CASE REPORT

Acute Tonsillitis

Moderator :
dr. Dyah Ayu Kartika D., M.Sc, Sp.THT-KL

Group 17204
Ade Rizal H KU/15633
Billy Ibnu Hilman T KU/15618
Euginia Natalia Bato KU/14398
Nadia Adelin KU/15824
Talitha Najmillah S KU/15990
Thantia Amandha KU/15650

Department of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine Universitas Gadjah Mada / Dr. Sardjito General Hospital
2017
INTRODUCTION
Tonsillitis is an inflammation of the
palatine tonsils due to bacterial or viral
infection. It frequently happens in children
between the age of 5-10 years and young
adult between 15-25 years old18. Acute
pharyngo-tonsillitis is one of the most
common disease that pediatricians and
general practitioners most frequently
encounter (15 million visits per year in the
US)9.
The incidence of tonsillitis in
Indonesia is increasing over time, according
to data on epidemiology of ENT diseases on
7 province in Indonesia on 2005, prevalence
of chronic tonsillitis is 3.8% of all cases of
ENT. According to medical record of RSUP
dr. M. Djamil Padang in year 2010,
tonsillitis cases was 456 of 1.110 patients
visit to ENT clinic, and 163 cases undergo
tonsillectomy20.
The palatine tonsil represents the
largest accumulation of lymphoid tissue in
the head and neck region. Each tonsil has a
compact body with a definite thin capsule on
its deep surface. A stratified squamous
epithelium lines the outer surface of the
tonsil and invaginates deeply into the
lymphoid tissue to form multiple crypts. The
tonsillar fossa is composed of three muscles:
the palatoglossus muscle, the
palatopharyngeal muscle, and the superior
constrictor muscle. The palatoglossus
muscle forms the anterior pillar and the
palatopharyngeal muscle forms the posterior
pillar. The tonsillar bed is formed by the
superior constrictor muscle of the pharynx19.
The cause of tonsillitis is virus or
bacteria. The viruses involved are similar
with those in upper respiratory infection
such as; Epstein-Barr virus, rhinovirus,
corona-virus, adenovirus, herpes simplex
virus, parainfluenza virus, and
1
cytomegalovirus .
The most common bacterial
pathogen in acute tonsillopharyngitis is
Group A Streptococcus Hemolyticus
(GABHS), which attributes nearly 37% of
all cases of tonsillitis followed by other
pathogens, including group C beta-
hemolytic streptococci, Neisseria
gonnorheae, viridan streptococci and
Pyogene streptococci3.
Tonsillitis is divided into 3
classifications based upon frequency of
tonsillitis and duration of inflammation.
Acute tonsillitis includes cases where
symptoms last anywhere from three days to
about two weeks. Recurrent tonsillitis occurs
when a person suffers from multiple
episodes of tonsillitis within a year. Chronic
tonsillitis cases have symptoms which
persist beyond two weeks2.
Patients with acute tonsillitis usually
come with sore throat, dysphagia,
odynophagia, malaise, fever (up to 40 C),
and foul breath. Otalgia can be present as a
referred pain. Sometimes otitis media could
be the complications of the throat
inflammation. Cervical adenopathy with
tenderness is often found13.
From physical examination we can
find inflamed tonsils and tonsillar
hypertrophy. Usually, tonsils can be found
with spots and sometimes with exudates.
Culture can be a useful diagnostic
procedure to find the causative agents of an
infection. However due to the time needed
to gain result; physicians would first
prescribe empiric antibiotics followed by
specific treatment based on the result of the
culture7.
We can classify the tonsils into
several groups by examining the size of the
tonsil.
Pict. 1. Tonsillar Hypertrophy Grading Scale2
Management of a child with
adenotonsillar disease depends on the
underlying etiology and can include medical
and surgical approaches. Acute infections
need appropriate antibiotic therapy and
symptoms control. Drug of choice for
treating bacterial tonsillitis are Penisilin V
500mg (adult) or 25-50mg/kg/day (child),
Amoxicilin 250-500 mg (adult) or
50mg/kg/day divided in 2 or 3 dosage
(child)2.
Another therapy for tonsillitis is
operation (tonsillectomy). The relative
indications are: more or equal to three tonsil
infections per year after adequate treatment;
halitosis; chronic or recurrent tonsillitis
which is not responding to beta lactamase
resistant antibiotic; unilateral tonsil
hypertrophy which is suspected to be
neoplastic. The absolute indications are:
enlarged tonsils that cause upper airway
obstruction; severe dysphagia; sleep
disorder; cardiopulmonary complications;
peritonsillar abscess; tonsillitis that causes
febrile convulsions; and tonsillitis that
requires biopsy to define tissue pathology9.
Acute tonsillitis could cause an
increase of morbidity for the patient and the
family. The complications of tonsillitis
could be divided into two, which are:
suppurative complication and non-
suppurative complication. Suppurative
complications are: peritonsillar abscess,
deep neck infection, and adenotonsillar
hypertrophy. Meanwhile non-suppurative
complications are: scarlet fever, acute
rheumatic fever, and acute
15
glomerulonephritis .
CASE REPORT
A 7 years old female patient came to
ENT clinic of UGM Academic Hospital
with the chief complaint of sore throat since
