ANATOMY:

The posterior part of the nose (nasopharynx) and the rich lymphoid tissue in the throat are collectively known as Waldeyer’s Ring. This structure plays an important role in the body’s defense against infections entering through the mouth and nose, especially during the early years of life.

Structures Comprising Waldeyer’s Ring:

  • Tonsils,
  • Lingual tonsils,
  • Adenoid (pharyngeal tonsil),
  • Lymphoid tissue located at the opening of the Eustachian tube in the nasopharynx (tubal tonsils, Gerlach’s tonsil),
  • Lymphoid follicles located on the posterior wall of the throat.

In children, especially diseases of the tonsils and adenoids are of particular importance because they can serve as chronic infection foci and lead to secondary problems.

Tonsils (Tonsil):

Tonsils are encapsulated lymphatic system tissues located on both sides of the throat. They contain 15-20 crypts (indentations) surrounded by lymphoid nodules. Due to bacteria residing in the crypts, tonsils can become a source of chronic infection, leading to recurrent acute tonsillitis when the body’s immune defenses are weakened.

Additionally, as a result of recurrent infections, the lymphoid tissue can increase in size, causing symptoms such as snoring, sleep obstruction, and apnea due to the enlargement.

Adenoid (Adenoid):

Located at the roof of the nasopharynx behind the nose, the adenoid has no capsule and does not contain crypts. Adenoid tissue begins to grow around the age of 2 and enters a regression phase around 5-7 years of age, typically completely disappearing by 12-14 years of age. If adenoidectomy is indicated, the goal is to ensure that the child undergoes this period with proper facial and dental development and maintains good nasal airflow.

Enlargement of the adenoid can lead to nasal obstruction, snoring, and sleep apnea by blocking the openings from the nasopharynx to the nose. Additionally, frequent adenoid infections can disrupt the functions of the Eustachian tube, which opens to both sides of the nasopharynx and helps equalize middle ear pressure. This disruption can cause negative pressure and fluid accumulation in the middle ear (effusion otitis media) or recurrent middle ear infections (acute otitis media).

ACUTE TONSILLITIS:

Acute tonsillitis is an active infection of the tonsils whose severity varies depending on the type of microorganism causing it and the patient’s immune resistance.

Main Causative Agents:

Bacteria: Group A Beta-hemolytic Streptococci, Staphylococci, Pneumococci, Haemophilus influenzae, and anaerobic bacteria.

Viruses: Influenza, parainfluenza viruses, Herpes simplex virus, Coxsackie virus, Echoviruses, Rhinoviruses, Respiratory Syncytial Virus (RSV).

Viral agents are more common in the preschool period, while bacterial agents are more frequent in adolescents and young adults.

Symptoms:

It begins rapidly with chills and fever, followed by a sore throat. Involvement of the muscles around the throat causes difficulty swallowing. Other symptoms include headache, weakness, and joint pain. It usually resolves within 4-6 days.

Examination Findings:

Enlarged tonsils covered with varying amounts of white membranes and inflammation at the openings of the crypts (indentations) on the tonsils. Presence of bleeding foci on the tonsils may indicate a reaction in all the lymphoid tissue of the throat. Painful enlargement of the lymph nodes behind the jaw corner is typical.

Laboratory:

There is an increase in white blood cells in the blood. Microscopic examination of throat swabs with Gram staining identifies the causative microorganism, which is cultured in throat cultures and can be detected with rapid streptococcal tests. ASO, CRP, and Sedimentation rates assist in diagnosis. The normal ASO value is 166-200 u/dl, and values above this indicate a past streptococcal infection. However, elevated ASO can also occur in streptococcal infections in other parts of the body, such as the skin, which limits its specificity.

Treatment:

  • Adequate fluid intake, rest
  • Mouth antiseptics
  • Pain relievers and fever reducers
  • Antibiotics: Especially oral antibiotics should be used for at least 7-10 days. In order of preference:
  • Penicillin G (Procaine Penicillin = Iecilline)
  • Amoxicillin + Clavulanic Acid (Augmentin)
  • Clindamycin
  • Erythromycin is also used.

In severe clinical cases where oral medication is difficult, treatment may begin with intravenous or intramuscular injections. The first choice is intramuscular (IM) procaine penicillin. In adult patients, 800,000 units IM twice a day for 3-4 days can be continued, after which treatment can be completed with oral penicillin for 10 days once the clinical condition improves, or with a single intramuscular injection of depot benzathine penicillin (1,200,000 units). If beta-lactamase-producing microorganisms are present, treatment response may decrease. In such cases, after culture identification, an antibiogram should be performed, and appropriate antibiotics should be administered.

