organism confirms the diagnosis in 2 to 8 days; (4) there is a membrane which is
firmly adherent and which extends beyond the tonsil. The disease is reportable
to public health authorities.
Differential diagnosis. This includes nonspecific tonsillitis, infectious
mononucleosis, Vincent's angina, candidiasis, agranulocytosis, leukemia, and
syphilis.
Treatment. Antiserum in a dose of 200 to 500 IU/kg must be given intramuscularly
at the earliest reasonable suspicion of the diagnosis, i.e., before
bacteriologic confirmation. In severe cases a high dose of 1,000 IU/kg may be
given accompanied by antibiotic cover. Treatment also includes bed rest, oral
hygiene. Diphtheria immunization by diphtheria toxoid is protective but does not
become effective for several weeks.
Complications. These include general toxicity, failure of the heart and
circulation, hemorrhagic nephritis or nephrosis, palatal paralysis due to
polyneuritis, airway obstruction, and danger of asphyxia. A proportion of the
population are silent carriers of the disease.
Normally, excretion of virulent diphtheria bacteria ceases after several weeks.
However, carriers may remain a source of infection for months or even years.
Cultures are therefore necessary until three cultures at weekly intervals are
negative.
Long-term carriers should be treated by local and parenteral antibiotics and
local disinfection. If this does not eradicate the organism, it may be necessary
to carry out tonsillectomy, accompanied by adenoidectomy in children, to remove
the source.
Tonsillitis
CLASSIFICATION OF TONSILLITIS
I. Acute.
1) Primary: catarrhal, lacunar, follicular, Vincent’s tonsillitis
(ulceromembranous tonsillitis).
2) Secondary:
a) in acute infectious diseases: diphthteria, scarlet fever, tularemia,
abdominal typhoid;
b) in blood vascular diseases: infections mononucleosis, agranulocytosis,
alimentary-toxical aleukia, leukemia.
II. Chronic.
1) Nonspecific:
a) stage of compensation;
b) stage of decompensation.
2) Specific: having infectious granulomatous-tuberculosis, syphilis, scleroma.
Acute Tonsillitis
Symptoms. The disease usually begins with high temperature and possibly chills,
especially in children. The patient complains of a burning sensation in the
throat, persistent pain in the oropharynx, pain on swallowing, and pain
irradiating to the ear on swallowing. Opening the mouth is often difficult and
painful, the tongue is coated, and there is oral fetor. The patient also
complains of headaches, thick speech, marked feeling of malaise, and swelling
and tenderness of the regional lymph nodes. Both tonsils and the surrounding
area including the posterior pharyngeal wall are deep-red and swollen, but in
catarrhal tonsillitis there is no exudate on the tonsil. Later, yellow spots
corresponding to the lymphatic follicles form on the tonsils, hence the name
follicular tonsillitis. Alternatively, yellow spots occur over the openings of
the crypts, hence the name lacunar tonsillitis. A membrane occurs in
ulceramembranous tonsillitis, but is seldom confluent and rarely spreads beyond
the tonsil. There is also swelling of the neighboring organs such as the faucial
pillars, the uvula, and the base of the tongue. The patient also complains of
sialorrhea and difficulty in eating.
Pathogenesis. The most common organism is the beta-hemolytic streptococcus.
Staphylococci, pneumococci, mixed flora, hemophilus influenza, and E. coli are
much less common. If the symptoms worsen and multifocal symptoms occur, a
generalized disorder expressing itself particularly in the lymphoepithelial
organs should be suspected. On the other hand, there are also tonsillar
infections in which the generalized symptoms are minimal and only the local
changes can be recognized. Virus infections are particularly important in this
respect, e.g., herpangina. The tonsillar parenchyma is infiltrated with
leukocytes in tonsillitis, causing small abscesses in the parenchyma and in the
crypts. In addition, a fibrinous exudate is formed and there are marked changes
in the parenchyma and the epithelium.
Bacteria are constantly present in the mouth and pharynx. These saprophytic
organisms include: saprophytic streptococcus viridans, pneumococci, fusiform
bacteria, leptothrix, neisseria. lactobacteria, staphylococci, sarcina, and
fungi.
