Infections of Waldayer's ring

By

Dr. T. Balasubramanian M.S. D.L.O.

Bacteriology:  Normal flora gets established in the upper respiratory tract immediatly after birth.  Actinomyces, Fusobacterium & Nocardia are acquired by 6 - 8 months of age.  Later Bacteroids, Leptotrichia, Propioniobacterium and candida also become established as part of normal oral flora.  Fusobacterium populations reach high numbers after dentition and reach maximal number by 1 year of age.
   

During an episode of infection (viral/bacterial) the colonization of gram negative organisms and Staph aureus increase by 70%.  Many organisms induce inflammation of Waldayer's ring.  They are:

1. Bacterial -  Aerobic

                        Anaerobic

2. Viruses

3. Yeasts.

4. Parasites

Infact some of thee infectious organisms are part of the normal oral and pharyngeal flora; while others are external pathogens.  Most infections of waldayer's ring are polymicrobial and the infecting organism work synergistically.  One other feature of mixed infection is the ability of organisms resistant to an antimicrobial agent to protect an organism susceptible to the agent by production of antibiotic degrading enzymes thus rendering the antibiotics used in the treatment ineffective.

Among all the bacterial infections affecting the waldayer's ring streptococcal infections needs a prominent mention because of its ability to produce such sequlae like Rheumatic heart disease and Glomerular nephritis.  Group A beta haemolytic streptococcus is the common bacteria affecting the waldayers ring.  Acute streptococcal tonsillitis is a disease of childhood.  The peak age of incidence being between 5 - 6 years.  Outbreaks of epidemic proportions  are common.

The history given by the patient determines whether the patient is suffering from acute, recurrent or chronic tonsillitis.

Acute tonsillitis:
The duration of illness is less than three weeks old.  The patient infact may not give any history of recent similar attacks.
Clinically these patients have 1. Fever
2. sore throat
3. Foul smelling breath
4. Odynophagia (painful swallowing)
5. Tender enlarged upper deep cervical node belonging to the jugulodigastric group.  These nodes are palpable just below the angle of the mandible.
6. In young children this condition is almost always associated with enlarged adenoids which may cause nasal airway obstruction and obstructive sleep apnoea syndrome.
7. Generally these pateints are lethargic and toxic.

Causative organisms of acute tonsillitis:
1. Streptococci pneumoniae (commonest)
2. Staphylococcus
3. Pneumococcus
4. H. Influenzae
5. Diphtheroids
6. Viral

Investigations:
Throat culture is a must to identify the presence of beta haemolytic streptococci.  The major disadvantage is that it takes a minimum of 48 hours for the culture to be reported.  There is also the false negative results to contend with.  Cultures must be performed when the body temperature is more than 38.3 .C or when the illness is characterised by sore throat.  But a culture cannot differentiate between acute and chronic infections.
Carrier states are common among false negative patients.  These patients can be identified by ASO titre assessment.  A carrier will have a positive culture for haemolytic streptococci with a negative ASO titre.
Rapid tests for streptococci have been introduced among which rapid strep test has prooved accurate and cost effective.

Medical management:

Therapy is directed at aerobic pathogens i.e. beta haemolytic streptococci.  Penicillins are the drug of choice.  Ampicillin / Amoxycillin in doses of 40 - 50 mg /kg body weight can be used.  Anaerobes have been shown to be involved in recurrent tonsillitis hence clindamycin in considered in recurrent and resistant cases.

Complications of tonsillitis:
1. Peritonsillitis
2. Quincy
3. Pharyngeal abscess
4. Otitis media
5. Septic foci leading on to subacure bacterial endocarditis, nephritis or rhematic fever
6. Septicaemia (rare)

