Tonsillitis

 

Mr. Shantinath, D. Sajane.

Lecturer in Peadiatric Nursing, Shree Gomatesh Education Society, Ankali

*Corresponding Author’s Email: shantinath.sajane@gmail.com

 

ABSTRACT:

Tonsils are the two lymph nodes located on each side of the back of your throat. They function as a defense mechanism, helping to prevent infection from entering the rest of your body. When the tonsils themselves become infected, the condition is called tonsillitis. The most common cause is viral infection and the second most common cause is bacterial infection of which the predominant is Group A β-hemolytic streptococcus (GABHS), which causes strep throat. It shows signs and symptoms of pain, red swollen tonsils sore throat and so on. Swollen tonsils may cause difficulty breathing, which can lead to disturbed sleep. Tonsillitis that is left untreated can result in the infection spreading to the area behind the tonsils or to the surrounding tissue. Symptoms of tonsillitis caused by a bacterial infection usually improve a few days after you begin taking antibiotics.

 

KEYWORDS: Conflict resolution styles, Nursing Professionals.

 

 


INTRODUCTION:

Tonsils are the two lymph nodes located on each side of the back of your throat. They function as a defense mechanism, helping to prevent infection from entering the rest of our body. When the tonsils themselves become infected, the condition is called tonsillitis. Tonsillitis can occur at any age and is a common childhood ailment. It is most often diagnosed in children from preschool age through their mid teens. Symptoms include a sore throat, swollen tonsils, and fever. This condition can be caused by a variety of common viruses and bacteria and is contagious. If left untreated, tonsillitis caused by strep throat (Streptococcus bacteria) can lead to serious complications. Tonsillitis is easily diagnosed and treated. Symptoms usually fully resolve within seven to 10 days.1

 

Definition:

Tonsillitis is inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms may include sore throat and fever. When caused by a bacterium belonging to the group a streptococcus, it is typically referred to as strep throat. The overwhelming majority of people recover completely, with or without medication. In 40%, symptoms will resolve in three days, and within one week in 85% of people, regardless of whether streptococcal infection is present or not.2

 

Causes of Tonsillitis:

The most common cause is viral infection and includes:

·        Adenovirus, rhinovirus, influenza, corona virus, and respiratory syncytial virus.

·        It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV. The second most common cause is bacterial infection of which the predominant is :

·        Group A β-hemolytic streptococcus (GABHS), which causes strep throat.3 

·        Less common bacterial causes include: Staphylococcus aureus (including methicillin resistant Staphylococcus aureus or MRSA),4 Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, Fusobacterium sp., Corynebacterium diphtheriae, Treponema pallidum, and Neisseria gonorrhoeae.3

·        Anaerobic bacteria have been implicated in tonsillitis and a possible role in the acute inflammatory process is supported by several clinical and scientific observations.5 Sometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina.6

 

Pathophysiology:

Under normal circumstances, as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils. Within the tonsils, white blood cells of the immune system destroy the viruses or bacteria by producing inflammatory cytokines like phospholipase A2, which also lead to fever. The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx.7 Illustration comparing normal tonsil anatomy and tonsillitis

 

http://upload.wikimedia.org/wikipedia/commons/thumb/b/b8/Blausen_0860_Tonsils%26Throat_Anatomy.png/220px-Blausen_0860_Tonsils%26Throat_Anatomy.png

 

Common signs and symptoms:

·        Sore throat

·        Red, swollen tonsils

·        Pain when swallowing

·        High temperature (fever)

·        Coughing

·        Headache

·        Tiredness

·        Chills

·        A general sense of feeling unwell (malaise)

·        White pus-filled spots on the tonsils

·        Swollen lymph nodes (glands) in the neck

·        Pain in the ears or neck

·        Weight loss

·        Difficulty ingesting and swallowing meal/liquid intake

·        Not able to sleep well

 

Less common symptoms include:

·        Nausea

·        Fatigue

·        Stomach ache

·        Vomiting

·        Furry tongue

·        Bad breath (halitosis)

·        Voice changes

·        Difficulty opening the mouth (trismus

)

·        Loss of appetite

·        Anxiety/fear of choking 3

 

In cases of acute tonsillitis, the surface of the tonsil may be bright red and with visible white areas or streaks of pus.8

 

Incidence:

Tonsillitis occurs in up to 10% of the population frequently due to episodes of tonsillitis.9

 

Diagnosis:

·        The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing both tonsillar surfaces and the posterior pharyngeal wall and plating them on sheep blood agar medium. The isolation rate might be increased by incubating the cultures under anaerobic conditions and using selective growth media. A single throat culture has a sensitivity of 90%-95% for the detection of GABHS (which means that GABHS is actually present 5%-10% of the time culture suggests that it is absent). This small percentage of false-negative results is part of the characteristics of the tests used but are also possible if the patient has received antibiotics prior to testing.

