It's about inflammation of tonsils

1. TONSILLITIS
THE BLESSED ONE
2/3/2023 Mr.KASONGO

2. Introduction
• A tonsil is a mass of lymphoid tissue comprised
particularly of one or two small almond shaped
bodies situated one on each side of the pillar of the
forchette fauces.
• It is covered by mucous membrane and its surfaces
fitted with follicles.
• The term tonsil is used in its commonly accepted
sense of indicating the faucial tonsils
2/3/2023 Mr.KASONGO

3. Introduction
• The term adenoid is synonymous with hypertrophy
of the pharyngeal tonsils.
• The tonsils and adenoids are part of the lymphoid
tissues which arch the pharynx and are collectively
known as Waldeyer’s Ring.
2/3/2023 Mr.KASONGO

4. Introduction
• This consists of the lymphoid tissue on the
base of the tongue (lingual tonsils) and the
two faucial tonsils, the adenoids (pharyngeal
tonsils) and the lymphoid tissue on the
posterior pharyngeal wall.
• This tissue naturally serves as a defense
against infection, and its defense mechanism
is overcome, it may become a site of acute or
chronic infection.(Lewis 2004)
2/3/2023 Mr.KASONGO

5. Objectives
GENERAL OBJECTIVE- To equip students with
knowledge on tonsillitis and its medical medical-
management
• SPECIFIC OBJECTIVE- At the end of the
lecture/discussion students should be able to;
• Define tonsillitis
• Mention the predisposing factors of tonsillitis
• Mention the causes of tonsillitis
• State the signs and symptoms of tonsillitis
• Describe the management of tonsillitis
2/3/2023 Mr.KASONGO

6. Definition
• Acute tonsillitis: is an inflammation of the
tonsils usually caused by streptococcus or less
commonly a viral infection.(Lewis 2004)
• Acute tonsillitis: is an abrupt or sudden
inflammation of the palatine tonsils. (Lewis
2004)
• Chronic tonsillitis: is an inflammation of the
tonsils which is recurrent between episodes of
acute tonsillitis in which the throat remains
uncomfortable. (Smeltzer & Bare 200
2/3/2023 Mr.KASONGO

7. Predisposing factors
• Overcrowding
• Poor ventilation and housing
• Upper respiratory tract infection (URTIs)
• Seasons especially in winter and spring
• Infectious like diphtheria
• Age – young children are predisposed because their
immunities are often low and are prone to
infections
• Lowered immunity in general
2/3/2023 Mr.KASONGO

8. Causes
• Beta haemolytic streptococcus
• Pneumococcus
• Staphylococcus
• Echo Virus (Enteric Cytopathogenic Human Orphan
Virus) causes meningitis and respiratory infection
• Adenovirus serotype viii
• Influenza virus
• Diphtheriae
• Treponema pallidum
2/3/2023 Mr.KASONGO

9. Signs and symptoms
• Enlarged lymph nodes due to the immune response
as the defense mechanism try to fight the infection.
• Dysphagia – may be as a result of swollen tonsils
and involvement of the trigeminal nerve
• Fever as a result of circulating microorganisms and
toxins in the blood.
• Sore throat due to ulceration in the depth of crypts
2/3/2023 Mr.KASONGO

10. Signs and symptoms
• Malaise due to the systemic infection in the body
• Difficulties in opening the mouth (trismus) due to
inflammation process
• Excessive salivation due to pain and inflammation
of tonsils
• Hyperaemic tonsils with swelling due to the
inflammatory process
• Yellowish exudates drainage draining from the
crypts.
2/3/2023 Mr.KASONGO

11. Investigation and diagnostic tests
• Clinical picture or presentation may reveal swollen
tonsils and enlarged swollen lymph nodes
• Throat culture may determine the infecting
organism
• White blood cell count usually reveals leucocytosis
2/3/2023 Mr.KASONGO

12. NON PHARMACOLOGICAL
TREATMENT
• Bed rest especially in the acute stage is very
important and advised
• Advise taking a lot of fluids by mouth
• Saline gaggles
• An ice collar may be applied to the neck to relieve
pain
• A bland diet is highly recommended especially in
the acute stage
2/3/2023 Mr.KASONGO

13. Medical Treatment
• Antibiotics such as oral penicillin e.g. Pen V 500mg
6 hourly orally for 10 days or Benzathine Penicillin
2.4mega units intramuscularly stat
• Analgesics e.g. Aspirin for pain
• Steroids e.g. Prednisolone to suppress the
inflammatory process (not recommended for the
immune compromised).
2/3/2023 Mr.KASONGO

