
where Hb level less than 10, in children under 3
years old, overt or submucous cleft palate,
bleeding disorders such as aplastic anaemia and
haemophilia, uncontrolled systemic disease
such as diabetes or asthma, tonsillectomy is not
recommended.1
Conditions such as acute otitis media,
peri-tonsillar abscess, obstructive sleep apnoea,
tonsilith, acute rheumatic fever, subacute
bacterial endocarditis and glomerulonephritis
might happen if not treated well.6

CASE REPORT
A 7 years old female patient came to the
ENT clinic in a hospital in Klaten with the chief
complaint of pain on swallowing since 3 days
ago. One day before coming to the ENT clinic,
the patient came to primary health care with the
same complaint, and then was referred to the
hospital.
Since one year ago, patient has on and
off complaints about her throat. The complaints
had recurred approximately 8 times. Until now,
the patient is still having the same complaints.
History of allergy, urticaria, asthma and same
complaint from the patient and family also
denied.
The patient's general condition at the
day of examination was good and awareness was
compos mentis. Patients vital signs: blood
pressure was 115/80 mmHg, respiratory rate was
22 times per minutes, heart rate was 82 times per
minutes, and axial temperature was 36.7 C.
On physical examination, ear
examination and nose examination are within
normal limits.
From throat examination we find that
there are no erythema and stomatitis found in the
lips. The teeth and gingiva have no caries, the
tongue has no erythema. There is hyperemia in
the uvula, and in the tonsil we found that there is
tonsil enlargement of both left and right tonsil
(T2-T2), detritus and enlarge crypta is shown.
And also the posterior wall of pharynx show
hyperemia.
4
From history taking and physical
examination, the patient was diagnosed with
chronic tonsillitis with acute exacerbation.
Patient was given antibiotic and
analgesic, Amoxicillin, 250 mg every 8 hour for
10 days and paracetamol, 250 mg if needed. And
patient is advised to bed rest, maintain oral
hygiene always brush the tooth twice a day.
Avoid irritating foods, Complete antibiotic
therapy, Suggested to undergo tonsillectomy
after the infection resolves. The patient was
given follow up were planned 1 week after
starting treatment.Patient was asked to come to
the hospital again after antibiotic therapy is
completed for follow up examination to
determine whether tonsillectomy was needed or
not.
The conclusion of this case is a 7 years
old female patient suffering from swallowing
pain for 3 days, physical examination shows
enlarged tonsils and the complaints have been
repeated 8 times since last year. The patient was
diagnosed with chronic tonsillitis with acute
exacerbation. The main problem in this case is
the etiology of the current exacerbation.
DISCUSSION
Tonsillitis is an inflammation of the
waldeyer ring caused by infection (viral or
bacterial) and inflammation of the tonsils. The
function of the waldeyer ring is as a bulwark for
the food channel as well as the airway to the
attack of germs that come in with food / drink
and air respiration.7 In addition, lymphoid
organs in the waldeyer ring produce antibodies
and lymphocytes.8
In chronic tonsillitis, repeated
inflammatory processes will result in the erosion
of the mucosal epithelium and lymphoid tissue,
resulting in the healing process of lymphoid
tissue replaced by scar tissue that will contract
so that the crypts widen. Clinically, crypts are
filled by detritus. The process runs continuously
so that it penetrates the capsule of the tonsils and
eventually gives attachment to the tissues around
the tonsillar fossa. In children this process is
accompanied by enlarged submandibular lymph
nodes.1
Tonsillitis is divided into
membranous and chronic tonsillitis. Acute
tonsillitis consists of viral tonsillitis with the
most frequent cause is Epstein Barr virus, and
bacterial tonsillitis is caused by Group A germs
Streptococcus Hemolyticus. Membranous
tonsillitis, a disease belonging to
membranous tonsillitis are diphtheria tonsillitis,
septic tonsillitis, Vincent's Angina Paut and
diseases of blood disorders. Chronic tonsillitis,
the same cause of bacteria with acute tonsillitis
but occasionally turns into a Gram-negative
1
germ.