These saprophytic organisms may become pathogenic due to a change in
environment.
A virus infection may prepare the way for secondary bacterial infection.
Diagnosis. This is made from the clinical picture of an acute onset with high
fever, pains in the neck and on swallowing, redness and exudate on the tonsils,
and from general investigations of the blood picture, the erythrocyte
sedimentation rate (ESR), the heart and circulation, and the urine. Appropriate
tests or even cultures are carried out if diphtheria is suspected, and blood
tests are done for mononucleosis.
Differential diagnosis. This includes scarlet fever, diphtheria, infectious
mononucleosis, agranulocytosis, leukemia, hyperkeratosis of the tonsils, stage 2
syphilis, and in unilateral disease, peritonsillar cellulitis or abscess,
tuberculosis, and tonsillar tumors.
Treatment. This consists of bed rest, analgesics, bland fluid diet, high-dose
penicillin for 10 days, and observation for complications. Local care should
include oral toilet and dental hygiene. Disinfectant and analgesic mouthwashes
may be used.
Course. Tonsillitis usually resolves within I week. On the other hand,
complications may occur such as respiratory obstruction due to laryngeal edema,
otitis media, or rhinosinusitis; sequelae may occur.
The following laboratory investigations should be done in tonsillitis:
1. Smear and culture to exclude diphtheria and determine causative bacteria
2. Urinalysis to exclude nephritis
3. Differential blood count to exclude mononucleosis and leukemia.
Vincent’s Angina (Angina Ulceromembranacea)
The patient usually complains of unilateral pain on swallowing, and there is
ipsilateral swelling of the jugulodigastric nodes. There is an ulcer, which is
often deep, on one tonsil with a whitish exudate, whose site of predilection is
the upper pole. The local findings are often impressive in contrast to the
symptoms, which are often slight. There may only be a feeling of a foreign body
in the throat, and the patient also has a characteristic oral fetor. Usually
there is no fever. The exudate which can be easily wiped off does not extend to
the palate, buccal mucosa, and gingiva.
Microbiology. There is an obligatory symbiosis of a spirochete and fusiform
rods.
Diagnosis. This is made on the clinical picture of a typical infection usually
of one tonsil, with unilateral lymphadenopathy, and on the results of bacterial
culture.
Differential diagnosis. This includes diphtheria, tuberculosis, syphilis,
tonsilar neoplasms, acute leukemia, agranulocytosis, and infectious
mononucleosis.
Treatment. Penicillin is given for 3 to 6 days. The course is usually short and
the prognosis good.
Chronic Tonsillitis
Chronic tonsillitis requires particular attention on diagnostic grounds because
it is difficult to differentiate from a normal tonsil. It may also be a focus of
infection with effects on the entire body.
Symptoms. The history usually shows recurrent attacks of tonsillitis, but this
is not always the case. There is often little or no pain in the neck or
difficulty on swallowing. There is a halitosis and a bad taste in the mouth. The
jugulodigastric lymph nodes are often enlarged. Chronic tonsillitis often
remains more or less symptomless. The systemic effect may declare itself by
lowering of resistance, tiredness, tendency to catch colds, unexplained high
temperature, and loss of appetite.
Pathogenesis. The organisms are usually a mixed flora of aerobic and anaerobic
bacteria in which streptococci predominate. Group A beta-hemolytic streptococci
are especially likely to cause focal symptoms. Poor drainage of the branching
crypts leads to retention of cell debris which forms a good culture medium for
bacteria. From such crypt abscesses, the infection extends via the epithelial
defects of the reticular epithelium into the tonsillar parenchyma to form a
cryptic parenchymatous tonsillitis. Alternatively it penetrates into the
capillaries surrounding the crypts, allowing intermittent or continuous
penetration of toxins and organisms into the general circulation. In the long
term, the tonsillar parenchyma undergoes fibrosis and atrophy.
Diagnosis.
a) History shows recurrent acute or subacute attacks of tonsillitis.
b) Local Findings
- The tonsils are more or less fixed to their bed as shown by the depressor
test.
