2011 Model case sheet Chronic Adeno tonsillitis



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Balakrishnan D, Model case sheet - Adenotonsillitis - excerpts

2011

Model case sheet


Chronic Adeno tonsillitis (with secretory otitis media)
Important note: In this case sheet, you will find that the history and clinical findings include throat pain, enlarged tonsils, bilateral jugulo digastric lymph nodal enlargement, nasal block, anterior nasal discharge, post nasal discharge and adenoidal facies. These are the features of adeno tonsillitis.
Additionally, you will also find features of Secretory Otitis Media (the commonest consequence of adenoidal enlargement), namely occasional ear pain, repeated ear block, dull tympanic membrane with impaired mobility. When you include such features in your history and findings, you must record the clinical diagnosis as ‘Chronic Adeno tonsillitis with secretory otitis media’.
Sometimes, the ascending tubo tympanic infection may not stop with secretory otitis media alone. It might have progressed further to a perforation of the tympanic membrane, resulting in ear discharge. You will have to carefully elicit a history of ear discharge and shrewdly present such cases as Chronic adenotonsillitis with chronic suppurative otitis media with central perforation (left side, right side or both sides), and not as mere chronic adeno tonsillitis.
Other common consequences of tonsillar and adenoidal enlargement are mouth breathing and snoring. When the snoring is associated with episodes of cessation of breathing and restarting, it indicates Obstructive Sleep Apnoea (OSA). When the snoring is not associated with such apnoeic episodes, it is termed ‘Primary Snoring’. Christian Guilleminault, who originally coined the term OSA, subsequently found that some children, who harbour airway obstruction, stop short of apnoeic episodes and exibiit labored breathing due to increased respiratory effort. To describe such children, he coined a second term ‘upper airway resistance syndrome’ (UARS).
A considerable proportion of patients with OSA will have disturbed sleep. Such fragmentation of sleep will lead to unrefreshed sleep. The next day, the patient will manifest excessive daytime sleepiness (EDS). When the OSA is associated with EDS, it is called Obstructive Sleep Apnoea Syndrome (OSAS). EDS is uncommon in children. Instead, the children become irritable, inattentive and may show scholastic backwardness.
Model case sheet
Subramanian, aged 8 years, coming from Muthiah Puram, Thoothukudi

Informant: Mother. Reliability of informant: Good.


Presenting complaints
Frequent episodes of sore throat, nasal block and nasal discharge, all since the last 3 years. The current episode started three days ago, and, is associated with fever.

History of present illness
Over the past three years, this child used to get frequent episodes of sore throat, nasal discharge, nasal block and occasional fever. Each episode used to last 4 - 7 days. Each episode would be associated with malaise, refusal to eat food and low-grade fever. Each episode used to get better with medicines, only to recur again once every month or once every two months. During some of these episodes, the child also used to get pain in the ear(s) and occasional blocking of the ear(s). There had never been any ear discharge. The child had always been breathing through the mouth. There had been snoring on occasions, particularly during the episodes of cold. However no cessation of breathing had been noticed while sleeping. The child had never thrived well.
The present episode started three days ago, with pain in the throat along with additional problems of nasal block and nasal discharge. All the problems gradually worsened over the last three days. On giving paracetamol syrup, the fever and pain subsided for a short while, only to recur after a few hours.
Note: Usually such acute cases with active presence of fever and pain will not be given to you. Only chronic cases, with no discomfort at present, will be given. In such cases, the presenting complaint will be as follows: “recurrent episodes of sore throat, pain on swallowing, associated nasal block, nasal discharge and fever (each episode lasting for about one week), over the last three years”.
History of past illness
No history of taking any medicines for prolonged periods. Such a history in children, for a long period of 6-9 months usually suggests primary complex.
No history suggestive of any bleeding tendency.

No history of any seizure disorder

No history of drug allergy or food allergy

No history of jaundice / blood transfusions in the past.

No history of any prolonged hospitalization in the past

No history of any ENT or other surgeries in the past.

No history of Diabetes or hypertension (This is particularly relevant in adults)
Note: The first line i.e. ‘no history suggestive of bleeding tendency’ is very important, particularly in this child, because you are going to offer surgery as treatment.

Personal history
This child is studying in 5th standard in school and is doing well in school. The childhood immunization schedule is complete. He is a vegetarian. The parents complain that the child does not have any appetite. He likes chocolates; but he is not allowed to eat them for fear of precipitating ‘cold’.
Note: In an adult, you must include a history of habits under this heading, namely, smoking, chewing tobacco, alcohol intake etc.
Family history
Father is a clerk working in a private fish export company. Mother is a house wife. Younger brother is aged 3 years, with no similar illness. There is no family history of bleeding disorders, diabetes or hypertension.
Socio economic status
Economic status: middle class. The family lives in a two room apartment.
General Examination
Thin built, well nourished, no pallor i.e. not anaemic, no icterus, no cyanosis, no clubbing. Features of adenoid facies are present.
Pulse rate: 84 / min.

