Leukemia (Blood Cancer)

Acute Tonsillitis.          

           Hello today, we're going to talk about acute tonsillitis before delving into the condition we need to learn about the anatomy, now the tonsils are part of what is called wild eyes ring generally when talking about the tonsils we're talking about the Palatine tonsils situated on both sides of the throat there are also the adenoids the tubular tonsils and lingual tonsils which make up walled eyes ring.

The tonsils are a lymphoid organ, containing macrophages t-cells and b-cells the immune cells, here are important in learning and building up the immune response the tonsils are important in the early years of life because the lymphoid tissues containing the immune cells are continuously exposed to many antigens so that is why until the age of six tonsils is typically hyperplastic, they're big and tend to regress so basically shrink by 12 years of age the Palatine tonsils have a strong blood supply from five different vessels that is why there is a risk of a lot of bleeding with Tonsillectomy (Removal of the tonsils) zooming into the tonsils we can see they have deep crypts and lymph nodules.

The crypts are normally colonized by many species of bacteria and also exposed to many viral organisms then you have lymph nodules which contain immune cells that are your T cells, B cells, and macrophages, many viral and bacterial organisms can cause tonsillitis which is inflammation of the tonsils causing tonsillar edema, hypertrophy erythema, redness, and pain. The inflammation may affect other areas of the back of the throat including the adenoids and the lingual tonsils. This inflammatory response produces exudate either white gray or yellow discharge, cultures are not often useful in distinguishing the offending pathogens, because even if you grow something there are probably commensal organisms.

Anyway they live there naturally generally with acute tonsillitis the pharynx is also inflamed which is the back of your throat and so a better definition is for Ringo tonsillitis, rather than acute tonsillitis in this blog we will use both terminologies now the majority of cases of tonsillitis are caused by viruses, common viral organisms that cause tonsillitis include Epstein Barr virus EBV, Adenovirus, Rhinovirus respira since serial virus influenza and higher influenza are the most common bacterial causes of acute tonsillitis is Group A streptococcus also known as strep pyogenes we will focus on the two most important clinical causes of acute tonsillitis that is Epstein Barr virus (EBV) and Group A streptococcus also known as strep pyogenes. 

Let's talk about, eBay v now EBV infection is usually asymptomatic if EBV virus infection causes symptoms it can be part of a condition called infectious mononucleosis so we'll be mainly focusing on infectious mononucleosis here and infectious mononucleosis most often begins insidiously with fatigue vague malaise followed by several days later sore throat for Ringo tonsillitis, headaches, fever, swollen posterior cervical lymph nodes, in some people there can be hepatomegaly leading to complications such as hepatitis and splenomegaly which may present with splenic rupture, EBV is a virus that is part of the herpes family and is transmitted via saliva that is why EBV infection is also known as the kissing disease once in the body the EBV targets b-cells in the oral pharynx such as in the tonsils and so in the tonsils they replicate and conquer as the body builds up an immune response investigations for infectious mononucleosis include a full blood count which may show (lymphocytosis) high lymphocyte count, (thrombocytopenia) low platelets and then you also want to do  Urea, creatinine Electrolytes, Liver function test, and CRP. A mono spot test is a useful test to perform and is very quick a mono spot test looks at heterophile antibodies which are produced by that abnormal b-cell infected by the EBV, further investigations that can be performed include EBV specific antibodies and throat swabs to look for differential diagnoses such as Group A streptococcus treatment for symptomatic EBV infection which is infectious mononucleosis is usually conservative and include pain and temperature relief using ibuprofen and paracetamol adequate rest fluids and good nutrition.

Primary EBV infection rarely require more than supportive treatment rarely the enlarged tonsils will cause airway obstruction, but if it does happen it is important to admit the person and they will likely need ENT involvement steroids are given to reduce swelling then potentially a nasopharyngeal airway is required intubation rarely and especially emergency tonsillectomy or tracheostomy may be required which is again rare complications of EBV infection include a splenic rupture leukoplakia Burkitt's lymphoma. Lymphoma a few diseases as well in some cases EBV, tonsillitis is treated with antibiotics accidentally usually ampicillin which when given to someone who has EBV, tonsillitis will cause a fine macular rash in up to 90% of people, the mechanism is unknown which leads to Group A streptococcus the bacterial cause of acute tonsillitis Group A streptococcus or streptococcus pyogenes is the most common bacterial cause of acute tonsillitis, pharyngitis ìletís caused by Group A streptococcus in sometimes referred to as strep throat the majority of episodes of pharyngitis are caused by viral infections as discussed and is usually treated conservatively.