 

·        Identification requires 24 to 48 hours by culture but rapid screening tests (10–60 minutes), which have a sensitivity of 85-90%, are available. Older antigen tests detect the surface Lancefield group A carbohydrate. Newer tests identify GABHS serotypes using nucleic acid (DNA) probes or polymerase chain reaction. Bacterial culture may need to be performed in cases of a negative rapid streptococcal test.10

 

·        True infection with GABHS, rather than colonization, is defined arbitrarily as the presence of >10 colonies of GABHS per blood agar plate. However, this method is difficult to implement because of the overlap between carriers and infected patients. An increase in antistreptolysin O (ASO) streptococcal antibody titer 3–6 weeks following the acute infection can provide retrospective evidence of GABHS infection 11 and is considered definitive proof of GABHS infection.

·        Increased values of secreted phospholipase A2  and altered fatty acid metabolism12 in patients with tonsillitis may have diagnostic utility.

 

Treatment:

Treatments to reduce the discomfort from tonsillitis include:3

·        Pain relief, anti-inflammatory, fever reducing medications (paracetamol/acetaminophen and/or ibuprofen).

·        Sore throat relief (warm salt water gargle, lozenges, dissolved aspirin gargle (aspirin is an anti inflammatory, do not take any other anti inflammatory drugs with this method), and warm/hot liquids).

·        If the tonsillitis is caused by group A streptococcus, then antibiotics are useful with penicillin or amoxicillin being primary choices.13

·        Cephalosporin’s and macrolides are considered good alternatives to penicillin in the acute state.14

·        A macrolide such as erythromycin is used for people allergic to penicillin. Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria15 such as clindamycin or amoxicillin-clavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins.16

·        When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however, symptoms may last for up to two weeks.

·        Chronic cases may be treated with tonsillectomy (surgical removal of tonsils) as a choice for treatment.17  

 

Prognosis:

Since the advent of penicillin in the Complications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and pharyngitis due to the spread of infection.3 an abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis. This is termed a peritonsillar abscess (or quinsy). Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading septicemia infection (Lemierre's syndrome). In chronic/recurrent cases (generally defined as seven episodes of tonsillitis in the preceding year, five episodes in each of the preceding two years or three episodes in each of the preceding three years),19 or in acute cases where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy can be performed to remove the tonsils. Patients whose tonsils have been removed are still protected from infection by the rest of their immune system. 1940s, a major preoccupation in the treatment of streptococcal tonsillitis has been the prevention of rheumatic fever, and its major effects on the nervous system (Sydenham's chorea) and heart. Recent evidence would suggest that the rheumatogenic strains of group A beta hemolytic strep have become markedly less prevalent and are now only present in small pockets such as in Salt Lake City.18  This brings into question the rationale for treating tonsillitis as a means of preventing rheumatic fever.

 

Complications:

In strep throat, very rarely diseases like rheumatic fever or glomerulonephritis can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations. Tonsillitis associated with strep throat, if untreated, is hypothesized to lead to pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).20

 

Preventing Tonsillitis:

Tonsillitis is highly contagious. To decrease the odds of getting tonsillitis, stay away from people who have active infections. Hands should be washed often, especially after coming into contact with someone who has a sore throat, is coughing, or is sneezing. If the individual has the tonsillitis, he or she must stay away from others until they are no longer contagious.1

 

Nursing care:

The client should be advised to do the following:1

·        Drink plenty of fluids.

·        Get lots of rest.

·        Gargle with warm salt water several times a day.

·        Use throat lozenges. (Throat lozenges can be a choking hazard for very young children).

·        Use a humidifier to moisten the air in home.

·        Avoid smoke.

·        Use over-the-counter pain medications, such as acetaminophen and ibuprofen. (Aspirin can be dangerous for children. Always check with doctor before giving aspirin to children).

