METHODICAL INSTRUCTIONS

TOPIC: ACUTE PHARYNGITIS. ANGINA. PARATONSILLAR ABSCESS.

  RETROPHARYNGEAL ABSCESS. LATEROPHARYNGEAL ABSCESS.
  DIPHTHERIA OF PHARYNX.  FOREIGN BODIES OF PHARYNX AND
GULLET. CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS. HYPERTROPHY
NASOPHARYNGEAL, LINGUAL AND PALATAL TONSILS. FARIHGOLEPTOTRIHOSIS.
CANDIDAMIKOSIS. AKTINOMIKOSIS.
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Subtopics:

1. Acute pharyngitis: etiology, clinic, treatment.

2. Quinsies: determination, classification (after clinical signs, localization, exciters).
3. Catarrhal, lacunar, follicular quinsies: clinic, diagnostics, treatment.
4. Differential diagnosis of catarrhal quinsy and acute pharyngitis, and follicle quinsy
lacunar.
5. Ulceromembranose quinsy (Simanovskiy-Plaut-Vensan).
6. Quinsies at the acute infectious diseases.
7. Agranulocytic quinsy: etiology, symptoms, diagnostics, treatment.
8. Monocytic quinsy: etiology, symptoms, diagnostics, treatment.
9. Paratonsillar abscess: etiology, diagnostics, treatment.
10. Retropharyngeal abscess: etiology, clinic, diagnostics, treatment, complication.
11. Lateropharyngeal abscess: clinic, diagnostics, treatment, complications.
12. Diphtheria of pharynx: forms, diagnostics, treatment, prophylaxis.
13. Differential diagnosis of quinsy lacunar and diphtheria.
14. Tactic of doctor at suspicion on diphtheria of pharynx.
15. Extraneous bodies of pharynx: origin, localization, diagnostics, methods of their delete.
16. Extraneous bodies of gullet: origin, localization, diagnostics, methods of delete.
17. Sequence of development of pathological process in place of finding of foreign body in a
gullet.
18. Testimony to the delete of extraneous bodies of gullet by the line of hypopharyngoscopy,
esophagoscopy, esophagotomy.
 
Theme: ACUTE AND CHRONIC PHARYNGITISИ. ANGINA. PARATONSILLAR
ABSCESS.  RETROPHARYNGEAL ABSCESS. LATEROPHARYNGEAL ABSCESS.
  DIPHTHERIA OF PHARYNX.  FOREIGN BODIES OF PHARYNX AND GULLET.

I. Actuality of theme:
Doctors must be able to appoint necessary treatment and shut out development of
possible complications at pharyngitis, tonsillitis and quinsies. At children under age 3th a
retropharyngeal abscess, which in the case of ill-timed diagnostics and treatment can result in
acute stenosis of larynx, asphyxia, aspirating pneumonia, mediastinitis, sepsis, is heavy
pathology, a prognosis at which is very serious.
Diphtheria is the problem of general medical is that social. In the conditions of the
nowaday tense epidemic state from diphtheria a substantial role belongs to the timely exposure
of patients, setting of adequate treatment, conducting of antiepidemic measures in the hearth of
infection.
Therefore knowledge of clinic, diagnostics and principles of treatment of these diseases
are necessary in work of the ENT doctors and doctors of a different type.

Tests and tasks for verification of initial level of knowledges

І. Find right answer complete and for a question.
1. What must be done for establishment of diagnosis «acute pharyngitis»?
а) to collect anamnesis and execute epi-meso-hypopharyngoscopy
б) to appoint antibiotics
в) to appoint anaesthetic facilities
г) to explore the nasal breathing
д) to explore a vocal function
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2. What department of pharynx more frequent all is attracted in an inflammatory process at
acute pharyngitis?
а) oropharynx
б) nasopharynx
в) laryngopharynx
3. What way do children have the infection of before spinal lymphatic knots by?
а) by the lymphatic ways of back departments of cavity of nose and nasopharynx
б) at the infectious diseases (measles, flu, scarlatina)
в) diseases of blood

4. What diseases does it follow to conduct differential diagnostics of retropharyngeal abscess

with?
а) acute pharyngitis
б) paratonsillar abscess
в) hypertrophy of palatal tonsils
г) adenoids to vegetation
5. What heavy (mortal) complications can be caused by the not in good time exposed and not
cut retropharyngeal abscess?
а) festering meningitis
б) empyema of lights
в) festering mediastinitis, sepsis
6. Basic way of transmission of infection at quinsies?
а) air-drop
б) domestic
в) alimentary
7. What tonsils from a lymphoid ring most often light up at quinsies?
а) tubal
б) nasopharyngeal
в) palatal
г) tongue tonsil
8. About what is it possible to think, if at a catarrhal quinsy the state of patient became worse
acutely, did the temperature of body, chill rise, in a blood neutrophilic leukocytosis?
а) tonsillar sepsis
б) acute respirator disease
в) development of follicle quinsy
г) origin of paratonzilitis
д) forming of paratonzilar abscess
9. What character of raids at diphtheria?
а) the raids are thin, superficial
б) the raids are dense, dirty gray color, is heavily taken off, a surface is abandoned, that bleeds
в) yellow
г) it is easily taken off
10. Is there what character of pain at a paratonzilar abscess?
а) moderate, poured out
б) gives in teeth
в) pain one-sided, increases at swallowing of saliva, gives in an ear
11. What appears at the review of patients with paratonzilar abscesses on 4—5 time of
disease?
а) impossibility widely to open company (lockjaw masticatory muscles)
б) a patient opens a mouth widely
в) hyperemia of soft palate, handles, back wall of pharynx
г) increase and edema of palatal tonsils
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II. Find all right answers for a question.
1. What principal reasons of origin of pharyngitis?
а) supercooling
б) viral infection
в) smoking
г) professional to harmfulness
д) tumours
е) nose-bleeds
2. Where is an inflammatory process at acute pharyngitis?
а) in palatal tonsils
б) in nasopharynx
в) oropharynx
г) laryngopharynx
3. What will you appoint to the patient with acute pharyngitis?
а) antibiotics
б) sulfonamides
в) liquid food, that does not annoy pharynx
г) alkaline rinses
д) Faringosept, Falimint
е) warming compress on a neck
4. How to treat lateral pharyngitis?
а) cauterization
б) by trichloracetic acid
в) cryo
г) dissection by the scissors of hypertrophy adenoids fabric
д) rinse by solutions of antiseptics
5. What treatment do patients with a retropharyngeal abscess require?
а) warming compress on a neck
б) resolvent therapy
в) fortifying treatment
г) dissection of abscess
6. What is observed in oropharynx at a retropharyngeal abscess?
а) hyperemia of mucus shell of back wall of oropharynx
б) rounded, asymmetric thrusting out of back wall of oropharynx
в) hypertrophy of palatal tonsils
7. Why by a patient with acute primary is tonsilities appointed by hyposensitizing facilities in
complex treatment?
а) quinsies arise up on a background allergization of organism
б) it is the disease able exactly to cause allergization
в) for diminishment of main pain
8. What forms of diphtheria of pharynx are selected?
а) noncommunicative (easy)
б) widespread (toxic)
в) with the raids
г) without the raids
9. What complications arise up at patients which carried diphtheria, in 2—3 weeks and later?
а) edema leafed
б) bleeding
в) violation of breathing
г) paralysis of soft palate
д) myocarditis
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10. What distinguish paratonsillar abscesses depending on localization?
а) front
б) lateral
в) overhead
г) back
д) middle
11. What are possible complication of paratonsillar abscess?
а) chronic tonsillitis
б) mediastinitis
в) sepsis
г) phlegmon of neck
д) edema leafed

III Find an error in answers for a question.