Based on the incidence, both acute and
chronic tonsillitis is more common in children
than adults.8 This is due to children susceptible
to acute respiratory infections and generally
children who suffer tonsillitis have viral
infections.9 From a study by Modena et al
(2009) on 121 children with tonsillitis, 118 had
viral infections, with most viruses being Epstein
Barr Virus.9
In this case, the patient is a 7-year-old
girl diagnosed with Acute Exacerbations of
Chronic Tonsillitis through anamnesis, clinical
manifestation and the result of examination.
Based on the incidence, in children most of the
cause of tonsillitis is virus.9 But, because the
patient is already have repeated complaints in
the past year, it indicates that the infection has
not been eradicated yet. So the use of broad
spectrum antibiotics are considered.10,11
Broad spectrum antibiotics is shown to
be effective against a wide range of infections of
acute, Gram positive and Gram negative bacteria.
Amoxicilin is one of the broad spectrum
antibiotics. Amoxicillin though originally
introduced in the early 1970s for oral use in
U.K., has found a gradually regular place as
broad spectrum antibacterial to treat the
the infections of various diseases.11,12
Amoxicillin is bactericidal against
susceptible microorganisms through the
inhibition of biosynthesis of cell wall
mucopeptide during bacterial multiplication. It
acts by binding to penicillin binding protein 1A
(PBP-1A) located inside the bacterial cell well.
The penicillins (amoxicillin), acylate the
penicillin-sensitive transpeptidase C-terminal
domain by opening the lactam ring causing
inactivation of the enzyme, prevents the
formation of a cross-link of two linear
peptidoglycan strands, inhibiting the third and
last stage of bacterial cell wall synthesis, which
5
is necessary for cell division and cell shape and
other essential processes; and thus, the lethality
of penicillin for bacteria involves both lytic and
non-lytic mechanisms. Cell lysis is than
mediated by bacterial cell wall autolytic
enzymes such as autolysins; it is possible that
amoxicillin interferes with an autolysin
inhibitor. Amoxicillin is more effective against
gram positive than gram negative
microorganisms and it demonstrates greater
efficacy to penicillin, penicillin V and
comparable to other antibiotics, e.g. ampicillin,
azithromycin clarithromycin, cefuroxime and
doxycycline in treatment of various infections/
12
diseases.
According to a study by Regioli et al,
amoxicillin is the drug of choice and the
duration of treatment is 10 days. But a new trend
has developed, they shorten the course of
treatment to 3-6 days, in order to increase
compliance. Also amoxicillin is an antibiotic
with low risk of side effect. Cephalosporin has
been considered to be drug of choice, if the
patient are allergic to penicillin. 11
The patient was also given paracetamol
for symptoms relief. Even though tonsillitis is a
self limiting illness, it is the symptoms of the
illness that compel a person with tonsillitis to
attend to a doctor. Analgesics such as
paracetamol and ibuprofen seems to be very
effective in relieving sore throat in pediatric
patients.12 In a trial conducted by Schaltel et al,
the administration of ibuprofen or paracetamol
6
are estimated may reduce sore throat symptoms
approximately 25%-31% in children.13
CONCLUSION
A 7-year-old girl diagnosed with Acute
Exacerbations of Chronic Tonsillitis with the
chief complaint of pain on swallowing. This
patient has on and off complaints about her
throat since one year ago. The complaints had
recurred approximately 8 times. From throat
examination we find that there is hyperemia in
the uvula, and in the tonsil we found that there is
tonsil enlargement of both left and right tonsil
(T2-T2), detritus and enlarge crypta is shown.
And also the posterior wall of pharynx show
hyperemia. Based on the symptoms shown by
the patient, the Centor Score for this patient is 2,
which means there is a probability of 1-17% the
patient suffer from GABHS infection. Because
this patient is most likely has bacterial infection,
antibiotics is indicated to eliminate the bacteria
causing this infection. The appropriate treatment
for this patient should be antibiotic treatment
administration such as amoxicillin and then we
observe the progress of patients condition.
Beside antibiotic, the doctor may give analgesic
and antipyretic drugs such as paracetamol.
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