Section 2


List two differential diagnoses for the above photograph.

  • Tonsillitis
  • Glandular fever

What investigation should you arrange to help determine this.

Blood test – Mono spot / Paul Bunnel to exclude or diagnose glandular fever

Which antibiotic should you avoid and why?

Avoid amoxicillin or ampicillin as may cause a type IV hypersensitivity rash in patients with glandular fever.

What are the SIGN criteria for tonsillectomy or recurrent tonsillitis?

  • Tonsillectomy if recurrent episodes of acute sore throats due to tonsilitis, which are disabling and prevent normal function.
  • 7 or more episodes of tonsillitis in preceding year
  • 5 or more episode s each year for two preceding years
  • 3 or more episodes each year  for the three preceding years

Describe three other indications for tonsillectomy.

  • More than one quinsy/peritonsillar abscess
  • Suspected cancer
  • Obstructive sleep apnoea
  • As part of another procedure e.g. uvulopalatoplasty

Supporting Information

Resources

Portsmouth Tonsillectomy Protocol

Bird JH, Biggs TC, Schulz C, Lower N, Faris C, Repanos C. Implementation of an evidence‐based acute tonsillitis protocol: Our experience in one hundred and twenty‐six patients. Clinical Otolaryngology. 2013 Oct;38(5):410-5. https://onlinelibrary.wiley.com/doi/abs/10.1111/coa.12162 

Scottish Intercollegiate Guidelines Network (SIGN) – Management of sore throat and indications for tonsillectomy www.sign.ac.uk › assets › sign117 

Information

Tonsillitis + glandular fever

  • Organisms- Group A, Beta haemolytic strep – pyogenes, EBV for glandular fever.
  • Presents- fever, otalgia, odynophagia, dehydration, sepsis, halitosis
  • Treatment- analgesia, fluid resus and abx to present secondary infection
  • Investigations
  • Complications– quinsy, retropharyngeal/parapharyngeal abscess, sepsis, Glomerulonephritis, endocarditis, mediastinitis. Necrotising tonsillitis- haemolytic streptococci (scarlet fever), diphtheria and vincent’s angina (fusiform and spirochetes)- necrotising pharyngeal infection.
  • Chronic tonsillitis- crypts with tonsiliths. 

Glandular fever – can cause hepatosplenomegaly – advice to abstain from contact sport for 6 weeks

Tonsillectomy– indications

  1. 7 or more episodes of tonsillitis in preceding year
  2. 5 or more for 2 consecutive years
  3. 3 or more for 3 consecutive years
  4. More than one quinsy- collection pus peritonsillar space- space between tonsillar capsule (lateral aspect of tonsil by condensation of the pharyngobasilar fascia) and the superior constrictor. Treat as tonsillitis with Incision/aspiration.
  5. Suspected cancer
  6. OSA
  7. Part of another procedure- uvulopalatoplasty

Contraindications include acute infection, bleeding disorder, cleft palate. 

Procedure– Boyle-Davis mouth gag held with draffin rods. Dissection using cold steel, diathermy, coblation, guillotine or laser. Haemostasis at the end, check PNS for clot. 

Complications:

  • Bleeding-
    • Primary in 24 hrs
    • Secondary normally 5-10 days post op
      • It is often from tonsillar arteries or its branches. It occurs in 2-5%. The bleeding can be treated with an adrenaline swab, cautery or return to theatre. Occasionally the pillars need to be stitched over a swab. Diathermy tonsillectomy has the highest risk.
    • Infection, damage to teeth, lips gums, TMJ, change in voice, Otalgia, Trauma to soft palate and pharyngeal wall.
Post a comment

Leave a Comment

Your email address will not be published. Required fields are marked *