1. Causes of membrane on the tonsils
Palatine Tonsils
Causes of membrane on the tonsils

2. Causes of membrane on the tonsils
1- Acute follicular tonsillitis.
2- Scarlet fever.
3- Vincent angina.
4- Infectious mononucleosis.
5- Diphtheria.
6- Membranes associated with blood diseases : e.g. agranulocytosis, leukemia.

3. Types of Acute tonsillitis
1- Acute catarrhal.
2- Acute follicular.
3- Acute parenchymatous.

4. Clinical pictures of Acute follicular tonsillitis
General:
1- flushed face.
2- temp.: 39-40°c.
3- pulse rate increases and proportionate.
Local :
Neck:
Enlarged tender jugulodigastric lymph node.

5. Complication of Acute tonsillitis
Local:
1- Peritonsillar abscess.
2- Para pharyngeal abscess.
3- Retropharyngeal abscess.
4- Chronic tonsillitis.
Spread of infection.
Systemic complications:
1- Acute glomerulonephritis.
2- Acute rheumatic fever.

6. Investigations 1- CBC. 2- Culture and sensitivity.
3- Rapid strep test: ELISA.
4- ASOT.
5- CRP.
6- ESR.

7. Treatment 1- Bed rest. 2- Open bowel. 3- Plenty of fluids.
4- Light diet.
5- Antibiotics.
Penicillin or its derivatives and if there’s allergy we use Erythromycin for 10 days.
6- Analgesics and antipyretics.

8. Chronic tonsillitis
Def.: chronic non specific inflammation of palatine tonsils.
Causes of chronicity:
1- Repeated attacks of acute tonsillitis.
2- Insufficient treatment.
3- High virulence of organism.
4- General factors as low resistance.
Size of Tonsils:
1- Hypertrophic.
2- Atrophic.

9. Quinsy

10. Symptoms 1- Recurrent attacks of sore throat.
2- OSAS and change of voice ( if large tonsils).
3- Sense of irritation.
4- Foetor Oris.
5- Septic focus e.g.: Bactremia.
6- Cervical lymphadenitis.

11. Sure sign of chronicity
1- Pressure on tonsil  extrusion of fluids from crypts ( surest sign).
2- Persistent congestion of ant. pillar.
3- Inequality of size and irregularity of tonsillar size.
4- Intratonsillar abscesses.
5- Persistent enlargement of Jugulodigastric LN.

12. Complications 1- Act as septic focus: 2- OSAS if marked hypertrophied.
A- chronic toxemia.
B- Rheumatic affection.
C- Ocular.
D- Circulatory.
E- Urinary.
F- Allergic.
2- OSAS if marked hypertrophied.

13. Treatment
Tonsillectomy

14. Vincent’s Angina Causes Acute specific pharyngitis by:
Fusiform bacilli.
Borrelia Vinenti.
C/P
G: mild or No fever
L: severe sore throat and dysphagia
O/E: ulcer : unilateral, deep, punched out, covered with false gray membrane
Investigation
Throat swab:
Film
C & S.
TTT
1- Penicillin/ Flagyl.
2- H2O2.

15. Scarlet Fever
Causes
Acute specific pharyngitis by ß streptococcus hemolyticus
C/P
Child with:
1- Acute tonsillitis and LN.
2- skin rash.
3- Circum oral pallor.
4- Strawberry tongue.
Investigation
CBC.
Schultz-Charlton test.
Dick’s test.
TTT
As Acute tonsillitis

16. Monilia ( Thrush) Causes Candida albicans PDF: 1- prolonged ABS.
2- Low resistance.
3- Malnutrition.
C/P
G: No fever.
L: severe sore throat and dysphagia.
O/E: multiple raised milky white patches on m.m. of mouth and pharynx.
Investigation
Throat swab film
TTT
1- avoid PDF.
2- local and systemic antifungal.

17. IMN Glandular Fever Causes: Viral infection by EBV.
C/P: 4 clinical types:
1- Febrile: Sudden FAHM not respond to TTT, Ampicillin  rash ( diagnostic).
2- Adenose (Glandular) : cervical LN
3- Aginose ( Ulcerative) : sore throat + multiple, discrete ulcers  shallow and whitish .
4- Icteric : pt. is jaundiced.
Investigations:
1- CBC: monocytosis and atypical lymphocytosis.
2- Monospot test.
3- Paul – Bunnel test.
TTT:
** Self limiting disease.
** Symptomatic ttt ( analgesics and Antipyretics ).