- The tonsillar surface is fissured or scarred.
- Watery pus and greyish-yellow material may be pressed out of the opening of
the crypts by a tongue depressor.
- Reddening of the anterior faucial pillar is present
- Peritonsillar tenderness is present
- Lymphadenopathy of the jugulodigastric group is found
c) General Findings
- History shows recurrent tonsillitis, unexplained high temperature, lowering of
resistance, etc.
- Blood picture: there is increased ESR.
The presence of fixed yellow tonsillar debris on pressure on the crypts by a
tongue depressor is not evidence of a chronic tonsillitis but is a physiologic
phenomenon (tonsillar plugs). The size of the tonsil is also not a criterion for
the presence of chronic tonsillitis. This disease can occur in large
hyperplastic tonsils, but is more common in small and medium-sized tonsils. It
is not always possible to make the diagnosis of chronic tonsillitis from the
local findings. The history and general findings must also be assessed
critically. The judgment and experience of the examiner is often decisive.
There are two stages of chronic nonspecific tonsillitis: stage of compensation
and stage of decompensation.
Stage of decompensation:
- Recurrent acute tonsillitis (more then 3 times per year)
- Peritonsillar abscess
- Tonsillogenic septicemia
- Tonsillogenic or posttonsillitis focal symptoms (diseases of the heart,
joints, kidneys, etc.).
Treatment.
Tonsillectomy is absolutely indicated in the following cases:
1. Chronic tonsillitis, stage of decompensation:
2. Marked hypertrophy of the tonsil causing mechanical obstruction.
3. If a tonsillar tumor is suspected.
Contraindications include pharyngitis sicca, leukemia, agranulocytosis, serious
generalized disorders such as tuberculosis or diabetes, and ulcerative or
destructive processes extending beyond the tonsil if the diagnosis has not been
confirmed.
The age of the patient has no contraindication in doubtful cases.
The previously popular tonsillotomy has now become obsolete because of the
danger of postoperative development of foci in the remaining scarred tonsillar
remnant. This is also true for procedures such as incising the tonsil.
The decision to advise tonsillectomy should not be taken lightly. Much critical
experience is required.
The balance between immunobiologic considerations and the local pathologic
findings must be weighed carefully before advising tonsillectomy, particularly
in children.
Conservative treatment: tonsillar irrigation, aspiration of the tonsils,
electrocoagulation.
Principles of Tonsillectomy
Tonsillectomy is usually carried out under local anesthesia. An incision is made
in the anterior faucial pillar, and the connective tissue layer between the
tonsillar parenchyma and the pharyngeal constrictor muscles is demonstrated. The
tonsil is then freed by combined blunt and sharp dissection proceeding from the
upper pole to the base of the tongue, preserving the faucial pillars. The entire
tonsillar tissue must be removed. Hemostasis is secured by pressure, ligatures,
or electrocautery. The same procedure is then carried out on the opposite side.
Complications include hemorrhage which may occur up to the 14th postoperative
day.
In countries where there is risk of infection by poliomyelitis, tonsillectomy
should not be carried out during the warmer season of the year. Tonsillectomy
should also not be carried out during epidemics of other infectious diseases.
Tonsillectomy by cryosurgery is technically easier and may be used for patients
with coagulation disorders or in poor general condition. Otherwise, it is not to
be recommended since compete removal of the entire tonsil cannot be guaranteed
and the procedure may need to be repeated for remnants of tonsillar tissue.
Complications During and After Tonsillitis
Posttonsillitis complications include rheumatic fever, often with a symptomfree
interval of 4 to 6 weeks, and endo-, myo-, or pericarditis. Acute
glomerulonephritis and focal nephritis, which require urinalysis after
resolution of the tonsillitis, are diseases secondary to streptococcal
infection.
Local Complications
Peritonsillar Abscess
Symptoms. Rapidly increasing difficulty in swallowing occurs after a symptomfree
interval of a few days after tonsillitis. The pain usually irradiates to the
ear, and opening of the mouth is difficult due to trismus. The speech is thick
and indistinct. The pain is so severe that the patient often refuses to eat, the
head is held over to the diseased side, and rapid head movements are avoided.
