A case we got during our ENT ward rotation.

1. PROBLEM BASED LEARNING
E.N.T
SAROSH UL HASSAN

2. 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.

3. WHAT ARE
YOUR
DIFFERENTIAL
DIAGNOSIS???

4. DIFFERENTIAL DIAGNOSIS

5. 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

6. 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

7. 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)

8. 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

9. BLOOD SUPPLY

10. VENOUS AND LYMPHATIC
DRAINAGE
Enlarged non tender jugulodigastric lymph
node is a sign of chronic tonsillitis

11. Nerve supply
- Lesser palatine branch of sphenopalatine ganglion
- Glossopharyngeal nerve

12. 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

13. COMING BACK TO
THE DIFFERENTIAL
DIAGNOSIS……

15. ACUTE TONSILLITIS

16. CATARRHAL TONSILLITIS
MEMBRANOUS TONSILLITISPARENCHYMATOUS TONSILLITIS
FOLLICULAR TONSILLITIS

17. MEMBRANE OVER TONSILS
MEMBRANOUS TONSILLITIS
DIPTHERIA
VINCENT ANGINA
INFECTIOUS MONONUCLEOSIS
AGRANULOCYTOSIS
LEUKEMIA
APHTHOUS ULCERS
MALIGNANCY TONSILS
TRAUMATIC ULCERS
CANDIDAL INFECTION OF TONSIL

18. MEMBRANOUS TONSILLITIS
• Occur due to pyogenic
organisms
• An exudative membrane
forms over the medial
surface of the tonsils
• Features of acute tonsillitis

19. 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

20. 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

21. 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

22. 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

23. CHRONIC TONSILLITIS

24. 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.