Tonsillitis, complicated (peritonsillar cellulitis, peritonsillar abscess)

J03.9

TONSILLITIS, COMPLICATED (PERITONSILLAR CELLULITIS, PERITONSILLAR ABSCESS)

DESCRIPTION

An infective process involving the tonsils with spread of infection into the adjacent tissue. It must be differentiated from hypertrophy of the tonsils without infection and a viral upper respiratory tract infection (these are associated with rhinorrea, nasal congestion and cough).
Local complications include peritonsillar abscess (quinsy), and parapharyngeal extension.
Systemic complications include glomerulonephritis, rheumatic fever and bacterial endocarditis.

DIAGNOSTIC CRITERIA

Clinical

  • Pyrexia, malaise.
  • Sore throat, dysphagia, drooling, trismus.
  • Enlarged, inflamed tonsils, often with superficial pus visible in crypts.
  • Earache (referred to as otalgia).
  • Tender and enlarged cervical lymph nodes.

Signs of peritonsillar abscess/cellulitis:

  • Usually unilateral.
  • Soft palate and uvula on the infected side are oedematous and displaced medially towards the uninvolved side.
  • Trismus.

Investigations

  • Blood microscopy, culture and sensitivity.

GENERAL AND SUPPORTIVE MEASURES

  • If necessary, maintain the airway.

MEDICINE TREATMENT

Empiric antibiotic therapy

  • Initiate antibiotic treatment immediately even if transfer of the patient is anticipated.
  • Adjust antibiotic therapy based on culture results, if available.

Early complications may be treated with antibiotic therapy alone.

  • Amoxicillin/clavulanic acid, IV, 25 mg/kg/dose of the amoxicillin component 8 hourly.

As soon as there is a response and patient can tolerate oral medication:

  • Amoxicillin/clavulanic acid, oral, 30 mg/kg/dose of the amoxicillin component 8 hourly for 10 days.

Adjust antibiotics once sensitivity results are obtained.

Penicillin allergy

See Chapter 24: Drug Allergies, Allergies to penicillins .

For pain and fever:

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly as required.

REFERRAL

  • Tonsillitis with local complications not responding to adequate treatment.
  • All cases where drainage may be required and is not available locally.

ACUTE BACTERIAL TRACHEITIS

J04.1

DESCRIPTION

An acute infective process characterised by marked subglottic oedema, with ulceration, erythema, pseudomembranous formation on the tracheal surface, and thick, mucopurulent secretion that frequently obstructs the lumen. Commonly due to S. aureus .

DIAGNOSTIC CRITERIA

Clinical

  • Severely ill and toxic with airway obstruction and respiratory distress.
  • Insidious onset, brassy cough, neck pain, dysphagia, no drooling.
  • Associated co-infection, e.g. pneumonia.

Investigations

  • Raised white cell count with left shift.
  • Lateral neck X-ray: hazy tracheal air column.
  • Upper airway endoscopy.
  • Bacterial cultures on blood and pharyngeal secretions.

GENERAL AND SUPPORTIVE MEASURES

  • Intubate and suction secretions if features of severe upper airway obstruction are present.
  • Mechanical ventilation if associated pneumonia present.

MEDICINE TREATMENT

  • Ceftriaxone, IV, 80 mg/kg once daily.

OR

If one month old or younger:

  • Cefotaxime, IV, 50 mg/kg/dose, 6–8 hourly.

Adjust antibiotics according to sensitivity results.

For pain:

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly.

Give 3 doses of corticosteroids to intubated patients prior to extubation:

  • Dexamethasone, IV, 0.15 mg/kg/dose 8 hourly.

REFERRAL

  • All cases requiring intubation.