The patient has sialorrhea and oral fetor, swelling of the regional lymph nodes,
increase of fever with high temperatures of 39° to 40°C, and the general
condition deteriorates rapidly. He also has an intolerable feeling of pressure
in the neck, obstruction of the laryngeal inlet, and increasing respiratory
obstruction. However, the symptoms may on occasion be only mild. Simultaneous
bilateral abscesses may occur.
Pathogenesis. Inflammation spreads from the tonsillar parenchyma to the
surrounding tissue, peritonsillitis, and forms an abscess within a few days. The
pharyngeal constrictor muscle is usually an effective barrier against further
spread.
Diagnosis. This is made on the clinical picture of swelling, redness, and
protrusion of the tonsil, the faucial arch, the palate, and the uvula. The uvula
is pushed to the healthy side, and there is marked tenderness of the tonsillar
area. Inspection of the pharynx may be difficult because of severe trismus.
There is an exudate on the tongue, rarely on the tonsils and palate. The blood
picture and ESR are typical of an acute infection. When the swelling is
fluctuant, it may be possible to aspirate its contents for diagnosis.
Differential diagnosis. This includes peritonsillar phlegmon, tonsillogenic
sepsis, allergic swelling of the pharynx without fever (angioneurotic edema),
malignant diphtheria, agranulocytosis, specific tonsillar infections
(tuberculosis and syphilis), and nonulcerating tumors of the tonsil or
neighboring tissues (malignant lymphoma, lymphoepithelial tumor, anaplastic
carcinoma, or leukemia).
Conservative treatment. High doses of antibiotics, e.g., penicillin or
cephalosporin, etc., for I week at least, can only prevent the formation of an
abscess in the early stages of infiltration of the peritonsillar tissues.
Analgesics, a fluid diet, cold foods, an ice pack to the neck, and mouthwashes
are prescribed.
Operative Treatment.
1. Abscess tonsillectomy which is usually carried out under local anesthesia.
This procedure may be performed on all patients who are fit for operation,
particularly those with a recurrent peritonsillar abscess. It prevents further
recurrence, the patient must endure only one course of treatment and time is
saved.
2. Drainage of the abscess followed by tonsillectomy 3 to 4 days later under
local anesthesia.
Principles of drainage of the abscess. Local anesthesia is induced carefully
with 3% topical Dicaine, and infiltration anesthesia with 1% Novocaine plus
Adrenaline 0,1% is used at the site of the intended incision. Pus often drains
from the puncture site when the anesthetic agents is introduced. The anesthetic
must be allowed approximately 5 min to act before incision.
The site of incision. This is made at the point of maximum protrusion, usually
between the uvula and the second upper molar tooth. A test aspiration may be
made on occasion before the incision. A long-handled pointed scalpel is used for
the incision. All but 1,5 to 2 cm of the point is wrapped in sterile adhesive
tape to prevent the point of the scalpel from penetrating too deeply and
injuring the major vessels of the neck. The incision is made parallel to the
ascending ramus of the mandible and must not pass externally since the internal
carotid artery and internal jugular vein are immediate relations. If the
diagnosis is correct, pus gushes out and must be removed with a powerful
aspirator to prevent aspiration into the trachea. After the abscess has drained,
a hemostat is introduced into the abscess cavity and opened widely usually
producing a further gush of pus. The abscess cavity must be opened up daily
until pus no longer drains from it.
An incision should not be made until the abscess is “ripe”, i.e., fluctuation
can be shown or is probable.
Course and prognosis. Regression of the inflammation and prevention of an
abscess is possible with timely administration of antibiotics. An abscess may
also drain spontaneously and heal. However, distressing pain and difficulty in
eating usually require active drainage. If tonsillectomy is not carried out,
there is a high risk of recurrent abscess in the paratonsillar scar tissue.