1. Are there what basic changes of .спостерігаються on the mucus shell of back wall of
pharynx at acute pharyngitis?
а) dry crusts
б) hyperemia
в) it was swollen
г) slid
2. Tactic of doctor at the cold натічних abscesses of pharynx?
а) dynamic supervision
б) sciagraphy of neck department of spine
в) periodic puncture of abscess
г) specific treatment
3. What quinsy?
а) acute infectiously-allergic disease of organism with an inflammatory process in palatal tonsils
б) acute inflammation of pharynx
4. What microorganisms more frequent cause a quinsy?
а) staphylococcus
б) streptococcus
в) pneumococcus
5. Name the sources of infection at quinsies?
а) eczema
б) sick man
в) self-infection
6. How enough for the disease by a quinsy only infected agent?
а) no, the decline of reactivity of organism is needed yet
б) enough
7. What departments of palatal tonsils is struck at quinsies?
а) surface of tonsils and lacunas
б) parenchyma
в) capsule of tonsils
8. What basic symptoms of quinsy?
а) insomnia
б) pains in a throat
в) head pain
г) broken
д) pain in joints
е) promoted temperature
9. What appears in the blood of patients by a quinsy?
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а) neutrophilic leukocytosis
б) thrombocytopenia
в) ESR a speed-up
10. What classification of acute tonsilities is offered by an academician Soldatov?
а) primary, second (at the acute infectious diseases and diseases of the system of blood)
б) easy, middle weight, heavy
11. What are abolitions of motion of quinsy lacunar in from catarrhal one?
а) in the degree of intoxication of organism
б) in the presence of raids on tonsils
в) in the increase of palatal tonsils
12. What is included in the chart of treatment of acute primary tonsilities?
а) hormonal preparations
б) antibiotics
в) antiseptics
г) salicylates
д) hyposensitizing facilities
13. Are there bacillicarriers of diphtheria?
а) no
б) it is
14. Name the most characteristic symptoms at diphtheria:
а) glassy edema of soft palate, tongue
б) increase of регіонарних lymph nodes
в) distribution of raids outside palatal tonsils
г) брудно-сірий color of raids which are heavily taken off
15. Can diphtheria of pharynx flow without the raids?
а) can
б) no
16. What is based on the diagnosis «diphtheria»?
а) increase of regional lymph nodes
б) by the presence of widespread raids
в) results of research of strokes from pharynx
17. What will you do to the child in the grave condition, to which the set diagnosis quinsy
lacunar and is not diphtheria of pharynx eliminated?
а) you will enter a antidiphtheritic whey, will take strokes from pharynx on the bacillus Lefler
б) you will enter antibiotics anaesthetic, rinses of mouth
18. Why do patients more frequent have anterior and superior paratonsilar abscesses?
а) here many Lymphatic vessels
б) here anymore lacunas
в) they are deeper and winding
г) here many cellulose, that is easily infected

V. Table of contents of studies

ACUTE PHARYNGITIS
Acute pharyngitis
Pharyngitis means inflammation of the pharynx. Since tonsils form part of the pharynx,
inflammation of the tonsils (tonsillitis) should, strictly speaking, be included hi the term
"Pharyngitis". But by convention, tonsillitis is described separately from inflammation of the rest
of the pharynx. In this chapter, this conception of the disease will be retained and "Pharyngitis"
will be described as inflammation of the pharyngeal wall.
Pharyngeal inflammation may be non-specific or specific. The former occurs generally
on account of infection with pyococci i.e., Haemolytic & non haemolytic streptococcus,
pneumococcus H. Influenzae, whereas in the case of the latter, specific organisms attack the
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pharynx. Examples of these are infection of the throat with diphtheria bacillus, Vincent's
organisms, tubercle bacillus, Spirochaeta pallida etc., Many times viruses are aetiological
organisms especially in children. In this chapter, only non-specific pharyngitis will be described,
whereas the common forms of specific pharyngitis will be considered in the next chapter.
Non specific pharyngitis
This may be acute or chronic.
Acute Pharyngitis
Aetiology: The pharynx may get acutely inflamed on account of attack by the
streptococcus, the staphylococcus or the pnenmococcus. However there are certain predisposing
factors which make a person liable to be attacked by these more than other people. Such
predisposing factors may be one or more of the following:
1. Diet. Indiscretion in the choice of ingestibles. Generally when some sour object is
taken, it may be followed by an attack of acute sore throat. Sour objects contain lot of acidic
substances e.g., citric acid and acetic acid which dissolve the mucus covering the mucous
membrane of the throat and expose it to attack by the organisms. Too much spices and
condiments in the food and indiscreet drinking and smoking are important predisposing factors.
Thermal trauma, for example too hot or too cold eatables may initiate an attack of phayrngitis.
Irritating cold drinks are becoming the fashion of the day; they may add some cases to this list.
2. Pharyngitis is commonly secondary to infection above or below the pharynx. Examples
of infection above are rhinitis, sinusitis stomatitis, etc., and examples of infection below are
bronchitis and lung infections.
3. Profession. Sedentary occupations with lack of exercise and professions demanding too
much voice production, for example teachers, singers and musicians, predispose to the disease.
4. Constitutional disorders like debility, malnutrition, gout, diabetes and rheumatism are
incriminating factors in the production of the disease.
5. Climate. Cold wet climate exposes the body to chills and lowers body resistance
whereby an attack of pharyngitis may be precipitated.
6. Infectious fevers. Measles, whooping cough, mumps, typhoid etc., lead to congestion
in the throat and attack of pharyngitis.
7. Trauma. Impaction of foreign bodies in the pharynx and their removal, and also other
operations on the throat produce tissue damage and may lead to pharyngitis.
Clinical features.
The disease may be mild or severe. In a mild case, there are no constitutional symptoms
but only local symptoms, e.g., a slight sense of irritation in the throat and a feeling of being
unwell. There may be slight cough and a feeling of something sticking in the throat.
In a severe case, there is rise of body temperature to 101 F or more and the pulse is quick.
The patient looks toxic and obviously unwell. He may-have anorexia and insomnia. There is
severe pain in the throat and there may be dysphagia due to pain during swallowing, the neck
glands may be enlarged. On account of swollen state of the palate, there may be too much nasal
twang in the voice and rarely regurgitation of fluids through the nose.
If the Eustachian tube shares in the inflammation, there may be conductive deafness.
The neck movements are generally painful.
Voice may be hoarse.
On examination the mucosa of the throat is deeply congested and perhaps swollen. There
is excess of mucus in the throat which is very sensitive and attempted examination may provoke
gagging reflex. The tonsils may partly share in the inflammatory process. The uvula is usually
swollen and the palate looks oedematous and hanging down. Its movements may be restricted.
Diagnosis.
This is simple and straight-forward but occasionally difficulty may arise in differentiating
this disease from pharyngeal diphtheria. For differentiating points, refer to the section on
diphtheria. If in doubt 10,000 units of antidiphtheritic serum should be given without waiting for
the result of the throat swab.
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Treatment.
This is general and local. General treatment consists in confining the patient to bed and
advising him fluid or semi-solid, easily digestible diet. If the patient is constipated, he should be
given a light laxative, for example calomel. For relief of pain, the patient should be given
analgesics, e.g., aspirin, and if the patient is insomniac, he should be given a soporific. Four
hourly dose of soda salicylas mixture is vejy beneficial. If the patient is markedly toxic and/or
there is rise of temperature, he should be given antibiotics after culture and senstivity test of
throat swab if necessary.
For local treatment, the patient should be advised warm saline or soda bicarb gargles
three to four times a day. Local application to the throat should be comforting and soothing, for
example tannic acid glycerin or iron glycerin, but those which contain an irritant should be
avoided, for example Mandl's paint. The patient may have lozenges to suck, for example
tyrozets, penicillin lozenges, etc.
On recovery fromacute attack, the cause should be traced and treated to prevent further
attacks. The patient should also be advised to build up his body resistance by proper schedule of
life and light exercise.
TONSILITIS
It may be acute or chronic.
Acute tonsillitis
In this condition, the severity of the attack may be limited to the surface of the tonsil, or it
may involve principally the crypts or it may invade the substance of the tonsils.
These three types of disease are described as catarrhal, follicular (lacunar) or
parenchymatous. In reality, the difference is only one of the severity of the attack and not of the
nature of the disease. In this book, it is proposed to do away with this confusing classification
and describe the condition as a mild or a severe form.
Aetiology.
Generally acute tonsillitis is a disease of ages from childhood to thirty. Both Sexes are
about equally affected. The aetiology resembles closely that of acute pharyngitis.
The disease is commoner in people living in dark, damp, and overcrowded houses.
Infection in the nose and throat, allergy and faulty diet predispose to the condition. When
tonsillectomy has been performed badly and tonsil remnants are left behind, such remnants tend
to hypertrophy to make up for lost tissue and undergo repeated attacks of acute inflammation.
The infecting organisms is generally streptococcus haemolyticus. The disease is
infectious and incubation period is three to seven days.
Pathology.
It is an acute inflammatory process with marked congestion and leucocytic infiltration of
the tonsils. As already described, in mild cases the surface of the tonsil is involved whereas in
severe cases the inflammation spreads deeply and involves the substance of the tonsil.
In follicular or lacunar form, the mouths of the crypts show collection of pussy material
and on examination they look like whitish or yellowish spots which may remain discrete or run
into each other, giving rise to the may by no general symptoms.
Children generally suffer more from general upset than local symptoms, whereas adults
complain more of local symptoms than general.
The attack is ushered in by a feeling of chill which in severe cases may amount to actual
rigor. This is soon followed by rise of temperature which may go up to 103° or 104°F. The pulse
is quick, the patient looks toxic and he may be anxious and anorexic.
Local symptoms
Local symptoms take on the form of irritation in the throat in mild cases and a frequent
desire to swallow one's own saliva.
In severe cases, there is actual pain in the throat which may radiate to the ears. The neck
and neck movements may be painful. Young children often do not complain of throat symptoms
 9
and an attack of acute tonsillitis in them may be missed if the physician does not make it a
routine to inspect the throats of all children suffering from general constitutional symptoms.
On examination the patient shows rise of temperature and pulse rate. The throat is
congested, the tonsils are hypertrophic and they vary in colour from deep pink to red depending
upon the severity of the condition.
The patient may have difficulty in opening the mouth and on pressing the tongue with a
tongue depressor, he may protest on account of pain.
There may be exudation of pus on the surface of the tonsils which may take the form of
distinct collections over the mouths of the crypts or these may spread and run into each other
forming a pseudo-membrane over the tonsils. Such membrane is bilateral, limited to the tonsils
and can be rubbed off easily with cotton wool on a cotton applicator, leaving behind smooth
surface with no bleeding points. The tonsillar lymph nodes are enlarged and tender.
Diagnosis.
This is generally easy. Difficulty may arise, particularly in children, to differentiate the
condition fr n pharyngeal diphtheria for which the reader is referred to the section on diphtheria.
Less commonly, Vincent's angina and agranulocytic sore throat may have to be
considered in differential diagnosis.
Complications:
1. Peri-tonsillar abscess (Quinsy).
2. Acute retropharyngeal abscess.
3. Acute rheumatism (particularly of the endocardium and the joint.).
4. Acute otitis media.
5. Septicaemia.
6. Acute laryngitis.
7. Acute nephritis.
Prognosis.
The disease is self-limiting, lasting about a week or ten days healing occurs even if no
treatment is taken, but with treatment the disease resolves much sooner.
Treatment.
This is general and local. The patient should be confined to bed. He should be given light,
easily digestible diet. If he is constipated, his bowels should be opened with a light laxative.
For relief of pain, he should be given analgesics e.g., aspirin or one of its derivatives.
Soda salicylas piixfure given three times a day is a time honoured remedy.
In severe cases, antibiotics should be instituted after culture and sensitivity test if
necessary. A collar of antiphlogistin applied to the neck is very comforting.
The throat may be painted with a soothing application, e.g., iron glycerin or tannic acid
glycerin. (Mandl's point contains iodine, is irritant and is contra-indicated in acute condition.)
The patient may be given warm saline gargles three times a day and some lozenges to suck, e.g.,
Iversal, Tyrozets, Penicillin, dybenal or Hexyl-resorcinol.