14. Surgical Treatment
TONSILECTOMY
Indications
Recurrent acute Tonsillitis
• If a patient has had more than 4 attacks of genuine
tonsillitis acute in nature per year for several years,
he can benefit from tonsilectomy.
• It is of course important to be certain that the
attacks described by the patient are tonsillitis and
not just sore throat; each attack should last for 5 –
7 days with fever, malaise severe enough to keep
the child away from school or an adult from work.
2/3/2023 Mr.KASONGO

15. A Quinsy (Abscess)
• If a patient has had quinsy, he is likely to get
another one unless the tonsils are removed.
• For Histology
• If one tonsil is abnormally larger or harder than the
other, or if it is ulcerated, it must be removed for
histology as it may be a good site for Squamous cell
carcinoma development
2/3/2023 Mr.KASONGO

16. Rheumatic Fever and Acute Glomerulonephritis
• Patients who have had one of these diseases will
often be treated with long term penicillins to avoid
further beta haemolytic streptococcal infection.
• However, patients may develop resistance to
penicillin or allergy.
• In this case tonsilectomy may be performed on
request by the physician or paediatrician.
2/3/2023 Mr.KASONGO

17. Size
• Size alone is not a common indication, but if they
are large enough to cause respiratory obstruction
with evidence of right sided heart stain and even
failure.
• Sleep apnoea is a significant symptom in this case;
the tonsils and adenoids must be removed as a
matter of urgency
2/3/2023 Mr.KASONGO

18. Complications Of Tonsilitis
• Peritonsilar abscess (Quinsy); this is situated near
the tonsils and lead to septicaemia.
• Chronic tonsillitis resulting from acute tonsillitis
• Rheumatic heart disease which can eventually lead
to heart failure
• Recurrent otitis media
• Acute nephritis
2/3/2023 Mr.KASONGO

19. Preoperative Nursing Care
Aims
• To reassure and prepare the patient for surgery
• To prevent complications
• To achieve healing as rapidly as possible
2/3/2023 Mr.KASONGO

20. Preoperative nursing care
Admission
• Tonsilectomy is not an emergency and thus is
admitted a day before surgery to allow him to adopt
the ward environment.
• This also allows orientation and explanation of the
operation to be done.
2/3/2023 Mr.KASONGO

21. • Assessment and investigations
• History of sore throat of 2 – 3 weeks with swollen
tonsils
• Heart and lung examination to ascertain
cardiovascular function, x ray is done.
• Blood investigations; full blood; haemoglobin to
check if the level and if it is low the patient may be
transfused.
• Bleeding and clotting time
• Urinalysis to rule out diabetes mellitus
2/3/2023 Mr.KASONGO

22. Psychological care
• The patient will be told what will be done on him
and what he will expect after the operation e.g. his
normal diet will change such as him eating light
food like custard for some time.
• He is allowed to ask questions which will be
answered clearly and those difficult ones referred
to the doctor.
• This enhances a good relationship.
• The significant others are also involved in the care.
2/3/2023 Mr.KASONGO

23. • If the patient is a child, the fears are reduced by
being with someone they know e.g. the mother or
guardian.
• The child is allowed to play with toys to continue
with the home environment he is used to.
• A chaplain or any other religious leaders are
invited in order to offer spiritual care and alley
anxiety.
• The patient is told that he may lose his voice
temporarily.
2/3/2023 Mr.KASONGO

24. Nutrition
• The patient will be provided with well-balanced
diet to correct the nutritional status.
• He is likely to be anorexic due to dysphagia.
• Light small frequent meals should be provided to
promote appetite.
• The food should be rich in proteins and vitamins to
repair worn out tissues and build the immunity.
2/3/2023 Mr.KASONGO

25. Hygiene
• If the patient has excessive solution, a sputum
mug to spit in is provided and a disinfectant
should be put in it before use. Oral toilet and
mouth gaggles with saline help in refreshing the
mouth and prevent mouth infections.
2/3/2023 Mr.KASONGO

26. Immediate Preoperative Nursing Care
• The patient is starved for 6 – 8 hours prior to
the operation.
• He will have an early morning bath and a
clean gown is given, dentures if any are
removed and kept safe with any jewellery.
2/3/2023 Mr.KASONGO

27. Immediate preoperative care
• Premedication is given as ordered by the
surgeon such as diazepam 10 mg an hour
before going to theatre to reduce anxiety.
• Atropine intramuscularly as ordered by the
anaesthetist to reduce secretions in the
mouth.
2/3/2023 Mr.KASONGO