Blood pressure: 100/80 mm Hg (In otherwise healthy children, blood pressure need not be recorded).

Temp: Normal (Afebrile)

Height: 112 cm

Weight: 30 Kg
Local examination (Throat)
Normal dentition, no dental caries, no loose tooth, the tongue appears clinically normal, Uvula appears normal i.e. there is no bifid uvula. Both tonsils appear enlarged, the anterior pillars appear congested. On pressing the anterior pillar, there is purulent secretion coming out of the tonsillar crypts (Irwin Moore’s sign positive). Post nasally, a bead of mucoid secretion is seen.
Neck
Jugulo digastric lymph nodes are enlarged bilaterally. They are about two cm in diameter, discrete i.e. not matted, firm and not tender.
Nose
External contour is normal. The nasal septum is in midline. The nasal mucosa is pinkish. Mucoid white discharge is seen in the nasal cavities, particularly over the inferior conchae i.e. in the middle meati. The conchae appear normal
Note: Before committing that the septum is in the midline, please have a look and then only write. If there is a mild deviation, do not hesitate to mention the same. About 66% of normal persons have some degree of nasal septal deviation. Unless there are symptoms or signs of sinusitis, do not venture to commit to a diagnosis of sinusitis. However, if an examiner asks you pointedly, whether there is sinusitis, you will have to say ‘because of the adenoidal enlargement, there could be sinusitis’. Also, be prepared for the next question to arise from the examiner’s mouth - what are the features of sinusitis?

Post nasal examination

Adenoids are enlarged, filling up most of the nasopharyngeal space. Rest of the nasopharynx is normal i.e. the posterior ends of septum, the posterior choana, the eustachian tubal orifice, the fossa of Rosenmuller, are all normal on both sides.


Note: Many children do not co-operate with a postnasal mirror examination. In that case, you may write that the postnasal examination could not be done because the child did not co-operate. If you write like that, the examiner will be tempted to ask you about alternate methods of visualizing the naso pharynx.
Ear

Particular part of each ear


Right ear


Left ear


Pre auricular region

Clinically Normal

Clinically Normal

Pinna

Normal

Same as the right ear

Post auricular sulcus


Normal

Normal

External ear canal


Normal

Normal

Discharge, if any
Nature

Colour


Quantity

Smell


Blood stained or not


No discharge



Same as the right ear



Tympanic membrane
Colour

Cone of light

Perforation

Type of perforation

Quadrant of perforation

Mobility of the TM




White,


Dull, Cone of light not distinctly seen,
No perforation,

Mobility impaired



Same as the right ear



Hearing

Whisper test

Watch test

Clinically normal


Clinically normal




Tuning Fork Tests

Rinne


Positive

Positive


Weber


Not lateralised

Absolute Bone Conduction test

Not reduced


Not reduced



Note: Quite obviously, for a case of T&A, you need not write in detail about the ear. Do not waste your time. You may just write ‘both the ears are clinically normal. Hearing in both ears is clinically normal’. In this particular case sheet, I have written the ‘Ear’ in detail, because I am offering an additional diagnosis of Secretory Otitis Media.
Other systems
Respiratory system: Rate 20 /min, regular, comfortable at rest i.e. not dyspnoeic, Bilateral air entry equal, No added sounds.
Cardio vascular system: Pulse 84 /min, regular, S1 and S2 are heard normally, no murmurs.
Abdomen: Soft, no tenderness, no organo megaly found.

Provisional Clinical Diagnosis
Chronic Adeno tonsillitis with Secretory otitis media bilateral with cervical lymphadenitis bilateral (with a current acute exacerbation of adeno tonsillitis)

Fig 4. 23. The appearance of the tonsils in this patient (Brodsky’s grade 3 enlargement. The ears are clinically normal, except for the dull tympanic membrane and indistinct cone of light.



tonsil diagr
Fig 4. 24. The right and the left ears in this patient. The ears are clinically normal, except for the dull tympanic membrane and indistinct cone of light.

ear tm left diag
eartm right diag
Investigations
Total leucocyte count (TC), Differential leucocyte count (DC), Haemoglobin

Bleeding time, Clotting time, Prothrombin time, Partial thromboplastin time, Platelet count, Blood grouping (ABO and Rh)

Urine: albumin, sugar, deposits

Blood sugar, Blood urea, ECG, X ray Chest

Throat swab for culture and sensitivity (in this particular case, you have to do this, because you have said that there is post nasal discharge.)