Chronic tonsillitis:
The duration of illness is more than 3 weeks.  These patients have milder symptoms when compared to those with acute tonsillitis.  Tonsils are enlarged.  Tonsillar enlargement can be graded under 4 groups:
Grade 0: The tonsils are fully inside the pillars.
Grade 1: Tonsils found to be enlarged and out of its pillars
Grade 2: Tonsillar enlargement extends just up to half the distance of the uvula
Grade 3: Tonsillar enlargement up to the level of the uvula.
Grade 4: Tonsillar enlargement is so huge that they are virtually in contact with each other i.e. Kissing tonsil.
The anterior pillars are congested.  The jugulodigastric nodes are enlarged and tender.
Types of chronic tonsillitis:
Chronic follicular tonsillitis:
In these patients the tonsillar enlargement is associated with the presence of prominent inflammed follicles.  Whitish material can be seen extruding from the follicles when the anterior pillars are pressed with a tongue depressor.  This is known as the squeeze test.  A positive squeeze test always indicate the diagnosis of ch follicular tonsillitis.  Inflammation and blockage of crypta magna in these pateints lead on to the formation of Quincy or peritonsillar abscess.
Chronic parenchymatous tonsillitis:
In these patients tonsils are enlarged but the follicles are not prominent. Infection is found within the substance of the tonsil.
Infection in patients with chronic tonsillitis is always poly microbial with a predominence of gram negative and anaerobic organisms.  Surgery is commonly indicated in these patinets.

Faucial diphtheria:
Causes membranous tonsillitis.  Membranous exudate are seen over tonsils and soft palate, followed by its distant toxic effects.
It is caused by corynebacterium diphtheria.  Three different strains of diphtheria have been identified, they are Gravis, Intermedius and Mitis.  These organisms grow in Loeffler's media or Tellurite agar.  These organisms ferment glucose.  This infection is rare these days because of the success of universal immunisation programme. 
Pathogenesis:
Multiplication of organism leads to production of toxins which cause epithelial necrosis with collection of polymorphs and fibrin leading formation of false membranous formation (because it consists of necrotic layer of mucosa, where as true membrane is superimposed over the intact mucosa).
Clinical features:
1. The child is very quiet
2. Lassitude
3. Malaise
4. Head ache
5. Fever
6. Foetor

On examination a greyish / yellowish thick membrane on one or both tonsils extending up to the soft palate and uvula.  The membrane can be removed leaving a raw under surface.  Massive cervical adenitis is also seen i.e. Bull neck. 
Diagnosis is by :
Signs and symptoms
Throat swab for culture and sensitivity
Lymphocyte count is raised
Albuminuria is seen
Schick test is postive

Differential diagnosis:
Acute streptococcal tonsillitis
Oral thrush
Infectious mono nucleosis
Quincy

Treatment:
The patient is kept in isolation for 2 weeks
If myocarditis has set in patient must be kept in bed rest till the ECG become normal
The patient must have 3 negative swabs before discharge
Anti diphthertic serum must be administered in acute cases:
     - for mild cases 20,000 units
     - moderate cases 40,000 units - 80,000 units
     Half dose is given as intra muscular injection and the other half as intra venous injections.
Injection penicillin is administered in doses of 5 - 10 lakhs
Tracheostomy is done in patient's with stridor.

Complications:
1. Myocarditis & circulatory failure
2. Peripheral neuritis with palatal palsy
3. Ocular muscle palsy
4. Peripheral neuritis


Differences between acute diphtheria and acute follicular tonsillitis

Acute follicular tonsillitis	Acute diphtheria
1. Occurs in individuals between 6 -20 yrs	Occurs in individuals under 10 years of age
2. H/O attacks of recurrent tonsillitis	H/O exposure to diphtheria
3. Pain is severe	Pain is mild
4. Toxemia absent	Toxemia present
5. Dirty white pseudo membrane limited to tonsil only and can be removed with no raw areas after removal	Membrane extensive on tonsil, uvula, and soft palate.  Can only be removed with difficulty, underlying raw area is seen on removal.
6. Throat swab shows streptococci	Swab shows c. diphtheria
7. Schick test negative	Schick test positive

Complications of tonsillitis:

The complications of tonsillitis can be classified under non suppurativve and suppurative complications.
Non suppurative complications are
1. Scarlet fever
2. Rhematic fever
3. Post streptococcal glomerular nephritis
Suppurative complications include all abscesses

Scarlet fever:
is secondary to acute streptococcal tonsillitis / pharyngitis with production of toxins by the bacteria.  It is characterised by
1. Erythematous rash
2. Severe lymphadenitis
3. Sore throat
4. Erythematous tonsils
5. Fever
6. Membrane is present over the tonsils and is friable
7. Strawberry tongue