18. Agranulocytosis Cause: B.M. depression  marked reduction of PNL.
either: 1ry ( unknown).
2ry ( drugs or radiotherapy).
C/P:
1- History of drugs: antithyroid and antimitotic OR radiotherapy.
2- Sore throat and dysphagia.
3- Oral ulcers : small and absence of red inflammatory zone around them.
4- Enlarged cervical LN.
Investigations:
1- CBC: marked leucopenia < 2,000/mm ( NO Granulocytes).
2- Sternal puncture and B.M. biopsy.
TTT:
1- Isolation Stop the cause.
3- Repeated Fresh blood transfusion.
4- Massive BS Antibiotics.

19. Acute Leukemia
Malignant disease of B.M.  increase non function WBCs with anemia and thrombocytopenia.
C/P:
1- Epistaxis and bleeding tendencies : hypertrophied bleeding gums.
2- Sore throat and dysphagia.
3- Ulcers similar to that of agranulocytosis.
4- Enlarged LN and spleen.
Investigations:
1- CBC : leucocytosis with blast cells + anemia + thrombocytopenia.
2- Sternal puncture.
TTT:
1- Cytotoxic drugs.
2- Fresh blood transfusions.
3- Antibiotics.
4- B.M. transplantation.

20. Diphtheria
Def: Acute specific inflammation caused by Corynebactrium diphtheriae ccc by formation of a membrane .
Organism: C. diphtheriae ( aerobic G +ve bacillus ) .
Mode of infection: Droplet infection.
Age: 2-5 years old.
IP: 2-5 days.
Sites of affection:
1- Anterior nasal Tonsillar and pharyngeal ( faucial ).
3- Laryngeal Cutaneous.
5- Ocular Genital.
Pathology:
Organism multiply on MM surface and not invade deep tissues.
Powerful Exotoxin – Necrosis of superficial layers of epithelium.
Subepithelial tissues escape necrosis and respond by secreting exudates rich in fibrinogen.
Fibrinogen  fibrin threads so membrane is adherent to underlaying tissues.
Capillaries trapped in the membrane so removal leads to bleeding.
False membrane :
Necrotic mucosa. - Fibrin network - Dead and living organisms. - RBCs and PNL
Exotoxin in circulation : toxemia ( Heart , Kidney, Liver and nervous tissues).

21. Clinical Pictures ( from asymptomatic to rapidly fatal toxic disease )
1- Faucial diphtheria:
Symptoms: General: low grade fever and headache and malaise ± vomiting.
Local : Sore throat and dysphagia + unilateral LN swelling.
Signs : General : Pale and flabby.
Pulse : weak and very rapid and out of proportion to fever.
Urine: albuminuria from 4th to 10th day.
Local : 1- Unilateral marked edema of submandibular areas and anterior neck
( Bull neck).
2- False membrane on tonsils.
2- Laryngeal diphtheria:
** Due to extension from faucial …rarely primary.
Hoarseness of voice and croupy cough (edema).
Stridor , dyspnea , cyanosis later due to obstruction by membrane.
Cyanosis is a late sign as it indicates severe respiratory distress or heart failure.

22. Investigations
Diagnosis is based on clinical presentation since it’s imperative to begin therapy quickly.
Gram stain of direct smear from membrane can be helpful.
Culture on Loeffler’s serum or blood tellurite agar.

23. Complications 1- Respiratory : Laryngeal obstruction. Vagal neuritis.
Lung collapse , lung abscess and bronchopneumonia.
Respiratory failure.
2- Cardiac ( 2nd week ) :
Heart failure due to: - Toxic myocarditis. - Vagal neuritis.
3- Neurological ( 3rd week ):
Paralysis of soft palate.
Paralysis of Ocular muscles 3rd , 4th , 6th .
Vagal paralysis : laryngeal and pharyngeal.
Paralysis of Diaphragm and intercostals muscles.
4- Toxic affection of other parynchamatous organ:
Liver : Hepatic failure.
Kidney : Toxic nephritis.

24. Management I- Patient: 1- Hospitalization and isolation.
2- Absolute bed rest.
3- Throat swab.
4- Once suspected , give immediately Antitoxic serum.
Dose: – IU , I.M or I.V repeated after 24 – 48 hours.
5- penicillin 1/5 – 1 million IU /day to kill the organism .
6- Tracheostomy.
II- Contacts:
IU antidiphtheritic serum ( passive immunization ).
2- Prophylactic antibiotics.
3- active immunization after 3 weeks by booster dose of toxoid.
III- Complications:
1- Heart failure : O2 – diuretics- digitalis – no salts.
2- Respiratory failure : Mechanical ventilation.
3- Liver cell support.
4- Renal failure : dialysis.
5- Palatal and pharyngeal paralysis : nasogastric tube feeding.

25. Prophylaxis
I- Active immunization:
Compulsory in infants.
Given at ages of 2, 4 & 6 months with booster doses at age of 18 months and 5 years.
II- Passive immunization :
5000 – 1000 IU of antitoxic serum.
I.M
To contacts.
Followed after 3 weeks by active immunization.