ANATOMY:
The rich lymph tissue in the back of the nose (nasal passage) and throat is called the Waldeyer Ring and plays an important role in the body's defense against infections coming through the mouth and nose, especially in the first years of life.
The structures that make up the Waldeyer Ring are;
- Tonsils (tonsils),
- Language tonsils (lingual tonsils),
- Adenoid (pharyngeal tonsil),
- Lymph tissue located at the mouth of the eustachian canal in the nasal cavity (tubal tonsils, Gerlah tonsil),
- Back of the throat These are lymphoid follicles located in the wall.
In children, especially tonsils and adenoid diseases have different importance because they can be the focus of chronic infection and cause secondary problems.
Tonsils:
They are encapsulated lymph system tissues located on both sides of the throat. They contain 15-20 depressions (crypts) surrounded by lymphoid nodules. Tonsils become a source of chronic infection due to bacteria settling in the crypts they contain, and recurrent acute tonsillitis may occur in cases where body resistance decreases. They may cause complaints such as:
Adenoid:
It is located on the roof of the nasal area, behind the nose. It has no capsule and no crypt. Adenoid tissue begins to grow around the age of 2 and begins to regress around the age of 5-7 and usually disappears completely around the age of 12-14. If there is an indication for adenoidectomy surgery, the aim is for the child to be a good nose breather during this period of facial development and dental development until the age of 12-14.
Complaints such as nasal congestion, snoring, and blockage in sleep (apnea) can be observed as the adenoid grows and covers the holes where the nose opens to the nasal passage at the back. At the same time, frequently recurring adenoid infections disrupt the functions of the Eustachian canal, which opens on both sides of the nasal area and ensures equalization of middle ear pressure, causing negative pressure and fluid collection in the middle ear (otitis media with effusion) or recurrent middle ear infections. It may cause ear infections (acute otitis media).
ACUTE TONSILLITIS (ACUTE TONSILLITIS):
It is an acute active infection of the tonsils, the severity of which depends on the type of microbe that causes it and the resistance of the patient's defense system. It is changing.
Main factors:
Bacteria: Group A Beta hemolytic Streptococci, Staphylococci, Pneumococci, H. influenzae, and anaerobic bacteria,
Viruses: Influenza, parainfluenza viruses, Herpes simplex virus, Coxsackie virus, Echoviruses, Rhinoviruses, Respiratory syncytial virus (RSV).
Viral agents are more common in the preschool period, and bacterial agents are more common in adolescents and young adults.
Symptoms:
It begins rapidly with chills and fever, and a sore throat occurs. Affecting the muscles around the throat causes difficulty in swallowing. There is headache, weakness, and joint pain. It usually resolves in 4-6 days.
Examination Findings:
There are enlarged tonsils covered with varying amounts of white membranes and inflammation in the opening areas of the recesses (crypts) on the tonsils. There may be bleeding foci on the tonsils and a reaction in the entire lymphoid tissue in the throat. Painful lymph node enlargement in the neck behind the corner of the jaw is typical.
Laboratory;
There is an increase in white blood cells in the blood. In microscopic examination of the throat swab, the causative microorganism is detected by gram staining, produced in throat culture, and can be demonstrated by rapid streptococcal test. ASO, CRP, Sedimentation help in diagnosis. The normal ASO value is 166-200 u/dl, values above this are in favor of previous streptococcal infection. However, its increase in streptococcal infections in other parts of the body, including the skin, etc., limits its value.
Treatment
- Adequate fluid intake, rest
- Oral antiseptics
- Painkillers, antipyretic drugs
- Antibiotic: Especially oral treatment should be used for at least 7-10 days. In order of preference;
- Penicillin G (Procaine penicillin = İecilline)
- Amoxicillin + Clavulinic Acid (Augmentin)
- Clindamycin
- Erythromycin is used.
If the condition is severe, treatment can be started intravenously or by intramuscular injection, taking into account the difficulty of taking medication orally. The first choice is intramuscular (IM) procaine penicillin. In adult patients, the administration of 800,000 u IM twice a day can be continued for 3-4 days, and when the clinical condition improves, the treatment can be completed for 10 days with oral penicillin, or the treatment can be terminated by intramuscular injection of 1,200,000 u of depot benzathine penicillin once. If beta-lactamase producing microorganisms are present in the environment, the response to treatment will decrease. Following the detection of this condition by culture, an antibiogram should be performed and the appropriate antibiotic should be started.