ADENOIDITIS
This means inflammation of the nasopharyngeal tonsil. It may be acute or chronic.
Aetiology.
The exciting cause is infection with gram positive cocci, but the following factors
predispose to the invasion of the nasopharyngeal tonsil with bacteria.
1. Other defects in the nose, for example sinusitis, deflected nasal septum, foreign body,
allergy etc.
2. Dietetic deficiency, as deficiency of proteins and vitamins. Excess of starch is also said
to predispose to upper respiratory tract infection.
3. Age. The nasopharyngeal tonsil is present at birth and shows physiological involution
just before puberty. Therefore it is a. disease of childhood. If the nasopharyngeal tonsil gets
 10
infected before disappearance, it usually lingers on for a much longer period, for example up to
the age of eighteen or even after that.
4. Cold and damp climate and congested housing also predispose to the development of
adenoiditis.
Symptoms and signs.
The importance of the adenoids lies in their situation. They are present at the junction of
the ears, the nose and the throat and therefore their inflammation may produce symptoms
referable to all the three regions.
1. The most common symptom is nasal obstruction. This is quite easy to understand.
Nasal obstruction leads to mouth breathing, producing dryness of the mouth and leading to poor
orodental hygiene.
On account of disuse of the nose, nature does not feel the necessity of enlarging it.
Therefore the palate does not descend. The dental arch of the upper jaw does not open out giving
rise to crowded teeth. The appearance of such a child is very characteristic. A child with open
mouth, looking rather dull with a triangular face, a short nose, a broad upper lip and prominent
upper teeth is said to have adenoid facies. It is pathognomonic of adenoiditis.
2. Nasal blockage leads to difficulty in feeding. The child has frequently to leave the
breast dr the bottle to take a breath. His nutrition therefore suffers and he loses weight.
3. Nature has made the nose for breathing and when it is blocked the mouth has to
perform the same function, but it cannot do so as efficiently as the nose. Mouth breathing cannot
adequately wash out carbon dioxide from the blood resulting in high carbon dioxide tension
which keeps the higher nerve centres irritated particularly during sleep. The child suffers from
nightmares and may pass urine in the bed (nocturnal cnuresis).
4. When the nose is obstructed from behind, nasal mucus cannot flow backwards into the
nasopharynx. It stays behind in the nose it gets infected giving rise to nasal discharge, rhinitis
and later sinusitis. (The reverse is also true i.e., if a child develops rhinitis or sinusitis, purulent
discharge always flowing over the nasopharyngeal tonsil leads to its infection, thus giving rise to
adenoiditis).
5. In some cases nasal infection leading to vasodilatation causes epistaxis from the Little's
area. The commonest cause of epistaxis in children is adenoiditis.
6. When the adenoids block the Eustachian tube, they set up Eustachian catarrh, or active
suppurative otits media. They also give rise to conductive deafness.
7. Nasal blockage gives rise to toneless speech (rhinolalia clausa).
8. A child with adenoiditis has, generally speaking, mental dullness, poor physique and
unattractive look. His face is deformed as described above. Excessive respiratory efforts to draw
the breath in may give rise to deformity of the chest. (Harrison's Sulcus).
On examination the patient is a weak, ill-looking child rather dull with triangular face and
other signs of adenoid fades given above. On anterior rhinoscopy, he usually has plenty of nasal
discharge with fissuring at the anterior nares. The tonsils may or may not be enlarged, but if they
are, adenoiditis is almost certainly present.
If the child is cooperative, posterior rhinoscopy will show adenoids hanging from the
superoposterior wall of the nasopharynx in the form of columns of lymphoid tissue looking very
much like stalactites. Digital palpation of the nasopharynx without anaesthesia is very
unpleasant. Its technique has been described elsewhere.
If carried out, the adenoids feel soft and smooth with a fancied resemblance to a bag of
worms. The tympanic membranes may look dull and retracted or perforated. Conductive
deafness may be present. True lateral X-ray will show soft tissue mass hi the nasopharynx.
Treatment.
This may be conservative or surgical
The conservative treatment is applied chiefly in the acute stage and consists of bed rest,
diaphoretics, vasoconstrictor nasal drops etc,, and if the child has got lot of toxidty, he may be
given antibiotics. Acute adenoiditis is seldom recognised as a separate clinical entity.
 11
Indications for Adenoidectomy.
1. Nasal obstruction and discharge in a child when it is due to adenoids hypetrophy.
2. Otitis Media. In recurrent attacks of acute otitis media or persistant chronic
Suppurative otitis media, due to adenoids.
3. Chronic Sinusitis or its complications secondary to adenoids.
4. Secretory otitis media due to adenoids.
5. Feeding problems due to adenoids.
6. Epistaxis due to adenoids.
7. Eustachian catarrh due to adenoids.
Contra-Indicatipns:
1. Blood dyscrasias like luekaemia, purpuras, aplastic anaemia and heamophilia.
2. Qeft palate to avoid Rhinolalia aperta.
3. Recent attack of adenoiditis and upper respiratory infection.
4. Uncontrolled systemic diseases e.g., diabetes, heart diseases.
5. In jaundiced patients.
In chronic cases, removal of adenoids becomes a necessity. It is preferable, though not
essential, to admit the child to the hospital day before the operation. The bleeding and
coagulation time may be tested. On the day of operation the child comes to the theatre on empty
stomach. Half an hour before the operation, he is given premedication with atropine.
The essential instrument is the adenoid curette. This is of two types, with or without a
guard. The guard consists of spikes which entangle the curetted off adenoids so that they may not
fall behind in the throat.
The child is put deeply under general anaesthesia, using oral endotracheal tube with cuff.
The operator stands on the patient's head side, facing him with a head-light on. A Doyne's mouth
gag applied in the left angle opens the mouth. The operator depresses the child's tongue with a
tongue-depressor held in the left hand and holds the adenoid curette in the right hand.
Most of the surgeons prefer to sit on a stool on the head-side of the patient and remove
the adenoids with the patient lying on his back and with the help of a Boyle-Davis gag. The
active end of the curette is make to enter the mouth, passes behind the uvula and then forwards
and upwards into the nasopharynx so as to come in contact with the posterior border of the
septum. Then the curette is pressed on the adenoids mass and is worked downwards the
oropharynx bringing with it the curetted off mass of adenoid tissue. Two more such manoeuvres
with curette-one on the right and one on the left-will bring out any lateral masses of the adenoids
near the openings of the Eustachian tubes.
It is preferable to feel the adenoids before and after removal to break any adhesions
between them and the surrounding chiefly the Eustachian openings or the soft palate and to see
that the adenoids have been completely removed respectively.
In cases of tubal catarrh and deafness, the adenoid tissue should be meticulously cleared
away from the openings of the Eustachian tubes, and in cases of marked nasal obstruction, from
the posterior nares. The bleeding is usually free for a minute or so and then gradually stop. Little
pressure over a post nasal, roll gauze for 4-6 minutes is usually sufficient t;o control bleeding.
It is more useful to perform adenoidect$my at the time of tonsillectomy in children,
because they are commonly diseased together. In such cases, the adenoidectomy is performed
after the tonsils and the intubation tube have been removed, after administering deep anaesthesia
or shifting to oral intubation which is more safe. Whatever method is used, it is important not to
leave behind any tags of adenoid tissue as they keep up heamorrhage. It is a fact that inefficiently
removed adenoids give rise to far more trouble than inefficiently removed tonsils.
During adenoidectomy, injury to the soft palate, the body of the atlas and the Eustachian
openings must be guarded against. Also the curette used should be sharp so that it will curette
out the adenoids cleanly and will not leave behind any tags of adenoid tissue. It is also important
to pick out any pieces of curetted off adenoids from the pharynx, otherwise there is danger of
 12
their being sucked into the respiratory passage during the postoperative period, which may cause
asphyxia and death.
After removal of the adenoids, the child is sent back to the ward. There is no special
postoperative care except that he should be given some antibiotics for three or four days and
should not be given any hot food for a similar period. After discharge from the hospital, many
children continue to breath through the mouth on account of habit. They should be given
exercises with the mouth closed so that they develop nose breathing.
Occasionally bleeding is serious after operation which does not stop with ordinary
measures, tor example ice to suck, coagulants, raising the head of bed and sedatives etc. In such
cases, a postnasal pack may have to be tied under anaesthesia for a day or so. Very rarely, there
may be a recrudescence of otitis media following adenoidectomy.
Adenoidectomy should not be performed during the acute stage or if the child is suffering
from bleeding tendency.
Sometimes, after adenoidectomy, there is compensatory overgrowth of lymphoid tissue
round the Eustachian tube opening, and the patient gets poor relief of symptoms. There may be
conductive deafness in such cases. The area of the tube may be irradiated with benefit.
Complications:
1. Haemorrhage: This may be during or after the operation. Heamorrhage after the
operation may be reactionary within a few hours or it may be secondary within a few days.
2. Injury to the surrounding structures:
(a) Soft palate and uvula.
(b) Eustachian tubes.
(c) Body of atlas vertebra.
3. Acute otitis media: It may occur for the first time after adenoidectomy or it may be
recrudescence of a previously existing, disease.
4. Nasal twang in voice: This sometimes happens after the operation if the palate does not
completely shut off the naso-pharynx during speech. Examination of palate before operation to
see if it is not too short, and palatal exercises in cases who develop nasal twang after the
operation will reduce the number of patients with this complaint.
5. Chrronic naso-pharyngitis: Ciliated mucous membrane having been removed from the
naso-pharynx, the sheet of mucus arriving from the nose does not get cleared off. It stays in the
naso-pharynx and produces irritation and hawking.
6. Recurrence of adenoids if incompletely removed.
Contraindications
l. Cleft palate or submucous palate. Removal of adenoids causes velopharyngeal
insufficiency in such cases.
2. Haemorrhagic diathesis.
3. Acute infection of upper respiratory tract.
Anaesthesia
Always general, with oral endotracheal intubation.
Position
Same as for tonsillectomy. Hyperextension of neck should always be
avoided.Adenoidectomy may be indicated alone or combined with tonsillectomy. In the latter
event, adenoids are removed first and the nasopharynx packed before starting tonsillectomy.
Indications
1. Adenoid hypertrophy causing sleep apnoea syndrome.
2. Recurrent rhinosinusitis.
3. Chronic secretory otitis media associated with adenoid hyperplasia.
4. Recurrent ear discharge in benign CSOM associated with adenoiditis/adenoid
hyperplasia.
5. Dental malocclusion. Adenoidectomy does not correct dental abnormalities but will
prevent its recurrence after orthodontic treatment.
 13
Contraindications
Steps of operation
1. Boyle-Davis mouth-gag is inserted. Before actual removal of adenoids, nasopharynx
should always be examined by retracting the soft palate with curved end of the tongue depressor
and by digital palpation to confirm the diagnosis, assess the size of adenoids mass and to push
the lateral adenoid masses towards the midline.
2. Proper size of "adenoid curette with guard" is introduced into the nasopharynx till its
free edge touches the posterior border of nasal septum and is then pressed backwards to engage
the adenoids. At mis level, head should be slightly flexed to avoid injury to odontoid process.
3. With gentle sweeping movement, adenoids are shaved off (Fig. 89.1). Lateral masses
are similarly removed with smaller curettes; small tags of lymphoid tissue left behind are
removed with punch forceps.
4. Haemostasis is achieved by packing the area for sometime. Persistent bleeders are
electrocoagulated under vision. If bleeding is still not controlled, a postnasal pack is left for 24
hours.
Post-operative care
Same as in tonsillectomy. There is no dysphagia and patient is up and about early.
Complications
1. Haemorrhage, usually seen in immediate postoperative period. Nose and mouth may
be full of blood or the only indication may be vomitus of dark coloured blood which the patient
had been swallowing gradually in post-operative period. Rising pulse rate is another indicator.
Treatment is same as for pre-operative haemorrhage. Postnasal pack under GA is often required.
2. Injury to eustachian tube opening.
3. Injury to pharyngeal musculature and .vertebrae. .This is due to hyperextension of
neck and undue pressure of curette.
4. Velopharyngeal insufficiency.
5. Nasopharyngeal stenosis due to scarring.
6. Recurrence. This is due to regrowth of adenoid tissue left behind.