Anti Streptolysin O titre, Erythrocyte Sedimentation Rate


Note: During the clinical discussion, be prepared to justify each investigation, as follows.



  1. Those tests which will help to confirm your diagnosis: - a high TC will confirm an infective process. Among the DC results, high neutrophils indicate acute bacterial infection, high lymphocytes indicate chronicity and high eosinophils alert you to a possibility of allergy.




  1. Those tests which will exclude other diagnoses: - A blood smear without any large and abnormal lymphocytes will exclude infectious mono nucleosis. Absence of an abnormally high leucocyte count rules out leukemia. Anti Streptolysin O titre and ESR alert you to the possibility of a rheumatic fever.




  1. Those that help you to plan the treatment: - Throat swab for culture and antibiotic sensitivity, Presence of protein, epithelial casts or red cells in the urine must alert you to a renal complication of tonsillitis. Please note that in this particular patient with secretory otitis, one investigation that must be done is tympanogram (impedance audiometry). This will indicate whether there is any fluid in the middle ear or not.




  1. Pre operative tests:- (a) for the purpose of anaesthesiologist’s assessment, namely, chest x ray, ECG urinalysis etc.to ensure safety (b) for excluding any bleeding tendency namely bleeding time, clotting time, prothrombin time, partial thromboplastin time, platelet count and blood grouping. In this regard, you have to remember that a history of past bleeding tendency either in the patient himself or the family would carry more weight than the laboratory tests.



Treatment
1. Adeno tonsillectomy (Enucleation of the tonsils and Curettage of the adenoids. Some ENT surgeons prefer to abbreviate this to ‘E&C’. Some in the United States call this ‘T&A’).

2. Watchful wait for about two months for the resolution of the secretory otitis media. If necessary, myringotomy and/or insertion of ventilation tube.



Section 6. FAQs on Tonsillitis and Adenoiditis



  1. Why do you say that this patient has ‘tonsillitis’?

Because



    1. Tonsils are enlarged. Also, I can see that the tonsils are inflamed, as evidenced by the following: congestion of anterior pillars, bilateral jugulo digastrics nodes and positive Irwin Moore’s sign.

    2. The history suggests recurrent attacks of sore throat, pain on swallowing and occasional fever. Also, there is a history of not thriving well.



  1. When will you describe the tonsils as enlarged?

When the tonsils are enlarged beyond the anterior pillar of the fauces, it is considered to be enlarged.


So, if the tonsils are well within the anterior pillar, will you consider them as normal?
No, sometimes when the tonsils get infected repeatedly, they may undergo fibrosis and shrink. Such tonsils stay within the fossa. In fact, a chronically inflamed tonsil may not show any sign of inflammation except for a crescentic streak of redness, at the edge of the anterior pillar. In such cases, Irwin Moore’s sign may be of some help.


  1. Name the tonsils in our body.

Faucial tonsils (also called palatine tonsils)

Lingual tonsils

Nasopharyngeal tonsils (more commonly called adenoids)

Tubal tonsils (Gerlack’s tonsils) above the Eustachian tubal orifice
Note: The above are all lymphoid tissues. There is also another tonsil, in the cerebellum. The inferior pole of the cerebellar hemisphere is also called tonsil. But, this one is a neural tissue.


  1. Where does the palatine tonsil develop from?

From the Second pharyngeal pouch.




  1. Name the functions of tonsils.

It has lymphoid follicles and elaborates lymphocytes. It produces antibodies. Thus, it serves an immunological function.


  1. What are the lateral relations of the tonsil?

From inside out, they are (i) loose areolar tissue containing the peritonsillar vein and its tributaries (ii) pharyngobasilar fascia (iii) pharyngeal constrictor muscles (iv)para pharyngeal space with the great vessels (v) buccopharyngeal facia (vi) pterygoid muscles and (vii) the mandible




  1. What is the blood supply of the tonsils?

The tonsil is supplied by branches of the external carotid artery system.



  • Tonsillar branch of the facial artery

  • Branch from the ascending pharyngeal artery

  • Branch from the ascending palatine artery (a branch of facial artery)

  • Branch from the dorsalis linguae (branch of lingual artery)

  • Branch of descending palatine artery (branch of maxillary artery)




  1. Name the complications of tonsillitis.

Obstructive Sleep apnoea

Sinusitis

Otitis media

Peritonsillar abscess

Parapharyngeal space abscess

Retropharyngeal space abscess

Suppuration of cervical lymph nodes

Rheumatic heart disease

Bacterial endocarditis

Acute glomerulo nephritis

Septicemia




  1. What is the other name for peritonsillar abscess?

Quinsy.