28. Immediate Preoperative care
• Narcotics are given to reduce pain e.g.
pethidine and if necessary an intravenous line
is put and identification on the patient’s arm
bearing his name, ward, sex, age, and details
of the type of operation to be done.
• The patient is taken to theatre together with
all his notes and a hand over given to theatre
staff nurse.
2/3/2023 Mr.KASONGO

29. Patient teaching
• The patient is advised to do normal breathing or
coughing exercises to attain full lung expansion and
gaseous exchange.
• He is told to be swallowing saliva after operation to
prevent infection which may be due to
accumulation of secretions.
• He is also told to avoid excessive coughing and
laughing which may lead to haemorrhage and avoid
highly spiced foods
2/3/2023 Mr.KASONGO

30. Post Operative Nursing Care
Aims
• To prevent haemorrhage
• To promote quick recovery
• To maintain a patent airway
• To prevent asphyxia from inhaled blood and
secretions
2/3/2023 Mr.KASONGO

31. Environment
• The patient is put in a clean room to prevent
infection.
• There has to be oxygen supply in case of an
emergency.
• A trolley with resuscitative equipment and
emergency drugs, an emesis bowl for expectoration
of mucus and blood should be available.
2/3/2023 Mr.KASONGO

32. Position
• The patient is put in lateral position with the head
turned on one side to facilitate drainage of
secretions from the mouth and pharynx.
• The head should be on a dressed/covered
mackintosh to prevent soiling of linen
2/3/2023 Mr.KASONGO

33. Observations
• The patient needs constant observation for the
first 12 hours.
• Ensure observation of pulse rate and blood
pressure to be done half hourly to detect early any
bleeding.
• Observe for the swallowing reflex as frequent
swallowing even when the patient is sleeping is a
sign that he is bleeding and the doctor should be
informed immediately.
2/3/2023 Mr.KASONGO

34. • Temperature should be observed to rule out
infection.
• Observe the swallowing reflex which can be
ascertained by the patient coughing out of the
airway.
• If the patient is vomiting observe the colour of the
vomitus because he may be vomiting blood.
2/3/2023 Mr.KASONGO

35. Hygiene
• If the patient is vomiting, an emesis bowls so that
he can help himself to prevent vomiting on the
floor.
• If there is excessive salivation, a clean dry cloth or
swab can be used to wipe the mouth.
• Throat gaggling with antiseptic solution or normal
saline for at least 10 days after meals should be
encouraged.
2/3/2023 Mr.KASONGO

36. Nutrition
• When the patient is fully awake and the gag reflex
has returned, he will be allowed to drink water and
later urged to take plenty of non-irritating foods
avoiding milk products which coat the throat
causing frequent throat cleaning and increasing risk
of bleeding
2/3/2023 Mr.KASONGO

37. • Taking fluids prevents stiffness of muscles. In the
morning after operation a light diet is provided and
a normal diet thereafter.
• Most children eat a full diet after the second day
but older ones will prefer soft foods.
• The acid of fruits and fruit juices causes
considerable pain and so should be avoided
2/3/2023 Mr.KASONGO

38. Advice on discharge
• Before discharge the patient or his parents are
provided with written instructions on home care.
• They are told to expect a white scab to form in the
throat between the 3rd and 4th day post
operatively and to report bleeding, ear discomfort
or that lasts longer than 3 days
2/3/2023 Mr.KASONGO

39. • Avoid spicy irritating foods and milk products as
they coat the mucous membrane.
• The patient should have soft foods for easy chewing
and also to avoid using straws or fork as these may
cause injury
2/3/2023 Mr.KASONGO

40. • Frequently following tonsilectomy the patient is
advised to stay indoors for several days and to avoid
strenuous exercise and sun bathing as this causes
dilatation of blood vessels.
• Activities contraindicated because there is a risk of
bleeding include sneezing, coughing the throat and
vigorous nose blowing etc. to be avoided
2/3/2023 Mr.KASONGO

41. • Prevention of anxiety; blood swallowed during
surgery may cause the patient to be tarry for a day
or so following tonsilectomy, he may be told this is
expected
2/3/2023 Mr.KASONGO

42. Hygiene
• Throat gaggles are encouraged to sooth the
throat.
• Prevention of constipation and placement of
electrolytes are important.
• Occasionally a mild laxative is necessary to help
relieve constipation and also unpleasant mouth
odour following surgery.
• Additionally, fluid intake helps compensate for the
slight temperature elevation which may occur for
a few days
2/3/2023 Mr.KASONGO