PERITONSILIAR ABSCESS
Synonym: Quinsy
It is a suppurative process in die loose areolar tissue around tne tonsil The condition
occurs generally at the upper pole because (1) the loose areolar tissue is maximum here and it
allows plenty of space for collection of pus and (2) the inflammatory process spreads from the
intratonsillar cleft (crypta magna) to the tissues surrounding the tonsil and these are situated at
the upper pole.
The disease is found generally in adults and is always unilateral. It is nearly always-
secondary to an attack of acute tonsillitis which often times is not well marked, or follows an
attack of acute inflammation in a remnant of the tonsil at the upper pole following incomplete
tonsillectomy. The causative organism is often a resistant strain of staphylococcus aureus, which
has not responded well to treatment for acute tonsillitis.
Symptoms.
The disease is markedly toxic and the patient suffers from severe rise of temperature and
pain which may even radiate to the ear. There is marked trismus and the patient may not swallow
his own saliva which dribbles from the angle of the mouth. The patient with quinsy can often be
diagnosed at sight; he has got his head bent to the affected side because of pain in the neck; he
places his hand over the ear on account of referred pain and saliva dribbles from the angle of his
mouth. The speech is thick and unintelligible. The tongue movements are also painful.
Examination.
On attempting to examine the throat, the patient feels it impossible to comply with the
wish of the examiner to open the mouth adequately for a satisfactory view. The examiner has to
be contented with a minimal view of the. pharynx; the tongue cannot be put out and pressing it
 14
down with a tongue depressor through the half open mouth is always very much resented.
Whatever view can be obtained shows a unilateral swelling of the soft palate. The swelling is red
and angry looking. The tonsil is also markedly congested and pushed medially. The uvula is
likewise swollen and pushed across the middle line to the healthy side. The mouth and throat are
full of saliva. The neck glands are very painful, tender and swollen.
Diagnosis.
This is general straight-forward. Rarely it may have to be differentiated from sarcoma of
the tonsil but in this disease generally there are no constitutional symptoms and the patient is a
child.
Treatment.
General. This follows the lines of acute tonsillitis described above.
In early days of the disease before actual pus formation and when there is only pre-
suppurative inflammatory condition of the peritonsillar tissues (a condition called Peritonsillitis),
exhibition of intensive chemotherapy and antibiotics will abort the condition.
If pus formation has already occurred, the abscess must be incised and drained. (Before
incision, aspirate with a thick bore needle to prove the presence of pus.)
The patient sits in front of the operator. The throat is sprayed with cocaine solution. Then
the operator catches hold of a phayngeal bistoury whose blade has been wrapped with sticking
plaster leaving only the terminal half a centimeter naked.
He throws light on to the abscess and with the bistoury gives an incision just in the
mucous membrane over the abscess. The point of incision is at the crossing of a line drawn
horizontally through the base of the uvula and another line drawn vertically through the medial
edge of the anterior faucial pillar.
The incision is given along the horizontal in the medial direction from this point. It is
about one fourth or one third of an inch.
The wrapping up of the blade of the bistoury, the incision just of the mucosa, the
selection of the point of incision as described above and the direction of the incision medially
from this point are all measures to avoid (1) injury to the soft palate which may get pierced
through and through giving rise to perforation if the incision is deepened and (2) the danger of
cutting some big vessel if the incision is directed laterally from the point. Alternatively, the
incision may be given where the abscess is pointing, or at a point midway between the last upper
molar and the base of uvula.
Having given the incision in the mucosa, a sinus forceps is taken and thrust through the
incision into the abscess cavity. Its blades are separated when the pus gushes out in a stream. The
patient is instructed to spit out. He is then given warm condy gargles. The operation gives very
sharp but transitory pain and the relief is soon appreciated'by the patient.
The incision has a tendency to close and needs dilatation every day for three or four days.
The other treatment as that for peritonsillitis has also to be given.
The tonsils should be removed three months after the attack.