  1. What is the differential diagnosis for quinsy?

Tumours of the tonsil, tonsillar cyst, tonsillolith

Abscess related to the upper molar teeth

Parapharyngeal abscess

Quinke’s oedema i.e. oedema of the soft palate


  1. Why the jugulo digastric lymph node is called such?

Because, it is situated where the internal jugular vein apparently crosses the posterior belly of digastric muscle. However, in fact, this node is situated at the junction of the common facial vein with the posterior belly of the digastric muscle.




  1. What is Waldeyer’s ring?

In the neck, the lymphoid tissues are aggregated in a ring like pattern. This is called the Waldeyer’s ring (Fig. 4.3). In fact there are two Waldeyer’s rings, an inner and an outer.




    1. Inner ring of Waldeyer comprises of submucosal aggregations of lymphoid tissues. They are palatine tonsils, adenoids, tubal tonsils, and lingual tonsils. Submucosal lymphoid aggregations over the entire pharyngeal wall complete the inner ring of Waldeyer.

    2. Outer ring of Waldeyer comprises of lymph nodes, namely, submental, submandibular, jugulodigastric, mastoid and sub occipital nodes.




  1. What are the differences between tonsils and adenoids?





Tonsils


Adenoids

paired

single

On the surface, crypts are seen

Vertical furrows are seen

Lined by stratified squamous epithelium

Ciliated columnar epithelium

Does not regress by puberty

Regresses by puberty

False capsule is present partially at the lateral aspect

No capsule



  1. In the diagnosis of this case, you told that there is adenoiditis. Did you see the adenoids?

No. I tried a post nasal examination. But, did not succeed because the child was apprehensive and did not cooperate.




  1. If you cannot do a post nasal examination by a mirror, is there any other way to assess the adenoids?

Several methods are available as follows:




    1. By taking a lateral view x ray of the neck with a soft tissue exposure, the adenoidal shadow could be visualized. For this purpose, a lateral cephalogram provides a standardized position and standardized magnification.

    2. A rhino pharyngo laryngoscope can be used. This is a flexible scope. With local anaesthetic spray and co operation from the child, this can be passed in the consulting office (out-patient department) itself.

    3. For this purpose, a rigid nasal endoscope can also be used.

    4. Palpation of the adenoidal cushion could be done under general anesthesia

    5. CT scan of the neck is also a good option. But, it is more expensive. Most importantly, it has a higher radiation dose.




  1. When you do not see the adenoids, why do you say ‘adenoiditis’?

The patient gives a complaint of frequent nasal block, nasal discharge and mouth breathing. On my examination, I find that there are features of adenoid facies.




  1. What are the features of adenoid facies?

Half open mouth, protrusion of the upper teeth, crowding of teeth, high arched palate, pinched nostrils, absence of the naso labial folds, persistent nasal discharge and dull looking face. Note: Nowadays, we rarely come across full-fledged adenoid facies. Because of increased awareness and increased availability of quality medical care, patients arrive early for treatment. Hence, adenoid facial features do not get time to develop.




  1. What are the complications of adenoiditis?

The adenoids are situated in between the two Eustachian tubal openings. Any infection in the adenoids and enlargement will impede proper aeration of the middle ear and will lead to acute otitis media, secretory otitis media, middle ear effusion, retraction of the tympanic membrane and also conductive hearing loss. Enlarged adenoids may also obstruct the airway leading to obstructive sleep apnoea and snoring.




  1. Why do you advise surgery in this patient?

Because, the tonsils show signs of chronic inflammation. The history suggests recurrent attacks of sore throat, pain on swallowing and occasional fever. Also there is a history of not thriving well over the last several months. The ears show signs of secretory otitis media. Thus, this particular patient meets several of the consensus criteria for surgical treatment.


Note: During the discussion, many questions on the surgical techniques may be asked. Some of them are listed below. Kindly read the section on surgery and instruments, for the answers.
What is the anaesthesia employed in tonsillectomy and in adenoidectomy?

How will you anaesthetize the patient?

What are the methods of doing tonsillectomy?

Describe the operative procedure by the dissection method.



Why the dissection method is preferred?

What are the complications of tonsillectomy

What are the methods of doing adenoidectomy?

What are the complications of adenoidectomy?

What other operation is likely to be done along with adenoidectomy?

What are the post-operative advice given to the T & A patients?




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