CASE REPORT

Chronic Tonsillitis Acute Exacerbation

Presented by:
1. Afifah Listiati
2. Bagia Ramadhan
3. Bernadetha Astrid
4. Dwina Lakabela
5. Dwiki Yuliya
6. Sayyidati Rokhimah

Moderator:
dr. Rivana

Department of Otorhinolaryngology - Head & Neck Surgery

Faculty of Medicine Gadjah Mada University
Dr. Sardjito General Hospital
Yogyakarta
2018
INTRODUCTION Tonsils are lymphoid tissue. The
lymphoid contents are covered by respiratory
epithelium that can invaginate and cause tonsillitis and chronic tonsillitis. Chronic
crypts. The common term “tonsils” refers tonsillitis refers to the presence of
specifically to the palatine tonsils. Waldeyer’s inflammation of tonsils for at least 3 months.
ring, a ring of lymphoid tissue in the pharynx, This chronic tonsillitis results in swallowing
is formed by the palatine tonsils as well as the and breathing difficulties. 4,5
pharyngeal tonsils (adenoids), tubal tonsils and
Predisposition factors of chronic
lingual tonsils. Tonsillitis is a inflammation of
tonsillitis are the history of smoking, bad oral
palatine tonsil which is a part of Waldeyer
hygiene, weather, physical fatigue and
ring. 1
inadequate of acute tonsillitis treatment. Fk ui
On the recent study about the The cause of chronic tonsillitis is likely
incidence of tonsillitis chronic in 7 provinces multifactorial. Cause of chronic tonsillar
of Indonesia are 3.8%. This data showed that inflammation include various viruses (ex.
the tonsillitis chronic incidences happen after Epstein-Barr virus), bacteria, gastroesophageal
the highest incidences of nasopharynx acute reflux disease, and possibly allergies and
2,3
are 4.6 %. asthma. Respiratory viruses (ex. Adenovirus)
are highly prevalent in the adenoid and
According to Survei Kesehatan
palatine tonsils of patients with chronic
Rumah Tangga (SKRT), the morbidity of
tonsillar diseases. 4
tonsillitis chronic in children aged between 5-
14 years old are 10,5 % for male and 13,7% The pathophysiology of chronic
for female. The result of examination in tonsillitis begin with microorganisms infiltrate
children and adult showed that the total of the epithelial layer of tonsil makes the epithel
incidences of ENT diseases is around 190-230 eroded. Then superficial lymphoid tissue will
per 1000 population and 38,4% included of react. . There is an inflammation damming
tonsillitis chronic incidences. 2,3 with the infiltration of polymorphonuclear
leukocytes. This process is clinically seen as
Based on the recent study, Chronic
corpus tonsil containing yellow spots called
tonsillitis was a disease that often happen in
detritus. Detritus is a collection of leukocytes,
ENT cases and it common happened to
bacteria and epithelium that are released. If
children 5-15 years old with prevalention of
there are recurrent inflammations, lymphoid
bacterial tonsillitis 15-30% in children with
tissue will be replaced by scar tissue. This
sore throat and 5-15% in adult with sore
tissue will shrink so that the space between the
throat. This term because of children were
widened (cryptic) group will be filled by the
easily got Upper Respiratory Tract Infection
detritus, this process extends to penetrate the
(ISPA) and immune system was still unstable.
2,3
capsule and eventually arising fixtures with
tissue around the tonsillar fossa. In children
Tonsillitis is divided into three
classifications; acute tonsillitis, membranous
this process is accompanied by enlargement of children and adolescents, show the greatest
submandibular lymph node. 1 benefit at the lowest cost. There were no
differences to cephalosporines.
Local complaints of chronic tonsillitis
Cephalosporines are, however, more effective
include swallowing pain, sore throat, halitosis,
in children under 12 years of age and for
fever, snoring, breathing disorders, nasal
chronic recurrent tonsillitis, as they can
congestion and cough. It can also be
eradicate more strains of streptococci.
accompanied by systemic complaints include
Macrolides and clindamycin in children evoke
decrease of appetite, headache, joint pain and
more side effects with the same efficacy and
weakness. In physical examination, tonsil may
therefore should be reserved only for proven
show varying degree of enlargement
penicilline allergy sufferers. One advantage of
depending on the type, tonsil’s crypt surface
modern macrolide antibiotics is a significantly
enlarged, detritus on crypt suppression,
shorter duration of treatment, which should
redness of anterior or posterior arc and
increase compliance. As before, the duration
submandibular gland enlargement. 1,5
of the recommended standard therapy with
Management include conservative and penicillines for acute Tonsillitis and sore throat
surgical treatment or tonsillectomy. Based on in children streptococcal infection is 10 days.
recent study, In clinically definite or proven Beside antibiotic, the clinician give analgesic