43. Review Dates
• The patient is given recommendations for rest and
follow up appointments and in addition to
instructions concerning pain relief and diet is given.
• He is also instructed before discharge to notify his
doctor if develops ear discomfort or temperature
elevation lasting longer than 3 days.
• He is encouraged to rest the voice avoid aspirin as
this precipitates bleeding.
• The importance of completing the course of
prescribed antibiotic therapy to promote
compliance is emphasized.
2/3/2023 Mr.KASONGO

44. Complications Of Tonsilectomy
Haemorrhage
• This may be reactionary occurring within 12 hours
or operation or secondary occurring 5 – 7 days
afterwards.
• The latter is due to sepsis.
• An adult is usually aware of blood on swallowing
and will indicate his concern to the nurse.
• A child may be too young to know and the nurse
must watch for excessive swallowing
2/3/2023 Mr.KASONGO

45. • The patient should be sat up in bed with head and
neck well supported by pillows.
• The nurse examines the tonsil bed for signs of
bleeding, take blood pressure and pulse rate and
record.
• Inform the surgeon of the patient’s medical
condition and he may remove the clot carefully by
means of Luc’s forceps and he then mops the fossa
with wool soaked in hydrogen peroxide.
• If this does not stop the bleeding, it may be
necessary to take the patient back to ligate one or
more blood vessels.
2/3/2023 Mr.KASONGO

46. Atelectasis
• This arise if a plug of mucus blocks one of the
bronchiole tubes and the signs are elevation of
temperature, rapid breathing, dyspnoea, coughing
and cyanosis, dullness on the affected lung with
absence of breath sounds on percussion and
auscultation respectively.
• Radiologically, the affected lung is displaced
towards the mediastinum and the diaphragm is
raised.
2/3/2023 Mr.KASONGO

47. TREATMENT
• The treatment is to sit the patient up if possible and
have him to cough or lie on the good side.
• If the measures fail then aspirate the occluding
plug of mucus bronchoscopically
2/3/2023 Mr.KASONGO

48. Pneumonia
• This evidenced by the same symptoms as of
atelectasis but the breath sounds on the affected
side are increased rather than absent and
fluoroscopically show the diaphragm is symmetrical
and the mediastinum is in the midline with lungs
aerating well
2/3/2023 Mr.KASONGO

49. • Pneumonia can result if the patient inhales blood
and this can be prevented by taking proper
precautions during operation e.g. hyperextension
of the head and proper suctioning and giving
benzyl penicillin 2MIU 6 hourly IV for 5 days
2/3/2023 Mr.KASONGO

50. Lung abscess
• This is evidenced by fever, cough and expectoration
of a mouthful of pus usually a week or two after
surgery.
• It can be prevented by hyper extending the head
during operation.
• It prevents inhalation of any material such as blood
and mucus.
2/3/2023 Mr.KASONGO

51. Sepsis of the operation site
• It can be prevented by encouraging the patient to
swallow or gaggle 2 – 3 times a day.
• Encourage taking plenty of oral fluids.
• TREATMENT
• Benzyl penicillin 2MIU 6 hourly intravenously for 5
days.
2/3/2023 Mr.KASONGO

52. Acute otitis media
• Infection may spread to the middle ear and cause
acute otitis media indicated by a rise of
temperature and earache.
2/3/2023 Mr.KASONGO

53. Summary
• Tonsillitis is simply the inflammation of the tonsils
by bacteria or less often viral. Overcrowding is one
of the predisposing factors of tonsillitis.
• It is mainly caused by beta haemolytic
streptococcus.
• Its management includes non-pharmacological
interventions such as rest, saline gaggles; taking
lots of fluids etc
2/3/2023 Mr.KASONGO

54. Summary
• Medical management require use of antibiotics if
the cause is bacterial.
• In severe cases such as recurrent acute tonsillitis,
rheumatic fever or quit enlarged tonsils,
tonsilectomy is performed.
• Tonsillitis and tonsilectomy are not without
complications; therefore any complications that
arise need to be managed accordingly
2/3/2023 Mr.KASONGO

55. REFERENCES
• Basavanthappa B.T, (2005), MEDICAL SURGICAL
NURSING,(3rdedition), New Delhi, INDIA
• Moroney. (1986). SURGERY FOR NURSES, (16th
edition), Churchill Livingstone, Hong Kong.
• Berkow.R, et al, (1997), THE MANUAL OF MEDICAL
INFORMATION, (1stedition), Merck research lab, New
Jersey
• Smeltzer & Bare, (2000), MEDICAL SURGICAL
NURSING, (9th edition), Lippincott Williams & Wilkins,
USA
• Lewis & et al, (2004), MEDICAL SURGICAL NURSING,
assessment and management of clinical problems, (6th
edition), Mosby, Inc. USA
2/3/2023 Mr.KASONGO