RETROPHARYNGEAL ABSCESS
As the name indicates, this is an abscess behind the pharynx This may result from
suppuration of the retropharyngeal group of lymphatic glands or a tuberculous process affecting
them, or by carries of the cervical spine. The retropharyngeal lymphatic glands are situated
between the pharyngeal wall and prevertebral muscles covered over by fascia. These glands are
at the level of the second and third cervical vertebrae, i.e., in the region of the oropharynx. They
are paired groups and inflammation from one side cannot extend to the other because of the
median fibrous raphe which receives the insertions of the pharyngeal constrictors and anchors
them on to the mid-prevertebral region.
As would be apparent from the above description, suppuration or cassation of the
retropharyngeal glands would be to one side of the middle line, whereas tuberculous process hi
 15
the cervical spine has no such limiting factor and may be to one side of the middle line or spread
across it to the opposite side.
Suppuration of the lymphatic glands is an acute process whereas tuberculous affection is
chronic. The abscess may therefore be (1) acute or (2) chronic. The latter may be due to
tuberculous process in the retropharyngeal lymphatic glands or in the cervical spine. The
retropharyngeal glands are situated quite low in infants. Therefore, retropharyngeal abscess in
infants occurs low in the throat. In adults, these glands are high and therefore the abscess is
situated higher. This explains greater frequency of dysphagia and dyspnoea in infants.

ACUTE ABSCESS
More than 50% cases occur below the age of one year. The focus is generally the infected
tonsils, the nose, the Eustachian tubes, the middle ear or the nasopharynx, but not infrequently
the original focus cannot be traced.
Symptoms.
It is an acute inflammatory process situated behind the pharynx which serves as food and
air passage. Therefore one would expect symptoms of acute inflammation, and also interference
with deglutition and respiration. The little patient cannot speak. He looks obviously ill, he is
febrile and toxic, the neck movements are painful and he may have torticollis. There is
dysphagia, the child may not swallow anything or may eject it immediately after swallowing.
There may also be dyspnoea which may be mild or severe.
Sings.
On opening the mouth, the swelling in the posterior pharyngeal wall can be easily seen.
On palpation, fluctuation is quire evident.
Treatment.
This is incision of the abscess through the mouth. Generally no anaesthesia is employed.
The child is wrapped in a bed sheet and is laid on the table on the side, the surgeon opens the
mouth with his left index finger and throwing the light in the throat incises the abscess by means
of a pharyngeal bistoury. Taking a sinus forceps next he plungs it into the abscess through the
incision in the mucous membrane and its jaws are opend. A gush of pus fills the throat and
mouth of the baby, who is now held by the feet upside down and the pus is allowed to flow out.
Penicillin injections are also given as well as other supportive treatment. The incision has
a tendency to close and it should be kept patent by daily insertion of the sinus forceps for three or
four days, during which time the abscess heals.

CHRONIC ABSCESS
This is a disease generally of adolescents and adults. It has got an insidious onset and
present indefinite symptoms of obstruction to deglutition, respiration and speech. It is discovered
on examination of the throat. It may be called a "cold" abscess.
Treatment.
It is said that this abscess should be opend from outside behind the posterior border of the
sternomastiod but the writers have the experience of opening it inside the mouth in the same way
as in the acute abscess and putting the patient on antitubercular treatment and penicillin in
addition. They have not come across the complication for which an external route is advised, i.e.,
secondary infection or fistula formation.

LUDWIG’S ANGINA
This is an inflammatory process of the floor of the mouth. The original focus is generally
a dental abscess in connection with a bicuspid or a tricuspid. The tissue planes in the floor of the
mouth get infected, resulting in a firm brawny swelling in the submandibular region. On opening
the mouth, the floor is swollen pushing the tongue upwards. This leads to difficulty in
swallowing and speech, the patient is markedly toxic and febrile. The oedema may spread to the
larynx causing dyspnoea.
 16
Treatment.
Intensive antibiotic therapy together with attention directed towards the appropriate tooth
often lead to resolution. An incision from the chin to the hyoid bone opening up the skin and the
subjacent tissues may rarely be required. If dysponea is marked, tracheotomy will be necessary.
Hot fomentation and analgesics are very soothing.

VINCENT’S ANGINA
(trench mouth)
It is an ulcerative disease of the mouth and throat, chiefly found in war conditions or in
states of malnutrition and under-nourishment. It is caused by two organisms living symbiosis-
Spirochaeta vincenti and a Fusiform bacillus.
Clinical features.
The incubation period is about a week and the onset is insidious. The symptoms are
general and local. Among the former, the temperature is only slightly raised. There may be slight
headache, malaise and loss of appetite. The patient docs not show much toxicity. The neck
glands are enlarged and tender.
Locally, there may be a slight complaint of sore-throat. The usual duration of illness is
about a week but some cases show repeated attacks.
On examination, the mouth and throat show ulcerative lesions. The ulcers are small and
multiple, but sometimes there may be a single large ulcer on only one tonsil. The multiple ulcers
are small and shallow, surrounded by hyperaemia and covered with greyish pseudo-membrane
with a characteristic odour. They may be found on the gums, cheeks, tonsils, posterior
pharyngeal wall and even the larynx. The single ulcer on one tonsil is generally deep on account
of destruction tissue, has ragged margins and is covered with sloughy material. It may be
mistaken for syphilitic or malignant ulcer.
Diagonosis.
The condition is diagnosed only if it is remembered and the only certain way is
bacteriological examination. But it is to be noted that occasionally these organisms arc found in
healthy throats and at other times they may be found in ulcers due to other causes. The
organisms are difficult to show in smears because they are very delicate. The differential
diagnosis has to be made from other ulcerative conditions of the mouth and throat, which are as
follows:
1. Diphtheria.
2. Syphilis.
3. Agranulocytosis.
4. Leukaemia.
5. Glandular fever.
6. Tuberculosis.
7. Lupus.
8. Carcinoma.
9. Non-specific.
10. Occasionally psychological upsets cause ulcers in the mouth and throat.
The principal distinguishing features are the clinical course of the disease, specific
laboratory tests, and biopsy as and when indicated.
Prognosis.
Death is very rare, but some cases may show recurrence.
Treatment.
 17
The patient should be confined to bed and segregated. He should be fed on light but
nourishing diet, and given tonics, e.g., Vit. B complex, Vit. C etc.' and any anaemia or
malnutrition should be corrected.
Parenteral penicillin should be administered until after complete resolution, or
intravenous arsenic may be given instead. For local use, several remedies have been
recommended:
1. 20% chromic acid solution for swabbing the ulcers followed immediately by 10%
hydrogen peroxide once daily.
2. Neoarsphenamine powder for local dusting of ulcers once or twice a day.
3. Hydrogen peroxide for cleaning the ulcers followed by the application of liquor
arsenicalis and vinum ipecac, in equal parts.
The teeth and gums should receive appropriate attention from a dental surgeon and the
patient should have his tonsils removed on recovery to avoid recurrence.
Complications.
1. Chronic tonsillitis with recurrent acute attacks. This is due to incomplete resolution of
acute infection. Chronic infection may persist in lymphoid follicles of the tonsil in the form of
microabscesses.
2. Peritonsillar abscess.
3. Parapharyngeal abscess.
4. Cervical abscess due to suppuration of jugulodigastric lymph nodes.
5. Acute otitis media. Recurrent attacks of acute otitis media may coincide with recurrent
tonsillitis.
6. Rheumatic fever. Often seen in association with tonsillitis due to Group A beta-
haemolytic streptococci.
7. Acute glomerulonephritis. Rare these days.
8. Subacute bacterial endocarditis. Acute tonsillitis in a patient with valvular heart
disease may be complicated by endocarditis. It is usually due to streptococcus viridans infection.