However early recognition of Group A streptococcus is important since failure to appropriately treat someone who has strep throat may lead to Group A streptococcus complications, unfortunately distinguishing between viral and bacterial acute tonsillitis is difficult the Group A streptococcus are beta-hemolytic cockeyed able to produce some exotoxins and also contains many surface antigens that play a vital role in the pathophysiology such as the EM proteins transmission of strep throat is through saliva and nasal secretion from an infected person, here Group A streptococcus targets Palatine tonsils, 

However, it's also important to remember Group A streptococcus is a common commensal organism as well clinical features the incubation period of strep throat is usually two to five days of no symptoms when symptoms do arise bacterial tonsillitis causes sudden onset fevers,, sore throat, pharyngitis and tonsillitis which are read enlarged and have purlins incident on the soft palate you can also potentially see palate petechia here is a photo of strep throat note the enlarged tonsils and exudate in yellow other features of Group A streptococcus tonsillitis include dysphasia difficulty   swallowing Odin aphasia pain when swallowing and tender cervical lymphadenopathy on physical examination the pharynx is red tonsils are red and enlarged with pearl and exited a throat swab can be performed a throat swab with microscopic culture sensitivity in blood agar will help diagnose Group A streptococcus because it will show a beta-hemolytic Kaka, the throat swab for rapid antigen detection tests are ADT can also be used in general though throat swabs are not very useful because remember Group A streptococcus are commensal organisms in many patients other investigations for group a streptococcus related tonsillitis include a full blood count which will show neutrophilia now it's important concept to remember to help differentiate viral and bacterial tonsillitis remember lymphocytosis supports a viral cause of acute tonsillitis whereas neutrophilia high neutrophil count supports a bacterial cause early recognition and management is important to reduce complications associated with group a streptococcus throat   infection.

The management for streptococcus certain fiction or antibiotics specifically penicillin or amoxicillin it's also important to monitor for complications of the antibiotics themselves so when you give someone antibiotics with someone who has two tonsillitis firstly if a rash eruption occurs asks yourself could this be a virus penicillin reaction which will support a diagnosis of EBV tonsillitis rather than bacterial tonsillitis in which case you have to stop the antibiotics the second thing to think about is whether this could be a proper allergic reaction to the antibiotic in which case you would have to stop the antibiotic and change It. Potentially the third thing is you have to ask yourself could this be a complication of a group a streptococcus which is scarlet fever there they also get a rash everywhere then you have other complications of Group A streptococcus which we will not discuss in this blog, specifically on strep throat important terminologies to remember regarding tonsillitis is something called recurrent tonsillitis now sometimes people experience recurrent tonsillitis, several attacks of acute tonsillitis a year and no symptoms in between attacks then you have chronic tonsillitis sometimes people suffer from chronic tonsillitis which is when a sore throat is present for at least three months and is associated with tonsillar inflammation halitosis which is smelly breath and persistently tender cervical lymphadenopathy chronic tonsillitis.

It may also be associated with tonsilloliths which are biofilms that form within the tonsil crypts which leads us to the management of tonsillitis obviously we have the  different causes the viral and bacterial but you know sometimes the tonsils have to be removed and this is called tonsillectomy, now there are specific indications for tonsillectomy and this is because firstly the tonsils play an important role in the first six to twelve years of life with the whole immune system business secondly because there are actually a lot of complications associated with tonsillectomy due to its anatomy location it's very important, you know  it's very important to follow the indications for removing the tonsils the indications for tonsillectomy include recurrent tonsillitis which means several attacks I think six in one year having chronic tonsillitis having a peritonsillar abscess tonsilloliths which I mentioned earlier having obstructive sleep symptoms tonsillitis which causes obstructive symptoms such as an EBV for example or something that will cause obstructive sleep apnea and finally a very important indication is suspected malignancy. Complications of tonsillectomy which is very important include general anesthesia associated complications dental injury, temporomandibular joint dislocation during the procedure, post-operative bleeding because remember there's a lot of blood supply to the tonsils airway obstruction causing pulmonary edema as well as aspiration of any contents during the surgery so in summary acute tonsillitis is inflammation of the tonsils the two most clinically important ones are tonsillitis caused by EBV and Group A streptococcus but the majority of acute tonsillitis are caused by viruses, just random viruses in general tonsillectomy is the removal of the tonsils and have specific indications but also keep in mind that there are complications associate with tonsillectomy.