TONSILITIS

 

TONSILITIS

A tonsil is a mass of lymphoid tissue comprised particularly of one or two small almond shaped bodies. 

FUNCTION OF TONSILS 

1. They act as a barrier against infections

2. They are necessary for antibody production which fight bacteria in the body

3. Production of some blood cells.

Types of Tonsillitis

Tonsillitis can be described as acute or chronic as follows:

1. Acute tonsillitis: 

is an abrupt or sudden inflammation of the palatine tonsils usually caused by streptococcus or less commonly a viral infection;

2. Chronic tonsillitis: 

is an inflammation of the tonsils which is recurrent between episodes of acute tonsillitis in which the throat remains uncomfortable.

INCIDENCE 

Tonsillitis is common in children between 5-7 years of age.

PREDISPOSING FACTORS 

1. Overcrowding

2. Poor ventilation and housing

3. Upper respiratory tract infection (URTIs)

4. Seasons especially in winter and spring

5. Infectious like diphtheria

6. Age: young children are predisposed because their immunities are often low and are prone to infections

7. Lowered immunity in general.

CAUSES

1. Beta haemolytic streptococcus

2. Pneumococcus

3. Staphylococcus

4. Echo Virus (Enteric Cytopathogenic Human Orphan Virus) causes meningitis and respiratory infection

5. Adenovirus serotype viii

6. Influenza virus

7. Diphtheriae

8. Treponema pallidum

SIGNS AND SYMPTOMS 

1. Enlarged lymph nodes due to the immune response as the defense mechanism tries to fight the infection.

2. Dysphagia: may be as a result of swollen tonsils and involvement of the trigeminal nerve

3. Fever as a result of circulating microorganisms and toxins in the blood.

4. Sore throat due to ulceration in the depth of crypts

5. Malaise due to the systemic infection in the body

6. Difficulties in opening the mouth (trismus) due to inflammation process

7. Excessive salivation due to pain and inflammation of tonsils

8. Hyperaemic tonsils with swelling due to the inflammatory process

9. Yellowish exudates draining from the crypts.

MANAGEMENT OF TONSILITIS 

Investigation and diagnostic tests

1. Clinical picture or presentation may reveal swollen tonsils and enlarged swollen lymph nodes

2. Throat culture may determine the infecting organism

3. White blood cell count usually reveals leucocytosis

Non pharmacological treatment

1. Bed rest especially in the acute stage is very important and advised

2. Advise the patient to take a lot of fluids by mouth

3. Advice the patient to take saline gaggles

4. An ice collar may be applied to the neck to relieve pain

5. A bland diet is highly recommended especially in the acute stage

Medical treatment

1. Antibiotics such as oral penicillin, e.g. Pen V 500mg 6 hourly orally for 10 days; or Benzathine Penicillin 2.4mega units intramuscularly stat

2. Analgesics e.g. Aspirin for pain relief

3. Steroids e.g. Prednisolone to suppress the inflammatory process (not recommended for the immune compromised).

SURGICAL TREATMENT – TONSILECTOMY 

Indications

The indications of tonsillectomy are:

1. Recurrent acute Tonsilitis: 

if a patient gets more than 4 attacks of genuine acute tonsillitis every year, then they may 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. A Quinsy (Abscess): 

if a patient has had quinsy, he is likely to get another one unless the tonsils are removed.

3. 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.

4. 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.

5. Size: 

size alone is not a common indication. It is only considered 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 and the tonsils and adenoids must be removed as a matter of urgency.

Complications of Tonsillitis 

These include:

1. Peritonsilar abscess (Quinsy): this is situated near the tonsils and leads to septicaemia.

2. Chronic tonsillitis resulting from acute tonsillitis

3. Rheumatic heart disease which can eventually lead to heart failure

4. Recurrent otitis media

5. Acute nephritis

PRE-OPERATIVE NURSING CARE

AIMS

1. reassure and prepare the patient for surgery

2. prevent complications

3. achieve healing as rapidly as possible

Admission

Tonsilectomy is not an emergency and thus is admitted a day before surgery to allow the patient to adapt to the ward environment. This also allows orientation and explanation of the operation to be done.

Assessment and investigations.