DIPHTHERIA OF THROAT
It is a highly toxic acute infectious disease, mostly of childhood, characterised by
symptoms generally in ear, nose and throat and caused by the diphtheria bacillus
(Corynebacterium diphtheriae; Klebs-Lofflers bacillus.)
Aetiology.
The causative agent is the diphtheria .bacillus. The usual election of the bacillus is the
throat of the patient. The disease is found in all climates and at all ages, but the highest incidence
is between the ages of two and five years. The disease may take on an epidemic form but
sporadic cases are occurring all the year round.
It is a disease generally found in poor people who are often under-nourished and have
already fallen a prey to some other infectious fever, particularly that affecting the upper
respiratory tract. The disease spreads from patient to patient by direct or indirect contact. Thus it
may spread by coughing, spitting or kissing or through the agencies of utensils, towels,
thermometers, tongue depressors, etc.
Some people harbour the bacillus in their throat on recovery from an attack which might
have been clinical or subclinical. such people are called carriers. They are a great source of
spread of the disease. The incubation period of the disease is three to four days.
Pathology.
The bacillus secretes a powerful exotoxin which has got local and distant deleterious
effects. Locally, at the site of invasion, it produces coagulation-necrosis of surface epithelium.
This process varies in depth from place to place in the affected area so that whereas in certain
places it may be quite superficial, in others it may go down deep below the surface in the form of
pegs. These pegs have the effect of anchoring the necrosed tissue to the healthy tissue below.
 18
The necrosed tissue at the surface becomes dull, greyish white, has got a specific odour
and looks like a membrane. This membrane is adherent to the subjacent tissues, which can be
pulled off with difficulty and when pulled off, leaves behind raw bleeding surface.
Distantly, the exotoxin has special affinity for three tissues:
1. The heart muscle.
2. The kidneys.
3. The peripheral nerves.
The heart muscle undergoes myocarditis, becomes flabby and cannot maintain blood
pressure. The tubules of the kidney show necrotic changes and cannot act a barrier against the
leakages of albumin through them.
The peripheral nerves are also affected by the toxin producing paralyses of affected
regions. The greatest incidence of paralyses is found in the eye muscles and the muscles of the
palate. There is loss of accommodation and palatal paralysis.
Diphtheria also affects to an appreciable extent the respiratory system. Other systems are
much less involved. Secondary pyococcal invasion is the rule and many complications which are
infective are in reality due to pyococci e.g., broncho-pneumonia.
Clinical features.
The disease has an insidious onset. The patient is generally a child below the age of ten,
mostly between two and five years. When first seen, the patient is generally very toxic. There is
a characteristic pallor on his face. He may have respiratory difficulty and is somewhat febrile.
The temperature is rather low, ranging between 99 to 101°F. The patient emits a characteristic
odour. There may be nausea and vomiting.
On examination of the throat, there is generally membrane formation. It is on one side
only and is present on the tonsil and extends beyond e.g., on to the pillars, palate or uvula. It is
dull greyish in appearance and is not easily detachable.
Since diphtheria toxin attacks the heart muscle, which becomes weak and flabby, the
blood pressure falls, and the pulse becomes quick, weak and irregular.
In some cases, the membrane extends downwards into the larynx, trachea and'bronchi.
Such cases have respiratory distress and croupy cough. When more severe, the patient is
markedly dyspnoetic, the dyspnoea being inspiratory. There is recession of the suprasternal and
the epigastric notches and the intercostal spaces. The child may even be cyanosed.
The neck glands are enlarged and tender, more so on the side of the lesion in the pharynx.
In some cases there may be paralyses of various parts of the body.
The commonest sites of paralyses are the eye muscles and the soft palate, but they may be
found elsewhere. Such paralyses occur generally after three weeks of the start of the ailment.
They almost always recover.
Diagnosis.
In a straight-forward case, this is easy on account of the patient's age, the markedly toxic
nature of the illness, the typical findings in the throat and a positive throat swab for the
diphtheria bacillus. However, difficulty often arises in distinguishing the case from acute
tonsillitis, foreign body in the bronchus and acute laryngotracheo-bronchitis.
In the case of acute tonsillitis in cnildren, the patient is alert and anxious. His face is
flushed and the temperature is high, usually 103°F or more. On attempted examination, the
patient offers resistance. The tonsils appear enlarged and acutely inflamed on account of recent
infection.
There may be no membrane formation on the tonsils; or follicles of pus may be seen on
the mouths of the crypts discrete from each other; or these follicles may run into each other to
give the appearance of membrane on the tonsils. Such membrane is found on both sides but more
or less in equal degree; it is easily detached from the surface of the tonsil by rubbing with cotton
wool on a cotton wool carrier and it leaves behind no bleeding surface. It is limited to the
tonsillitis, there is not the same degree of irregularity of the pulse or fall of blood pressure or of
the amount of albumin in the urine. The throat swab is negative for diphtheria bacillus.
 19
In foreign body bronchus, the symptoms may be paroxysmal, the most marked being
cough trying to expel the foreign body. On clinical examination, the affected part of the chest is
hyper-resonant and there are diminished breath sounds over it. The X-ray may show foreign
body, itelectasis or emphysema of the affected part of the lung.
In laryngo-tracheo-bronchitis, the throat is more or less clear and is negative for
diphtheria bacillus on swab test.
Prognosis.
It is a serious disease and before the introduction of the specific antiserum, the mortality
was round about 60%, but now-a-day the mortality is much lower provided the antiserum is
given in sufficient dose at the proper time. The prognosis is influenced by the following factors:
1. Tlie time at which the diagnosis is made and the antiserum given. If the antiserum is
given before the third day the prognosis is much better but if it is given after the fifth day the
outlook is much worse.
2. Patient's age: Very small children have got much worse prognosis. As age advances,
the prognosis becomes better and better.
3. The extent of the lesion and the virulence of the infection. These are self-explanatory.
Treatment.
There is hardly any local treatment. The specific drag is antidiphtheria serum. When the
patient is seen, either the diagnosis is clear on clinical grounds or it is not clear. If it is not dear,
10,000-100,000 units of antidiphtheria serum are injected intramuscularly immediately after
testing the sensitivity of the patient to the antitoxin depending on the toncity of the patient. A
throat swab is then sent for bacteriological examination and further course is regulated by the
result of the test.
If the diagnosis is dear, a sufficiently good dose of the antitoxin is given.
The dose of the antitoxin is regulated by the toxicity of the patient and by the extent of
the lesion rather than by the patient.
In a mild case 20,000 units of antitoxin are given intramuscularly at once and 10,000
units are given on the following day.
In a moderately severe case, about 50,000 units of the antitoxin are given intramuscularly
at once and about 20,000 units are given after 24 hours.
In a severe case, 100,000 to 200,000 units are given intravenously immediately and the
drug is repeated intramuscularly on the following one or two days in somewhat smaller doses.
The antidiphtheria serum is specific treatment of the disease.
There is no replacement for it.
To be effective it must be given in suitably large doses and preferably before the third
day of the disease.
Arrangement should be kept ready for treating sensitivity if the patient is found to be
sensitive, tested with a minute intradermal injection of the anti-serum. In such cases, the anti-
serum should be given in small doses and anti-allergies, stimulants, oxygen etc., administered to
the patient if necessary.
The diphtheria bacillus is also sensitive to penicillin, and there is another reason for using
penicillin in addition to the serum, viz., that diphtheria is often complicated by secondary
infection with cocci. Penicillin should also be given in sufficient doses repeated at frequent
intervals.
Also in severe cases, corticosteroids prove of great use. 5 mg, of prednisolone given daily
by injection for two to three days will be beneficial.
In dyspnoeic patients, from larvngeal obstruction, tracheotomy should be performed. If
the membrane is spreading down to the trachea and bronchi, it should be removed.
In case of paralysis, Vitamin 'B' Complex is often prescribed but its real value is rather
doubtful. The patient should be segregated. Since diphtheria toxin has a specific affinity for the
heart muscle, complete rest of the patient in a recumbent posture for two to: four weeks is
absolutely essential. The patient's strength should also be maintained by judicious feeding. After
 20
recovery from the disease, the tonsils and adenoids should be removed to treat the carrier state of
the patient.

