PROBLEM BASED LEARNINGE.N.T

SAROSH UL HASSAN

CASE SCENERIO• A 10year old boy comes to OPD with high

grade fever, sore throat and dysphagia to solids for past 4 days.

• Mother informs that he had multiple similar episodes in the past 2 years, always alleviated by taking antibiotics.

• On examination tonsils were inflamed, hypertrophied with whitish membrane. Child looks toxic though.

WHAT ARE YOUR

DIFFERENTIAL

DIAGNOSIS???

DIFFERENTIAL DIAGNOSIS

ANATOMY OF PALATINE TONSILS

• Palatine Tonsil is an ovoid mass of lymphoid tissue situated in the lateral wall of oropharynx between anterior and posterior pillars

• It has Two surfaces – Medial and Lateral, and Two poles – Upper and Lower

MEDIAL SURFACE• Medial Surface is

covered by nonkeratinizing stratified squamous epithellium which dips into the substance of tonsils in the form of crypts

• One of the crypts, situated near the upper part of tonsils is very large and deep and is called CRYPT OF MAGNA

LATERAL SURFACE• It is covered by the fibrous

capsule of the tonsil• The tonsillar bed is

separated from the capsule by loose areolar tissue

• This makes it is easy to dissect the tonsil from its bed during tonsillectomy

• It is the site of collection of pus in peritonsillar abscess (quinsy)

POLES OF TONSILS• UPPER POLE

– It extends into the soft palate

– There is a semilunar fold of mucous membrane which covers the medial part of the upper pole

• LOWER POLE– It is attached to the

tongue– The lower pole is

separated from the tongue by the tonsillolingual sulcus

• This sulcus may harbour carcinoma

BLOOD SUPPLY

VENOUS AND LYMPHATIC DRAINAGE

Enlarged non tender jugulodigastric lymph node is a sign of chronic tonsillitis

Nerve supply - Lesser palatine branch of sphenopalatine ganglion

- Glossopharyngeal nerve

FUNCTIONS OF TONSIL• It has a protective function in that it prevents

entry of pathogens through the nasal and oral route

• The crypts on the surface of the tonsil serve to increase the surface area and increase the efficiency of protection against pathogens

• It forms a part of Waldeyer’s lymphatic ring

COMING BACK TO THE

DIFFERENTIAL DIAGNOSIS……

ACUTE TONSILLITIS

CATARRHAL TONSILLITIS

MEMBRANOUS TONSILLITISPARENCHYMATOUS TONSILLITIS

FOLLICULAR TONSILLITIS

MEMBRANE OVER TONSILSMEMBRANOUS TONSILLITIS

DIPTHERIA

VINCENT ANGINA

INFECTIOUS MONONUCLEOSIS

AGRANULOCYTOSIS

LEUKEMIA

APHTHOUS ULCERS

MALIGNANCY TONSILS

TRAUMATIC ULCERS

CANDIDAL INFECTION OF TONSIL

MEMBRANOUS TONSILLITIS• Occur due to pyogenic

organisms• An exudative membrane

forms over the medial surface of the tonsils

• Features of acute tonsillitis

DIPTHERIA• Acute infection caused by

Corynebacterium Diptheriae• Formation of false

membrane which extends beyond the tonsils on to the soft palate and posterior pharyngeal wall.

• Dirty gray in color, firmly attached to mucosa.• Cause bleeding when membrane is removed• Diphtheria is slower in onset with less local discomfort

VINCENT ANGINA

• Insidious in onset with less fever and less discomfort in throat

• Gray membrane forms usually over one tonsils can be easily removed revealing an irregular ulcer on the tonsil.

• Throat swab will show both organisms typical of this disease, that are:

• Fusiform Bacilli• Spirochetes

INFECTIOUS MONONUCLEOSIS

• Also called as glandular fever, caused by epstein barr virus.

• Both tonsils are enlarged, congested and covered with mombrane.

• Lymph Node enlarged in the posterior triangle of neck along with speenomegaly

• Blood smear show more than 50% lymphocytes, out of which 10% are atypical.• White cell count is normal in first week but rises in the second week

LEUKEMIA• In children, 75% of leukemias

are acute lymphoblastic and 25% acute myelogenous or chronic

• Peripheral blood shows TLC>100,000/CU MM.

• It may be normal or less than normal.

AGRANULOCYTOSIS• Ulcerative necrotic lesions

not only on the tonsils but also in the oropharynx.

• Patient is severely ill.• In acute form, total

leucocytic count is dec. to <2000/cu mm

APHTHOUS ULCERS• They may involve any part of

oral cavity or oropharynx• Very painfull• It is solitary & may involve

the tonsil and pillars• May be small or large

MALIGNANCY TONSILS• Oral or pharyngeal tumors

are the excessive growth of cells in these regions.

• They may be benign or malignant.

• Most oral/pharyngeal tumors are malignant

CHRONIC TONSILLITIS

QUINSY• Also called as peritonsillar abscess. • It the collection of pus in the

peritonsillar space.FEATURES:• Dysphagia• High grade fever• Muffled and thick speech also

called HOT POTATO VOICE • Trismus• Swollen soft palate• Uvula swollen and edematous.