1. History of sore throat of 2-3 weeks with swollen tonsils

2. Heart and lung examination to ascertain cardiovascular function, 

3. X-ray 

4. Blood investigations: full blood, haemoglobin to check level

5. Bleeding and clotting time

6. Urinalysis to rule out diabetes mellitus

Psychological care

Educate the patient about the pre and postoperative requirements. For example, tell them that their normal diet will change to light meals, such as custard, after the operation. Allow them to ask questions and answer them clearly and refer the difficult ones to the doctor. This enhances a good relationship. Involve the significant others in the care. If the patient is a child, allow the mother or guardian to stay close as this reduces fears and anxieties. 

Allow the child to play with toys and to continue with the home environment he is used to. If necessary, you can invite a chaplain or any other religious leaders to offer spiritual care and allay anxiety. You should also tell the patient that they might lose their voice temporarily. 

Nutrition

Provide the patient with a well balanced diet to correct the nutritional status. He or she is likely to be anorexic due to dysphagia. Provide L]light small frequent meals to promote appetite. The food should be rich in proteins and vitamins to 

repair worn out tissues and build the immunity.

Hygiene

If the patient has excessive solution, provide a sputum mug with a disinfectant to spit in. Oral toilet and mouth gaggles with saline help in refreshing the mouth and prevent mouth infections.

Immediate Preoperative Nursing Care

The patient is starved for 6 – 8 hours prior to the operation. He or she is given an early morning bath and a clean gown. Dentures if any are removed and kept safe with any jewellery. Premedication is given as ordered by the surgeon such as diazepam 10 mg, an hour before going to theatre to reduce anxiety. Atropine intramuscularly may also be given as ordered by the anaesthetist to reduce 

secretions in the mouth. Narcotics are given to reduce pain e.g. pethidine and if necessary an intravenous line is put. Ensure the patient has an identification.

IEC

The patient is advised to do normal breathing or coughing exercises to attain full lung expansion and gaseous exchange. He or she is told to be swallowing saliva after operation to prevent infection which may be due to accumulation of secretions. The patient is also told to avoid excessive coughing and laughing 

which may lead to haemorrhage and avoid highly spiced foods.

POST-OPERATIVE NURSING CARE

AIM

1. prevent haemorrhage

2. promote quick recovery

3. maintain a patent airway

4. prevent asphyxia from inhaled blood and secretions.

Environment

Put the patient in a clean room to prevent infection. The room should have: oxygen supply in case of an emergency; a trolley with resuscitative equipment and emergency drugs; and an emesis bowl for expectoration of mucus and blood.

Position

Put the patient in a lateral position with the head turned on one side to facilitate drainage of secretions from the mouth and pharynx. The head should lie on a dressed/covered mackintosh to prevent soiling of linen.

Observations.

The patient needs constant observation for the first 12 hours. Ensure you take observations of pulse rate and blood pressure 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. Observe the temperature in order to rule out infection. If the patient is vomiting observe the colour of the vomitus because he may be vomiting blood.

Hygiene

If the patient is vomiting, give them an emesis bowl 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.

Nutrition

When the patient is fully awake and the gag reflex has returned, allow him or her to drink water and later to take plenty of non-irritating foods. The patient should avoid milk products which coat the throat causing frequent throat cleaning and increasing risk of bleeding. Taking fluids prevents stiffness of muscles. In the 

morning after the operation a light diet should be 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.

Advice on discharge

1. Tell them to expect a white scab to form in the throat between the 3rd and 4th day postoperatively and to report bleeding or ear discomfort that lasts longer than 3 days.

2. To avoid spicy irritating foods and milk products as they coat the mucous membrane. The patient should have soft foods that are easy to chew and should avoid using straws or fork as these may cause injury.

3. Advise the patient to stay indoors for several days and to avoid 

strenuous exercise and sun bathing as this causes dilatation of blood vessels. Activities contraindicated because of the risk of bleeding include sneezing, coughing and vigorous nose blowing. 

Prevent anxiety by informing the patient what to expect after surgery.

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.

Complications of Tonsilectomy

1. Haemorrhage

2. Atelectasis

3. Pneumonia

4. Lung abscess

5. Sepsis of the operation site

6. Acute otitis media