VІ. Oriented basis of action

Acute pharyngitis
Pharyngitis means inflammation of the pharynx. Since tonsils form part of the pharynx,
inflammation of the tonsils (tonsillitis) should, strictly speaking, be included hi the term
"Pharyngitis". But by convention, tonsillitis is described separately from inflammation of the rest
of the pharynx. In this chapter, this conception of the disease will be retained and "Pharyngitis"
will be described as inflammation of the pharyngeal wall.
Pharyngeal inflammation may be non-specific or specific. The former occurs generally on
account of infection with pyococci i.e., Haemolytic & non haemolytic streptococcus,
pneumococcus H. Influenzae, whereas in the case of the latter, specific organisms attack the
pharynx. Examples of these are infection of the throat with diphtheria bacillus, Vincent's
organisms, tubercle bacillus, Spirochaeta pallida etc., Many times viruses are aetiological
organisms especially in children. In this chapter, only non-specific pharyngitis will be described,
whereas the common forms of specific pharyngitis will be considered in the next chapter.
Acute tonsillitis
In this condition, the severity of the attack may be limited to the surface of the tonsil, or it
may involve principally the crypts or it may invade the substance of the tonsils.
These three types of disease are described as catarrhal, follicular (lacunar) or
parenchymatous. In reality, the difference is only one of the severity of the attack and not of the
nature of the disease. In this book, it is proposed to do away with this confusing classification
and describe the condition as a mild or a severe form.
Adenoiditis
This means inflammation of the nasopharyngeal tonsil.
Symptoms and signs.
The importance of the adenoids lies in their situation. They are present at the junction of
the ears, the nose and the throat and therefore their inflammation may produce symptoms
referable to all the three regions.
1. The most common symptom is nasal obstruction. This is quite easy to understand. Nasal
obstruction leads to mouth breathing, producing dryness of the mouth and leading to poor
orodental hygiene.
On account of disuse of the nose, nature does not feel the necessity of enlarging it.
Therefore the palate does not descend. The dental arch of the upper jaw does not open out giving
rise to crowded teeth. The appearance of such a child is very characteristic. A child with open
mouth, looking rather dull with a triangular face, a short nose, a broad upper lip and prominent
upper teeth is said to have adenoid facies. It is pathognomonic of adenoiditis.
2. Nasal blockage leads to difficulty in feeding. The child has frequently to leave the breast
dr the bottle to take a breath. His nutrition therefore suffers and he loses weight.
3. Nature has made the nose for breathing and when it is blocked the mouth has to perform
the same function, but it cannot do so as efficiently as the nose. Mouth breathing cannot
adequately wash out carbon dioxide from the blood resulting in high carbon dioxide tension
which keeps the higher nerve centres irritated particularly during sleep. The child suffers from
nightmares and may pass urine in the bed (nocturnal cnuresis).
4. When the nose is obstructed from behind, nasal mucus cannot flow backwards into the
nasopharynx. It stays behind in the nose it gets infected giving rise to nasal discharge, rhinitis
and later sinusitis. (The reverse is also true i.e., if a child develops rhinitis or sinusitis, purulent
discharge always flowing over the nasopharyngeal tonsil leads to its infection, thus giving rise to
adenoiditis).
5. In some cases nasal infection leading to vasodilatation causes epistaxis from the Little's
area. The commonest cause of epistaxis in children is adenoiditis.
 21
6. When the adenoids block the Eustachian tube, they set up Eustachian catarrh, or active
suppurative otits media. They also give rise to conductive deafness.
7. Nasal blockage gives rise to toneless speech (rhinolalia clausa).
8. A child with adenoiditis has, generally speaking, mental dullness, poor physique and
unattractive look. His face is deformed as described above. Excessive respiratory efforts to draw
the breath in may give rise to deformity of the chest. (Harrison's Sulcus).
Peritonsiliar abscess
Synonym: Quinsy
It is a suppurative process in die loose areolar tissue around tne tonsil The condition occurs
generally at the upper pole because (1) the loose areolar tissue is maximum here and it allows
plenty of space for collection of pus and (2) the inflammatory process spreads from the
intratonsillar cleft (crypta magna) to the tissues surrounding the tonsil and these are situated at
the upper pole.
The disease is found generally in adults and is always unilateral. It is nearly always-
secondary to an attack of acute tonsillitis which often times is not well marked, or follows an
attack of acute inflammation in a remnant of the tonsil at the upper pole following incomplete
tonsillectomy. The causative organism is often a resistant strain of staphylococcus aureus, which
has not responded well to treatment for acute tonsillitis.
Retropharyngeal abscess
As the name indicates, this is an abscess behind the pharynx This may result from
suppuration of the retropharyngeal group of lymphatic glands or a tuberculous process affecting
them, or by carries of the cervical spine. The retropharyngeal lymphatic glands are situated
between the pharyngeal wall and prevertebral muscles covered over by fascia. These glands are
at the level of the second and third cervical vertebrae, i.e., in the region of the oropharynx. They
are paired groups and inflammation from one side cannot extend to the other because of the
median fibrous raphe which receives the insertions of the pharyngeal constrictors and anchors
them on to the mid-prevertebral region.
Suppuration of the lymphatic glands is an acute process whereas tuberculous affection is
chronic. The abscess may therefore be (1) acute or (2) chronic.
Acute abscess
More than 50% cases occur below the age of one year. The focus is generally the infected
tonsils, the nose, the Eustachian tubes, the middle ear or the nasopharynx, but not infrequently
the original focus cannot be traced.
Symptoms.
It is an acute inflammatory process situated behind the pharynx which serves as food and
air passage. Therefore one would expect symptoms of acute inflammation, and also interference
with deglutition and respiration. The little patient cannot speak. He looks obviously ill, he is
febrile and toxic, the neck movements are painful and he may have torticollis. There is
dysphagia, the child may not swallow anything or may eject it immediately after swallowing.
There may also be dyspnoea which may be mild or severe.
Sings.
On opening the mouth, the swelling in the posterior pharyngeal wall can be easily seen.
On palpation, fluctuation is quire evident.
Treatment.
This is incision of the abscess through the mouth. Generally no anaesthesia is employed.
The child is wrapped in a bed sheet and is laid on the table on the side, the surgeon opens the
mouth with his left index finger and throwing the light in the throat incises the abscess by means
of a pharyngeal bistoury. Taking a sinus forceps next he plungs it into the abscess through the
incision in the mucous membrane and its jaws are opend. A gush of pus fills the throat and
mouth of the baby, who is now held by the feet upside down and the pus is allowed to flow out.
 22
Penicillin injections are also given as well as other supportive treatment. The incision has
a tendency to close and it should be kept patent by daily insertion of the sinus forceps for three or
four days, during which time the abscess heals.
Chronic abscess
This is a disease generally of adolescents and adults. It has got an insidious onset and
present indefinite symptoms of obstruction to deglutition, respiration and speech. It is discovered
on examination of the throat. It may be called a "cold" abscess.
Treatment.
It is said that this abscess should be opend from outside behind the posterior border of the
sternomastiod but the writers have the experience of opening it inside the mouth in the same way
as in the acute abscess and putting the patient on antitubercular treatment and penicillin in
addition. They have not come across the complication for which an external route is advised, i.e.,
secondary infection or fistula formation.
Ludwigs angina
This is an inflammatory process of the floor of the mouth. The original focus is generally a
dental abscess in connection with a bicuspid or a tricuspid. The tissue planes in the floor of the
mouth get infected, resulting in a firm brawny swelling in the submandibular region. On opening
the mouth, the floor is swollen pushing the tongue upwards. This leads to difficulty in
swallowing and speech, the patient is markedly toxic and febrile. The oedema may spread to the
larynx causing dyspnoea.
Diphteria of throat
It is a highly toxic acute infectious disease, mostly of childhood, characterised by
symptoms generally in ear, nose and throat and caused by the diphtheria bacillus
(Corynebacterium diphtheriae; Klebs-Lofflers bacillus.)
Aetiology. The causative agent is the diphtheria .bacillus. The usual election of the bacillus
is the throat of the patient. The disease is found in all climates and at all ages, but the highest
incidence is between the ages of two and five years. The disease may take on an epidemic form
but sporadic cases are occurring all the year round.
Pathology. The bacillus secretes a powerful exotoxin which has got local and distant
deleterious effects. Locally, at the site of invasion, it produces coagulation-necrosis of surface
epithelium. This process varies in depth from place to place in the affected area so that whereas
in certain places it may be quite superficial, in others it may go down deep below the surface in
the form of pegs. These pegs have the effect of anchoring the necrosed tissue to the healthy
tissue below.
Diagnosis. In a straight-forward case, this is easy on account of the patient's age, the
markedly toxic nature of the illness, the typical findings in the throat and a positive throat swab
for the diphtheria bacillus. However, difficulty often arises in distinguishing the case from acute
tonsillitis, foreign body in the bronchus and acute laryngotracheo-bronchitis.
Treatment. There is hardly any local treatment. The specific drag is antidiphtheria serum.
When the patient is seen, either the diagnosis is clear on clinical grounds or it is not clear. If it is
not dear, 10,000-100,000 units of antidiphtheria serum are injected intramuscularly immediately
after testing the sensitivity of the patient to the antitoxin depending on the toncity of the patient.
A throat swab is then sent for bacteriological examination and further course is regulated by the
result of the test.
If the diagnosis is dear, a sufficiently good dose of the antitoxin is given.
The dose of the antitoxin is regulated by the toxicity of the patient and by the extent of the lesion
rather than by the patient.
In a mild case 20,000 units of antitoxin are given intramuscularly at once and 10,000
units are given on the following day.
In a moderately severe case, about 50,000 units of the antitoxin are given intramuscularly
at once and about 20,000 units are given after 24 hours.
 23
In a severe case, 100,000 to 200,000 units are given intravenously immediately and the drug is
repeated intramuscularly on the following one or two days in somewhat smaller doses.
The antidiphtheria serum is specific treatment of the disease.
There is no replacement for it.
To be effective it must be given in suitably large doses and preferably before the third
day of the disease.