Complications and dangers. These include extension of the inflammatory swelling
and edema to the laryngeal inlet with increasing respiratory obstruction and
possibly danger of asphyxia. The abscess may also rupture into the
parapharyngeal space. From here it may extend
- A descending internal cervical phlegmon
- A parapharyngeal abscess
- An ascending involvement of the orbit or the cranial cavity causing
meningitis, cavernous sinus thrombosis, and brain abscess
- Thrombosis of the internal jugular vein
- Erosion of the carotid artery or its branches (rarely)
- Invasion of the parotid (purulent parotitis).
RARE ABSCESSES IN THE PHARYNGEAL AREA INCLUDE:
Retropharyngeal Abscess in Children
An abscess may form by breaking down of lymphadenitis of the retropharyngeal
lymph nodes after pharyngeal infection in children especially in the first 2
years of life.
Symptoms. These include swelling of the posterior pharyngeal wall, difficulty in
swallowing, thick speech, difficulty in eating, elevated temperature, relieving
posture of the neck (differential diagnosis: torticollis), leakage of food
through the nose, possibly nasal obstruction, croup, and laryngeal edema.
Differential diagnosis. Benign and malignant prevertebral tumors must be
considered.
Treatment. This is by paramedian incision and drainage with the head hanging if
fluctuation occurs. The patient must be protected from aspiration and is given
antibiotic cover
Retropharyngeal Abscess in Adults
This is usually a descending prevertebral cold abscess originating from
tuberculous canes of a cervical vertebra or of suppuration in osteomyelitis of
the temporal bone, e.g., petrositis, and in mastoiditis.
Symptoms. These include pressure in the neck, attacks of coughing, difficulty in
swallowing, mild dysphagia, stiffness of the neck, and typical lesions of the
cervical spine on radiographs.
Differential diagnosis is benign and malignant tumors and spondylosis of the
cervical spine.
Treatment. A test aspiration is made. If a cold abscess is present it is
drained, if possible to the lateral part of the neck and not into the
oropharynx. Antituberculous treatment is given, and the patient is referred to
an orthopedic surgeon.
OTHER PHARYNGEAL INFLAMMATIONS
Acute Catarrhal Pharyngitis
Symptoms. These include pain on swallowing, possibly radiating to the ear, a
feeling of dryness, heat, and soreness in the pharynx, itching, scratching,
burning, clearing the throat, and attacks of coughing. The patient usually feels
sick. The entire pharynx (naso-, oro-, and hypopharynx), is usually involved in
the infection. Fever occurs, especially in children.
Pathogenesis. This is usually a primary virus infection often with later
secondary bacterial infection. Less often it is a primary bacterial infection
due to streptococci, hemophilus influenza, or pneumococci. There are prodromal
symptoms on acute infection such as measles, scarlet fever, and rubella. An
acute pharyngitis may also be caused by physical or chemical injury, scalds,
caustics, etc.
Diagnosis. The mucosa appears red and thickened. The palatal and pharyngeal
mucosa are dry with a glazed surface. Mucus is produced which is initially
colorless but later tenacious and yellow. Deep-red, solitary follicles are
usually prominent, and there is a regional lymphadenopathy with swelling and
tenderness, especially in children. Tonsillitis often occurs, or if the tonsils
have been removed there is infection of the lateral bands.
Treatment. Symptomatic treatment includes hot milk and honey, cold or warm
cervical dressings, pharyngeal irrigation, and steam inhalations. Smoking is
forbidden, and anesthetic and disinfectant lozenges are given. Parenteral
antibiotics are only given for severe bacterial infections. Bed rest is advised
for fever.
Chronic Pharyngitis
This is a comprehensive term for several chronic irritative or inflammatory
conditions of the pharyngeal mucosa.
Symptoms. There are several forms.
1. Simple chronic pharyngitis. This causes a globus sensation, constant throat
cleaning, bouts of coughing, a feeling of dryness or phlegm in the throat, pain
in the neck and on swallowing of varying degree, and tenacious secretion. The
course is intermittent, and there is no generalized upset and no fever.