Differential Diagnosis
Infectious Mononucleosis: It is a viral disease caused by the Epstain Barr Virus. It is frequently observed in school-age children. The infection, also known as kissing disease among the public, is transmitted through saliva and airborne droplets. Clinical findings are very similar to acute tonsillitis, with high fever, sore throat, enlargement of the tonsils, flushing, followed by a white-gray membrane covering the tonsils. Along with the enlargement of the lymph nodes in the neck, the liver and spleen enlarge as the virus spreads in the blood. In diagnosis, an increase in cells called monocytes in the blood, monitoring of cells specific to this disease, and immunological tests are used. Lack of increase in the total number of white blood cells, increase in sedimentation and CRP, increase in liver enzyme levels, and detection of liver and spleen enlargement are other findings useful in diagnosis. Blood smear evaluation made with a microscope in patients is very important in differentiating other blood diseases that may cause similar findings.
Diphtheria:The onset is slow and general findings are not obvious. Hoarseness, shortness of breath, croup, and swollen lymph nodes in the neck are observed. There is a thick, grey, tightly adherent membrane on the tonsils, and bleeding is typical when removed. Heart palpitations incompatible with fever may be detected due to the release of toxins that affect the nervous system and heart. Diagnosis is made by Gram stain and throat culture.
Scarlet fever:Inflammation of tonsillitis with thick membranes, d A red spotted appearance (strawberry tongue) occurs in the province. There are widespread raised rashes on the body. Diagnosis is made by throat culture and immunological tests (Dick test, Schutz-Charlton fading phenomenon).
CHRONIC TONSILLITIS (CHRONIC TONSILLITIS)
It is a permanent inflammation of the tonsils that develops due to recurrent infections. Enlargement, degeneration, and blockage in the tonsils occur in the tonsils. Although tonsils usually grow with recurrent infections, they can sometimes shrink and disappear. The causative agent of chronic tonsillitis is bacteria located in the tonsils, in the crypts.
Findings:
Recurrent sore throat, Enlargement and increased vascularity in the tonsils, Foul-smelling inflammatory materials accumulating in the crypts, Febrile attacks, joint pain, weakness, Lymph node swelling in the neck (during active periods) is evident.
Treatment:
Although preventive antibiotics (monthly depot penicillin injections) can be used in frequently recurring infections, it is generally Removal of tonsils (tonsillectomy) is preferred. In children under three years of age, if the tonsils are too large and do not cause frequent infections, it may be preferable to partially reduce the size of the tonsils to relax the air duct, instead of removing them completely, in order to preserve their contribution to the immune system. Techniques on this subject will be discussed in the tonsillectomy section.
ABSSE AROUND THE TONSIL (PERITONSILLAR ABSCESS)
It occurs as a result of the infection spreading past the tonsil capsule. The causative agent is often anaerobic bacteria that grow in an oxygen-free environment. High fever, chills, weakness, vomiting, difficulty swallowing, drooling, difficulty opening the mouth, and difficulty speaking are observed.
In examination; There is swelling, edema, inflammation and membrane formation around the tonsil. The edematous uvula is bent in the opposite direction.
Treatment* Antibiotics are started intravenously, they should be effective against penicillin-resistant bacteria (producing beta lactamase), painkillers and antipyretics should be given, and oral hygiene should be provided with mouthwash.
Draining the abscess increase Cellulitis (the period when inflammation does not accumulate) or localized small abscess can disappear with drug treatment. When there is significant inflammation accumulation, it must be surgically drained. Removal of tonsils - Tonsillectomy (when there is a peritonsillar abscess = hot tonsillectomy) It should not be performed in cases where there are serious signs of infection such as high fever and fainting. Tonsillectomy can be performed following 12 hours of antibiotic treatment in pediatric patients where evacuation and subsequent patient follow-up are problematic and in patients with a history of frequent tonsillitis or peritonsillar abscess.
COMLICATIONS OF TONSILLITIS
Regional and distant spread of infection may occur. Heart membrane inflammation (endocarditis), kidney inflammation (nephritis), and brain abscess may develop due to blockage and infection in the vessels. There may be obstruction in the respiratory tract due to edema on the larynx. Spread to the neck and accumulation of inflammation in the neck (neck abscess), pneumonia, lung abscess, and ruptures in the large vessels in the neck may occur.
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