 

Nursing Assessment for Acute Tonsillitis:21

Medical history factors associated with the occurrence of tonsillitis as well as supporting the bio-psycho-socio-spiritual. Circulatory: Palpitations, headache at the time of a change in position, drop in blood pressure, bradycardia, and body felt cold, pale extremities appearance. Elimination: Changes in the pattern of elimination (incontinence uri/Alvi), abdominal distension, bowel sounds disappearance.

 

Activity / rest:

There is a decrease in activity due to body weakness, loss of sensation or pareses / plegia, tiredness, difficulty in recuperating from muscle spasms and pain or spasm. The reduced level of consciousness, decreased muscle strength, general body weakness.

 

Nutrition and fluids:

Anorexia, nausea, vomiting due to increased ICP (intracranial pressure), impaired swallowing, and loss of sensation on the tongue.

 

Nerves system: Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the face and extremities. Mental status coma, kelmahan in the extremities, facial muscles paradise, aphasia, dilated pupils, decreased hearing.

 

Comfort: Tense facial expressions, headache, restlessness.

 

Breathing: Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

 

Security: Fluctuations of temperature in the room.

Psychology: Denial, disbelief, anguish, fear, anxiety.

 

Nursing Diagnosis and Interventions for Acute Tonsillitis:

1. Ineffective breathing pattern related to tissue damage or trauma to the respiratory center. Goal: The patient demonstrated the ability to perform adequately the respiratory blood gas results show stable and good as well as the loss of signs of respiratory distress.

 

Interventions:

1.      Clear the airway patent (keep the head position in a state parallel to the spine / as Indicated).

2.      Perform suction if necessary.

3.      Assess the function of the respiratory system.

4.      Assess the patient's ability to perform cough/ discharging effort.

5.      Observation of vital signs before and after the action.

6.      Observation for signs of respiratory distress (skin becomes pale / cyanosis).

7.      Collaboration with therapists in the provision of physiotherapy.

 

2. Impaired physical mobility related to neuromuscular weakness in the extremities.

Goal: Patients showed an increased ability to perform physical activity.

 

Interventions:

1.      Assess the patient's ability to perform the activity.

2.      Teach the patient about the range of motion that can still be done.

3.      Perform active and passive exercises at extremities to prevent stiffness and muscle atrophy.

4.      Instruct the patient to take a straight position.

5.      Assist patients in performing ROM gradually according to ability.

6.      Collaboration in the provision antispasmodic or relaxant if necessary.

7.      Observation of the patient's ability to perform the activity.

 

3. Ineffective Cerebral Tissue Perfusion related to the brain, bleeding in the brain.

Goal: The patient showed an increase in awareness, cognitive and sensory function. Interventions:

1.      Assess neurologic status and note the changes.

2.      Give the patient supine position.

3.      Collaboration in the provision of oxygenation.

4.      Observation level of consciousness, vital signs.

 

4. Acute pain related to physical trauma.

Goal: The patient expresses pain is reduced and shows a relaxed and calm state.

Interventions:

1.      Assess the level or degree of pain felt by the patient using a scale.

2.      Help the patient in finding factor in precipitation of pain felt.

3.      Create a quiet environment.

4.      Teach and demonstration to patients about several ways to do relaxation techniques.

5.      Collaboration in the provision of appropriate indications.

 

5. Impaired verbal communication related to the effects of damage to the area to talk to the cerebral hemispheres:

 

Goal: The patient was able to communicate to meet their basic needs and showed improvement in their communication capabilities.

 

Interventions:

1.      Do a personal communication with the patient (often but short and easy to understand).

2.      Create an atmosphere of acceptance of the changes experienced by the patient.

3.      Instruct patients to improve communication techniques.

4.      Use non-verbal communication techniques.

5.      Collaboration in the implementation of speech therapy.

6.      Observation of the patient's ability to communicate both verbally and non-verbally.

 

6. Self-concept Disturbance related to a change of perception.

 

Goal: The patient showed improvement in the ability to accept the circumstances.

 

Interventions:

1.      Assess the patient's degree of self-concept change.

2.      Mentor and listen to patient complaints.

3.      Give support to actions that are positive.

4.      Assess the patient's ability to rest (sleep).

5.      Observation of the patient's ability to receive state.

 

CONCLUSION:

Swollen tonsils may cause difficulty breathing, which can lead to disturbed sleep. Tonsillitis that is left untreated can result in the infection spreading to the area behind the tonsils or to the surrounding tissue. If tonsillitis is caused by a strep throat infection that is not treated or does not go away, it could lead to rheumatic fever (inflammation of the heart, joints, and other tissues), or to post-streptococcal glomerulonephritis (inflammation of the kidneys). Symptoms of tonsillitis caused by a bacterial infection usually improve a few days after the initiation of antibiotic therapy. Strep throat is considered contagious until the individual is with antibiotics for a 24-hour period. Tonsillitis generally resolves completely within seven to 10 days.