2. Chronic hyperplastic pharyngitis. The mucosa of the posterior pharyngeal wall
is thickened and granular with prominent solitary follicles. It is a smooth red
to greyish-red in color, possibly with venous telangiectasis and secretion of
stringy colorless mucus. There is usually a very disturbing, strange sensation
in the pharynx with compulsive throatclearing and swallowing, gagging, and even
vomiting.
3. Chronic atrophic pharyngitis. The posterior pharyngeal wall is dry, glazed
often with dry, tough crusts of secretion. The mucosa is smooth, pink, often
very tender and transparent, but may also be red and thickened. Simultaneous
atrophic rhinitis and laryngitis sicca may occur. The patient is constantly
obliged to spit out the stringy secretion. At night there is a feeling of
choking and disturbance of sleep. Continuous clearing of the throat may produce
slight mucosal hemorrhage. The disease depends on climatic or temperature
conditions, and the symptoms resolve at the seaside but are worse in hot dry
air. Older people are more often affected.
Pathogenesis. The patient often has a constitutionally determined functional
weakness of the mucosa. On the other hand, the disease may be due to chronic
exogenous damage from dust, chemicals, heat (e.g., at work), marked changes in
temperature, and working in drafty and smoky conditions (butchers and restaurant
personnel), and dry or incorrectly air-conditioned atmosphere, marked nicotine
and alcohol abuse, mouth breathing, nasal obstruction, abuse of nose drops,
chronic sinusitis, and adenoidal hypertrophy. Other causes include endocrine
disorders (menopause, hypothyroidism), avitaminosis A and general disorders
(heart and kidney malfunction, diabetes, pulmonary insufficiency, chronic
bronchial diseases). Finally, mucosal allergy and incorrect use of the voice in
professional speakers such as teachers, politicians, and singers may be
responsible.
Diagnosis. The local findings are typical. The disease lasts for years with an
intermittent course. There is often a discrepancy between the unremarkable local
findings and the marked symptoms.
Treatment. The above-named local or distant causes are looked for and
eliminated.
Symptomatic treatment includes moisturizing of the pharyngeal mucosa by steam
inhalations. Nicotine and alcohol must be avoided. Local measures are include
oily preparations to provide a protective film for the dry mucosa. A change of
climate is advised, and the air humidity at work is tested. The patient may even
have to change his job or place of residence.
Part 8
DISEASES OF THE LARYNX
Acute laryngitis
Symptoms. These include hoarseness, aphonia, pain in the larynx, and coughing
attacks. In children there is a danger of airway obstruction. Acute laryngitis
is usually due to ascending or descending infections from other parts of the
airway. Fever can take place.
Pathogenesis. The cause is viral or bacterial infection, although thermal,
allergic, or inhaled chemical toxins may occasionally be responsible.
Diagnosis. There is reddening of the tip of the epiglottis and there may be some
slight oedema. The arytenoids are reddened and also show some swelling. Oedema
and flushing of the false cords may be one of the most marked features of the
infection. The false cords may be so swollen that they conceal the true cords
beneath. The true cords will appear watery. They are thickened and rounded;
their colour may vary from a slight pink to a bright red, the reddening being
most marked at first at the part of the cord farthest from the free edge.
Movement of the cord may be restricted owing to the swelling of the surrounding
parts, but the movement is equal and there is no paralysis. The whole larynx
shows the presence of hypersecretion, and the vocal cords may be covered with
mucus or pus. Depending on the underlying disease, the neighboring pharyngeal or
tracheal mucosa, may also be inflamed.
Treatment. Since viral infections are often followed by secondary bacterial
infection, antibiotics are indicated. Steroids are also indicated for marked
edema. General measures include steam inhalation, infusion of the solutions,
which contains Ectericide, Hydrocortizone by special laryngeal syringe into the
larynx.
Voice rest is indicated, and smoking should be forbidden. Chemicals such as
certain dyestuffs or artificial products and allergic toxins such as hair
sprays, shellfish, and crustaceans should be eliminated.
If the symptoms do not improve considerably or resolve within 3 weeks,
telescopic or microlaryngoscopy is indicated to exclude other laryngeal
diseases. Ulceration, proliferation, and exudate are not typical of
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