Differential Diagnosis

Infectious Mononucleosis: A viral disease caused by the Epstein-Barr Virus, commonly observed in school-age children. Also known as the “kissing disease,” it is transmitted through saliva and airborne droplets. Clinical findings are very similar to acute tonsillitis, including high fever, sore throat, enlarged and reddened tonsils, followed by white-gray membranes covering the tonsils. Enlargement of lymph nodes in the neck, liver, and spleen occurs due to viral spread in the blood. Diagnosis involves an increase in monocytes in the blood, detection of specific cells for this disease, and immunological tests. Absence of an increase in total white blood cells, elevation of sedimentation and CRP, increased liver enzyme levels, and enlargement of the liver and spleen are other helpful diagnostic findings. Blood smear evaluation under a microscope is crucial for differentiating from other blood diseases with similar findings.

Diphtheria: Begins slowly with non-specific general symptoms. Symptoms include hoarseness, shortness of breath, croup-like symptoms, and swollen lymph nodes in the neck. The tonsils have thick, gray membranes tightly adhered to the base, which may bleed upon removal. Due to the secretion of toxins affecting the nervous system and heart, fever may be inconsistent with heart palpitations. Diagnosis is made through Gram staining and throat cultures.

Scarlet Fever: Characterized by thick-membraned tonsillitis, red spots on the tongue (strawberry tongue), and widespread maculopapular rashes on the body. Diagnosis is made through throat cultures and immunological tests (Dick test, Schutz-Charlton blanching phenomenon).

CHRONIC TONSILLITIS

Chronic tonsillitis is a persistent inflammation of the tonsils caused by recurrent infections. It involves enlargement, degeneration, and obstruction of the crypts in the tonsils. Despite recurrent infections often causing the tonsils to enlarge, they can sometimes shrink and disappear. In chronic tonsillitis, the causative agents are bacteria residing within the tonsils and their crypts.

Findings:

Recurrent sore throats, enlargement and increased vascularization of the tonsils, accumulation of foul-smelling inflammatory materials in the crypts, febrile attacks, joint pain, weakness, and enlargement of lymph nodes in the neck (during active periods) are prominent.

Treatment:

While prophylactic antibiotics (monthly depot penicillin injections) can be used for frequent infections, tonsillectomy (removal of the tonsils) is generally preferred. In children under three years of age, if the tonsils do not frequently get infected but are excessively large causing problems, partial reduction of the tonsils to relieve the airway is preferred instead of complete removal to preserve their contribution to the immune system. Techniques related to this are discussed in the tonsil surgery section.

PERITONSILLAR ABSCESS

A peritonsillar abscess occurs as a result of the spread of infection beyond the tonsil capsule. The causative agents are often anaerobic bacteria that thrive in oxygen-deprived environments. Symptoms include high fever, chills, weakness, vomiting, difficulty swallowing, excessive salivation, difficulty opening the mouth, and difficulty speaking.

On Examination: Swelling and edema around the tonsil, presence of inflammation and membranes on the tonsil, and deviation of the swollen small uvula to the opposite side.

Treatment:
* Start antibiotics intravenously, ensuring they are effective against penicillin-resistant (beta-lactamase-producing) bacteria.
* Administer pain relievers and fever reducers.
* Maintain oral hygiene with gargles.

Drainage of the abscess is essential. Cellulitis (a stage where the inflammation has not formed a mass) or localized small abscesses may resolve with antibiotic therapy alone. When there is a significant accumulation of pus, surgical drainage is necessary. Tonsillectomy (hot tonsillectomy when a peritonsillar abscess is present) should not be performed in patients with severe infection signs like high fever and debilitation. In children with problematic postoperative follow-up or those with a history of frequent tonsillitis or peritonsillar abscess, tonsil surgery can be performed after a 12-hour antibiotic treatment.

COMPLICATIONS OF TONSILLITIS

Infections can spread regionally and distantly. Complications include thrombosis of blood vessels and infective endocarditis (inflammation of the heart valves), nephritis (kidney inflammation), and brain abscess. Edema in the larynx can cause airway obstruction. Further complications include neck abscesses, pneumonia, lung abscesses, and ruptures in the large blood vessels of the neck.