Clinical Case Discussion: Tonsillitis

🧠 Clinical Case Discussion : Tonsillitis

Today, we'll be doing a clinical case discussion on Tonsillitis, a common case often encountered in examinations.

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

📋 Patient History

Here's the history of our patient:

• Patient Name: Kavita
• Age: 10 years
• Sex: Female
• Location: Hyderabad
• Religion: Hindu

History of Present Illness (HPI):

Patient was apparently asymptomatic 3 days back when she started complaining of:

1. Difficulty in Swallowing:

   • Onset: Insidious
   • Duration: 3 days
   • Progress: Gradually progressive in nature.
   • Aggravated by: Eating cold food or drinking cold drinks.
   • Relieved by: Medication.
   • Associated with pain while swallowing and pain in both ears (insidious onset, mild in nature).

2. Fever:

   • Onset: Insidious
   • Duration: 3 days
   • Character: Continuous in nature.
   • Associated with: Weakness.
   • No: Chill or rigor, no aggravating factor.
   • Relieved on: Taking medications.

Negative History (Crucial Rule-outs):

(Though not a formal heading, these points are crucial to ask and document within the History of present illness)

• No history of mouth breathing, snoring, increased daytime sleepiness, decreased scholastic performance.
• No history of change in voice, difficulty in breathing, headache, cough, nose complaints.
• No history of ear discharge, decreased hearing, or any ringing sensation in the ears.

Past History:

• History of several similar episodes: 2 times this year, last episode 2 months back, and 4 episodes in the previous year.
• No history of Diabetes Mellitus, Bronchial Asthma, TB, Epilepsy.
• No history of surgeries in the past.
• No history of known drug allergy.

Family History:

• No similar history in siblings.

Treatment History:

• Similar complaints in the past were treated by antibiotics and analgesics, post which she recovered.

Personal History:

• Sleep: Normal.
• Appetite: Normal.
• Diet: Non-vegetarian.
• Bladder and Bowel movements: Normal.
• No addiction history.

🗣️ Discussion of History Points

Let's analyze the significance of each history point, inferring clues for our diagnosis.

1. Patient Particulars (Age, Sex, Location):

• Age (10 years): This is a very common age group for recurrent tonsillitis. Other conditions common in this age group include Adenoid Hypertrophy, Otitis Media with Effusion. Malignancies are less common.

• Sex (Female): While tonsillitis affects both sexes, this case does not point to specific gender-predominant conditions like post-cricoid carcinoma (females) or oral/laryngeal cancer (males).

• Location (Hyderabad): Not specifically relevant to tonsillitis, but geographic prevalence might be considered for other ENT conditions (e.g., Laryngeal TB in North India, Plummer-Vinson in Gujarat).

2. History of Present Illness:

A. Difficulty in Swallowing (Dysphagia):

• Insidious Onset & Gradually Progressive: Typical of inflammatory or slowly developing lesions like chronic tonsillitis.

What are some diseases where we see sudden onset of dysphagia?

What are the different causes of Dysphagia?

• Aggravated by Cold Food/Drinks: Indicates an inflammatory process in the throat where cold temperatures cause irritation or muscle spasm.

• Relieved by Medication: Suggests the underlying process is responsive to anti-inflammatory (analgesics) or anti-infective (antibiotics) treatment.

• Associated with Pain while Swallowing (Odynophagia)

List all the causes of Odynophagia.

• Associated with Pain in both Ears (Insidious Onset, Mild): This is a referred otalgia. There is no primary ear pathology.

What is Referred Otalgia? Name the different causes of Referred Otalgia & the involved nerve.

Name the branch of Glossopharyngeal nerve supplying the middle ear.

B. Fever:

• Insidious Onset & Continuous: Suggests a gradual onset of infection or inflammation that is persistent. (Contrast with sudden onset for pyogenic/septic causes).

• No Chill and Rigor: Absence suggests a less severe, non-septic, mild-to-moderate infection, consistent with tonsillitis (e.g., not pyogenic abscess, malaria, severe septicemia).

• No Aggravating Factor: Rules out specific triggers for fever.

• Relieved on taking Medication: Indicates a responsive inflammatory process.

• Associated with Weakness: A common constitutional symptom of infection and fever.

4. Negative History Significance:

These points help rule out other diagnoses or complications.

• No Mouth Breathing, Snoring, Increased Daytime Sleepiness, Decreased Scholastic Performance - These are classic symptoms of Adenoid Hypertrophy and/or Obstructive Sleep Apnea (OSA) in children. Their absence makes significant adenoid hypertrophy less likely as the primary cause of obstruction in this case.

What is the pathophysiology of Obstructive sleep apnea?

Why do we see Nocturnal Enuresis in Obstructive sleep apnea?

What are the features of Adenoid Facies?

• No Change in Voice (Hot Potato Voice)

What is Hot Potato voice? What are the different causes of Hot Potato Voice?

• No Difficulty in Breathing (Dyspnea): Suggests the tonsillar enlargement/inflammation is not yet causing significant airway compromise

What is Brodsky grading for Tonsillar enlargement?

• No Headache, Cough, Nose Complaints: Less typical for significant sinusitis or lower respiratory tract involvement.

• No Ear Discharge, Decreased Hearing, Ringing Sensation: Rules out primary ear pathology (e.g., AOM, Serous Otitis Media due to ET obstruction by nasopharyngeal mass/inflammation) and confirms the ear pain is referred.

5. Past History Significance:

• Similar Episodes (2 this year, 4 last year): Crucial! This establishes the chronicity of the tonsillitis and meets the criteria for recurrent tonsillitis, making her a candidate for tonsillectomy based on Paradise Criteria.

What is Paradise Criteria for Tonsillectomy?