bacterial tonsillitis associated with distress, drugs such as paracetamol or ibuprofen to
antibiotic therapy using a beta-lactam reduce pain for this patient.1,5,6,7
antibiotic is justified. It shortens the course of
Tonsillectomy is the surgical removal
the disease by an average of one day.
of tonsils. Indications include absolute
Antibiotics reduce the fever and reduce pain
indications where there is obstructive sleep
compared to placebo, most clearly on the third
apnea, failure to thrive, abnormal dentofacial
day after administration. In addition, a
growth, hemorrhagic tonsillitis and suspicion
betalactam antibiotic therapy provides
of malignancy. Relative indications include
relatively reliable protection against the
upper airway obstruction, dysphagia, speech
dreaded rheumatic fever and
impairment, halitosis, recurrent or chronic
glomerulonephritis, which often leads
pharyngotonsillitis, peritonsillar abscess and
especially in third world countries to arthritis,
streptococcal carriage. 8
myocarditis and death. Some studies have
shown that antibiotic therapy can prevent
sequelae such as peritonsillar abscesses, acute
However there are also
otitis and sinusitis. A recent Cochrane analysis
contraindications to this procedure. In situation
from 2013 showed the effectiveness of
where anemia, acute infection, bleeding
different antibiotics in acute (streptococcal)
diathesis and poor anesthetic risk or
tonsillitis. The penicilline, in particular in
uncontrolled medical illness tonsillectomy is Tympanic membrane were intact. In head and
not recommended. 9 neck examination also showed no
lympadenopathy.
Conditions such as chronic rhinitis,
sinusitis or otitis media by percontinuatum This patient was diagnosed by acute
might happen if not treated well. Endocarditis, exacerbation of chronic tonsilitis, based on
arthritis, myositis, nephritis, uveitis, anamnesis and physical examination.
iridocyclitis, dermatitis, pruritus, urticarial and
The medication given to this patient
furunculosis are complication that spread by
was amoxicillin forte syrup 125mg/5ml three
1
hematogen/lymphogen.
times daily, and paracetamol forte syrup three
times daily if needed (fever). Patient asked for
CASE REPORT
follow up a week later, if complaint decrease
A five year-old boy presented to ENT considers tonsilectomy.
clinic RSUP Dr Soeradji Tirtonegoro Klaten
After one week, patient control to
on March 8th 2018 with chief complain pain
ENT clinic with persistent complaint and
during swallowing. Her parent also
cough since 3 days ago. Her complaint runny
complained of runny nose with difficulties
nose was getting worse with mucopurulent
getting sputum out (”sendrap-sendrup”),
sputum and fever on the night before.
fever, snoring during sleep, and frequently
waking up after falling asleep last night. No Physical examination of both left and
history of nasal congestion, hoarseness, right nose showed discharge mucopurulent
productive cough, and sneezing. Other with no concha edema or hyperemic. In throat
conditions such as dizzy, head and face pain, examination, hyperemic and hypertrophy
ear complatint were denied. No allergic and tonsil still grade T3 in both tonsils, with crypts
asthma history. There were no family history appearance and detritus.
related to the complaints as well as similar
The medication given to this patient
complaints in the family. However, the patient
was cefixime syrup 125mg/5ml twice times
has history of previous similar complaints
daily, trifed syrup twice times daily and
since one year ago.
paracetamol syrup three times daily if needed
Physical examination of both left and (fever). Patient asked for follow up a week
right nose showed no discharge, no concha later, if complaint decrease considers
edema or hyperemic. Continued by throat tonsilectomy.
examination. Hyperemic and hypertrophy
DISCUSSION
tonsil grade T3 were noticed in both tonsils,
accompanied by crypts appearance and This patient came with history of

detritus. In physical examination of both left odynophagia for a year and also obstructive

and right ear showed normal condition. sleep apneu (OSAS). The problem of this case
is the acute symptopms on this patient as SUMMARY
chronic tonsilitis can lead to recurrency of
We reported a 5 year old male patient
acute exacerbation if there had not been
diagnosed with chronic tonsilitis with acute
undergo tonsilectomy.
exacerbation that is given amoxicillin then
Group A Bacterial Streptococcus changed to cefixim as antibiotic and
found in most of acute tonsilopharyngitis paracetamol as antipiretic. The patient is
cases. The infection of streptococcus tonsilitis advised to check again next week to evaluate
can lead to rare but serious complication such treatments.
as glomerulonephritis and rheumatic fever
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