 

REFERENCES:

1.       http://www.healthline.com/health/tonsillitis#Overview1

2.       Mar CB, Glasziou PP, Spinks AB (October 2006). Del Mar, Chris B, ed. "Antibiotics for sore throat". Cochrane Database Syst Rev. 18;(4) (4):

3.       Wetmore RF. (2007). "Tonsils and adenoids". In Bonita F. Stanton; Kliegman, Robert; Nelson, Waldo E.; Behrman, Richard E.; Jenson, Hal B. Nelson textbook of pediatrics. Philadelphia: Saunders. ISBN 1-4160-2450-6.

4.       Brook, I.; Foote, P. A. (2006). "Isolation of methicillin resistant Staphylococcus aureusfrom the surface and core of tonsils in children". Int J Pediatr Otorhinolaryngol 70 (12): 2099–2102. 

5.       Brook, I. (2005). "The role of anaerobic bacteria in tonsillitis". Int J Pediatr Otorhinolaryngol 69 (1): 9–19

6.       Cauwenberge P (1976). "[Significance of the fusospirillum complex (Plaut-Vincent angina)]". Acta Otorhinolaryngol Belg (in Dutch; Flemish) 30 (3): 334–45.

7.       MedlinePlus Encyclopedia Tonsillitis

8.       Tonsillitis and Adenoid Infection Medicine Net. Retrieved on 2010-01-25.

9.       S. G. Nour; Mafee, Mahmood F.; Valvassori, Galdino E.; Galdino E. Valbasson; Minerva Becker (2005). Imaging of the head and neck. Stuttgart: Thieme. p. 716. 

10.     Leung AK, Newman R, Kumar A, Davies HD (2006). "Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis". Expert Rev Mol Diagn 6 (5): 761–6. 

11.     Brook I (2007). "Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis". Int J Pediatr Otorhinolaryngol 71 (10): 1501–8.

12.     Ezzedini R, Darabi M, Ghasemi B, Darabi M, Fayezi S, Moghaddam YJ et al. (2013)."Tissue fatty acid composition in obstructive sleep apnea and recurrent tonsillitis". Int J Pediatr Otorhinolaryngol 77 (6): 1008–12.

13.     Touw-Otten FW, Johansen KS (1992). "Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries". Fam Pract 9 (3): 255–62.

14.     Casey JR, Pichichero ME (2004). "Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children". Pediatrics 113 (4): 866–882. 

15.     Brook I (2009). "The role of beta-lactamase-producing-bacteria in mixed infections".BMC Infect Dis 9: 202. 

16.     Brook I (2007). "Microbiology and principles of antimicrobial therapy for head and neck infections". Infect Dis Clin North Am 21 (2): 355–91.

17.     Paradise JL, Bluestone CD, Bachman RZ et al. (1984). "Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials". N. Engl. J. Med. 310 (11): 674–83.

18.     Shulman ST, Stollerman G, Beall B, Dale JB, Tanz RR (Feb 15, 2006). "Temporal changes in streptococcal M protein types and the near-disappearance of acute rheumatic fever in the United States". Clin Infect Dis 42 (4): 441–7. 

19.     Scottish Intercollegiate Guidelines Network. (January 1999). "6.3 Referral Criteria for Tonsillectomy". Management of Sore Throat and Indications for Tonsillectomy.Scottish Intercollegiate Guidelines Network. 

20.     Pickering, Larry K., ed. (2006). "Group A streptococcal infections". Red Book: 2006 Report of the Committee on Infectious Diseases (Red Book Report of the Committee on Infectious Diseases). Amer Academy of Pediatrics. 

21.     http://nursing-care-plan.blogspot.com/2014/02/acute-tonsillitis-6-nursing-diagnosis.html

 

 

Received on 06.07.2015           Modified on 27.07.2015

Accepted on 05.08.2015           © A&V Publication all right reserved

Int. J. Adv. Nur. Management 3(4): Oct. - Dec. 2015; Page 372-376

DOI: 10.5958/2454-2652.2015.00037.2