• No Diabetes Mellitus, Hypertension, TB, Epilepsy: Rules out systemic conditions that can influence disease course or surgical fitness.

What is the importance of a history of seizures in Tonsillectomy?

• No Surgeries/Drug Allergies: Important for pre-operative assessment.

6. Treatment History:

• Recovery with antibiotics and analgesics: Confirms responsiveness to standard medical treatment, characteristic of bacterial tonsillitis.

7. Personal History:

• Normal Sleep/Appetite/Bowel/No Addiction: Generally good health otherwise, and absence of risk factors for malignancy.

✨ Clinical Examination Findings

Let's discuss the significance of the findings on physical examination, mainly focusing on the ENT-relevant areas.

General and Systemic Examination: Normal

Oral Cavity Examination:

• Mouth Opening: Adequate

What is Trismus? What are its causes and grading?

What is normal mouth opening?

What are the Muscles of Mastication?

• Lip and Oral Commissures: Normal

What is Cheilitis?

What is Glossitis?

• Tongue: Normal

What are the causes of coated tongue?

What is Tongue Tie? Grading of Ankyloglossia.

• Floor of Mouth: Normal (Rules out swellings like Ranula).

What is Ranula? What are the different types of Ranula?

• Buccal Mucosa, Gingivobuccal Sulcus, Teeth, Retromolar Trigone, Hard Palate: All normal

What are the Pre-malignant lesions of oral cavity?

What are the boundaries of Retromolar Trigone? What is the clinical significance of Retromolar Trigone?

What are the Hidden Areas of Head & Neck?

Oropharynx Examination:

• Halitosis Present: Bad breath, common with infected tonsils, poor oral hygiene, dental caries.

• Uvula Congested.

• Soft Palate Congested.

• Bilateral Anterior Pillars Congested.

• Bilateral Grade 3 Enlargement of Tonsils (Congested): This is the key finding.

What are the different grades of tonsillar enlargement?

What are Kissing Tonsils?

• Bilateral Posterior Pillars NOT Seen: This is expected with Grade 3/4 tonsillar enlargement, as the large tonsils obscure them.

• Posterior Pharyngeal Wall Congested.

• Indirect Laryngoscopy: Not done (due to patient's age and acute condition making cooperation difficult).

Difference in procedure between Indirect Laryngoscopy and Posterior Rhinoscopy?

How to prevent mirror fogging in Indirect Laryngoscopy?

What are the Blind sites in Indirect Laryngoscopy?

Neck Examination:

• Trachea midline. Laryngeal crepitus present.

• Single nodular swelling felt on both sides of the neck, 1 cm below the angle of the mandible (Jugulodigastric/Level II lymph nodes).

• Nodes: 2 x 2 cm (enlarged, >1cm pathological), tender (indicates acute inflammation), firm, mobile, smooth surface, regular margins. Skin normal.

What does tender enlarged lymph nodes indicate?

Other Examinations:

• Nose and Paranasal Sinus Examination: Normal.
• Ear Examination: Normal. (Consistent with referred otalgia).

📝 Case Summary

A 10-year-old female presents with 3 days of difficulty and pain while swallowing, bilateral ear pain, and fever. The fever is insidious in onset, continuous, and associated with weakness. Difficulty in swallowing is insidious, gradually progressive, aggravated by cold food/drinks, and relieved by medication. She has a history of recurrent similar episodes (2x this year, 4x last year). Negative for snoring, daytime sleepiness, voice changes, breathing difficulty, headache, cough, nose complaints, ear discharge. Past/family/personal history are non-contributory except for reduced sleep and prior response to antibiotics/analgesics. On examination, she is febrile (102°F). Oropharynx shows halitosis, congested uvula, soft palate, and anterior/posterior pharyngeal walls. Bilateral Grade 3 tonsillar enlargement with congestion. Tender 2x2 cm bilateral jugulodigastric lymph nodes. Rest of ENT and systemic examination is normal.

🩺 Provisional Diagnosis

Acute Exacerbation of Chronic Tonsillitis.

What are the points in favour of your diagnosis?

What are the 3 cardinal signs of Chronic Tonsillitis?

What is Irwin Moore sign?

What are the different Types of Acute Tonsillitis?

What are the differences between True Membrane and False membrane over Tonsil?

DIfferential Diagnosis of Membrane over tonsil.

What are the Complications of Acute Tonsillitis?

🏥 Management Plan

Management always comprises Investigations and Treatment.

Since this is an acute exacerbation, the first priority is to treat the acute infection, then plan for definitive management (tonsillectomy).

Investigations:

• Routine Blood Investigations (Preoperative Evaluation):

What are the routine blood investigations done in a case of Tonsillitis and Why?

• X-ray Nasopharynx (Lateral View): If Adenoid Hypertrophy is suspected (e.g., mouth breathing, snoring, adenoid facies). Helps assess adenoid size.

• Throat Swab for Culture & Sensitivity (C&S): If antibiotics are not working, helps guide specific antibiotic choice.

Treatment:

A. Acute Phase Management (Treating the Exacerbation):

• Antibiotics
• Analgesics & Antipyretics
• Antiseptic Mouth Gargles
• Advise plenty of fluids

When would you plan for Tonsillectomy in this case?

B. Definitive Management (Tonsillectomy):

What is Hot Tonsillectomy and Interval Tonsillectomy?

What are the Indications for Tonsillectomy?

What are the Contraindications for Tonsillectomy?

What are the different techniques of Tonsillectomy?

What position is used in Tonsillectomy?

What are the Steps of Tonsillectomy?

What post operative care would you take in a case of Tonsillectomy?

What are the Complications of Tonsillectomy?

What are the different types of hemorrhage seen post tonsillectomy> What are the causes of each of them? How would you manage them?

What is Grisel Syndrome?