one week ago. The complaints also followed
by difficulty of swallowing and fever. No
hoarseness, cough, sneezing, foul breath,
snoring, headache, arthralgia, no ear and
nose complaint were reported. Breathing
difficulties during daily activities was
absent. No history of allergic or asthma. The
patient has no history of previous similar
complaints and no history of medication.
On general examination, patient was
compos mentis and sluggish. The result of
vital sign was 120/80 mmHg (blood
pressure), 38.2C (temperature), 20
times/min (respiratory rate), 100 beats/min
(heart rate) and VAS score was 2. Patients
body weight was 20 kg, and height was 120
cm. In physical examination, both right and
left ear showed normal condition. Both
tympanic membranes were intact. Normal
result were also showed in nose
examination. Neither hyperemic concha nor
mucosal discharge were found in anterior
and posterior examination. Continued by
throat examination, hyperemic and
hypertrophy tonsil grade T3 were noticed in
both tonsils. While cervical
lymphadenopathy palpation showed no
enlargement.
This patient later was diagnosed with
acute tonsillitis, based on the anamnesis and
physical examination. The medication given
to this patient was Amoxicillin syrup 350
mg (7 ml) every 8 hours and paracetamol
200 mg (10 ml) three times daily. Patient
was asked to come for a follow up in one
week. Patient was educated to have
nutritious diet and proper rest, avoid
irritating food, and maintain oral hygiene.
The discussion for this patient is the usage
of antibiotic therapy.
Discussion
Patient came with chief complaint of
sore throat since one week ago, and
according to throat examination there were
enlarged hyperemic tonsils (grade T3 in both
tonsils). Ear and nose examination were
normal. General condition including vital
sign was normal, except patient had a
sluggish appearance. Thus, based on the
physical examination, patient was diagnosed
with acute tonsillitis.
Acute tonsillitis is an infection of the
parenchyma of the palatine tonsil where
symptoms last from three days to about two
weeks. The cause of tonsillitis can be from
viral, bacterial, or immunologic factors. The
most common cause in tonsillitis between
the age of 5 -15 years old is bacterial18.
The tonsils have a role as host
defense, local immunity, and immune
surveillance against antigens. Once the
antigen enter the body, it will penetrate the
mucous barrier then attach to the epithelial
cells. Then it spread from cell to cell and
possibly penetrates the outer most layer of
epithelial cells. When epithelial cells eroded,
in turn it will provoke cytokine production
and/or complement activation of superficial
lymphoid tissue. These events will induce
inflammatory reaction with PMN infiltration
in the tonsillar tissue17.
In this case, most probable etiology
of the tonsillitis was bacterial, it was
depicted from the Centor Score. The Centor
Score was used to identify the likelihood of
Group A Streptococcus Hemolyticus
(GABHS) infection and to make a decision
for empirical antibiotic use. The Centor
Score consist of: swollen or tender anterior
cervical lymph nodes; fever > 38 C; the
presence of tonsillar exudate; the absence of
cough; and age range (3-14 years: +1, 15-44
year: 0, 45 years: -1)14.
This patients Centor Score was 4
which means the infection could be bacterial
so it needs to be treated with antibiotics
empirically, because the patient has fever,
absence of cough, tonsillar swelling, and
patient is 7 year old.
The treatment depends on the
causative agents, and in this case, which was
probably bacterial, so the patient was
prescribed with broad spectrum antibiotic
(amoxicillin), antipyretic, antiinflammation
and analgetic (paracetamol). The most
common bacterial pathogen in acute
tonsillitis is GABHS which is sensitives to
penicillin derivate, thus antibiotic such as
amoxicillin is the drug of choice14.
The dosage of amoxicillin for
children is 50 mg/kgBW/24 hours, this
patient is 20 kg, which means the needed 2.
dose is 1000 mg/24 hours divided into 3
doses, so each dose is 350 mg. Because we
use a 250 mg/5 ml syrup packaging, we
prescribe amoxicillin syrup 7 ml/ 8 hours16. 3.
For the fever and pain, the patient
was prescribed with paracetamol 10-15
mg/kgBW/dose, so each dose is 200 mg,
three times daily. Because we use a 120
mg/5 ml syrup packaging, we prescribe 4.
paracetamol syrup 10 ml three times a day16.
Another therapy for tonsillitis is
operation (tonsillectomy). In this patient,
there was no indication for tonsillectomy
5.
because it didnt meet either relative or
absolute criteria.
The patient was advised to come
back in one week for follow up. Patient was
educated to have nutritious diet and proper
rest, avoid irritating food, and maintain oral 6.
hygiene. This can help prevent the
recurrence of tonsillitis.
7.
Conclusion
The conclusion of this case is a 7
years old female patient suffering from sore
throat and odynophagia, physical
examination shows enlarged tonsils and the 8.
complaints started one week ago. The
patient was diagnosed with acute tonsillitis.
The main problem in this case is sore throat
that patient had. 9.
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