Situation tasks for verification of eventual level of knowledges.

Task N1.
Quinsy is the disease is known from ІV - V age to our era; prevalence of her is large,
especially in countries with the low level of socio-economic development. The disease has
polietiological character.
1. Give determination, that exposes maintenance of concept of quinsy as disease.
2. Role of seasonality in development of epidemics of quinsies which factors more
frequent all do influence on it?
3. Name the groups of exciters of quinsies, most frequent and reliable from them?

Task N2.
At the patient Ch. feeling of being tearing to pieces, dryness, extraneous body in a throat,
indisposition appeared on a day next after the common supercooling. After it he marked pain in a
throat (which irradiate in a left ear) and joints of lower extremities. The common state of health
is satisfactory.
Objectively: size of palatal tonsils achieves the first degree; the moderately expressed
hyperemia of their mucus shell spreads on front and back handles. Lymphatic knots near the
cutting edge of m. sternocheіdomastoіdeus single, by a size with small bean, soft consistency,
unsickly at palpation.
1. Put a diagnosis, clinical form of disease.
2.How does a temperature factor (for example; supercooling of organism) on
development of pathological process in tonsils influence (as a result of experimental and clinical
researches)?
3. Possible transition of this clinical form in other? If so, in which?
4. Motion of this clinical form at little children (comparative with adults): and) more
heavy?,) more easy?
Task N3.
Patient Sh. grumbles about acute pain in a throat, high temperature of body (40.2
degrees), which is accompanied by a chill, broken, head pain, indisposition, pain in joints and
heart.
Motion of disease is stormy. Blood test: leucocytes 18 х 10 9/л, neytrophillic change to
the left, ESR - 48 мм/hr.
Mesopharyngoscopy: palatal tonsils megascopic, acutely hyperemic, filling out, lacunas
extended, filled by rather yellow-white maintenance which on the surface of tonsils forms tapes,
that the Regional lymphatic knots megascopic, acutely sickly at palpation, are easily deleted.
1. Diagnose.
2. With what diseases above all things is it necessary to conduct differential diagnosis,
their basic mesopharyngoscopic signs?
3. Treatment.
Task N4.
Hа second day after supercooling of organism at a patient Is. the temperature of body of
to 38.8 degrees rose, head pain, muscular pain, in the region of stomach and loin, pain, in a
throat appeared (increased at swallowing of saliva and meal). Common state of health of middle
weight.
 24
Blood test: leucocytes 13.2 х 10 9/л, ESR - 32 мм/hr, change of formula of blood to the
left.
At research of pharynx the exposed hyperemia of palatal tonsils, through their epithelium
examine with x-rays whiter-rather yellow humps by a size with pin head. The surface of tonsilа,
after the utterance of prominent otorhynolaringologist, reminds "star sky".
1. Diagnose.
2. By what ендоскопічного method diagnosed?
3. What pathology is it necessary to differentiate this disease with?
4. What scientist does the utterance belong to "star sky"?

Task N5.
Patient A. during 5 days treated oneself independently concerning pain in a throat,
promoted temperature of body (to 38.6 degrees), by the reception of aspirin. The improvement
came as a result of it (the temperature of body went down, pain in a throat diminished). From a
6th day the higher noted symptoms increased, that induced a patient to appeal to
otorhynolaringologist, which estimated the common state of health of patient as satisfactory (the
temperature of body is a 38.1 degree, leukocytosis 11.3 х 10 9/л, ESR - 29 мм/hr).
Mesopharyngoscopy: palatal tonsils hyperemic, here and there on their surface point
humps of yellow, left tonsil filling out, tense, megascopic, sickly at palpation. Hа levels of
corner of lower jaw the sickly package of lymphatic knots palpation moderately.
1. Put a previous diagnosis.
2. How do you imagine stage-by-stage development of this disease?
3. Differential diagnosis him with a paratonsilar abscess?
4. Treatment.
Task N6.
At a 5-years-old boy the temperature of body of to 39.9 degrees, which was accompanied
by the symptoms of intoxication, rose suddenly (vomits, irritation of brain-tunics, intestinal
disorders). The labouring nasal breath, pain, in the throat of irradiating in an ear, closed nasality
of voice, appeared in two days; excretions of серозно-mucus character from a nose, megascopic
лімфовузли, in the area of overhead third of jugular chain joined on a 3th day. In a blood is
moderate leukopenia.
ENT-organs: hyperemia and swelling mucus shell of nose, after its anemization general
nasal motions wide, breathing through a nose is acutely laboured. The overhead two third of
choans are covered hyperaemic, with an unequal surface by "fabric".
1. Your previous diagnosis.
2. What methods of research is it possible to define the defeat of nasopharynx by at adults
and at this patient?
3. Possible complications of disease which is diagnosed at a boy.

Task N7.
Patient by age 48 years appealed to the district doctor with complaints about the increase
of temperature of body (38.2 degrees), acute pain in a throat, which increased at swallowing of
meal, pulling out of language, talk. In a 34 annual age carried tonsillectomy.
A doctor examined the throat of patient (using a spatula here), diagnosed "quinsy",
appointed the proper treatment.
1. The defeat of what link (areas) of pharynx lymphoid ring can be foreseen, coming
information of anamnesis and complaints of patient from?
2. What method was used by a doctor at the review of throat at a patient? Expedient he in
this case? If no, what method it follows apply?
3. Name quinsies after the sign of their localization.
4. Possible complications of the diagnosed disease?
 25
Task N8.
Patient In. appealed to the doctor with complaints about an unpleasant smell from a
mouth, indisposition, presence of the slight swelling in a left submandibular region, increase of
temperature of body (37.6), insignificant painfulness in a throat. The disease binds to work in the
environment of pesticide, by the insufficient use of meal of rich in vitamins (vegetables, fruit).
ENT-status: on left palatal tonsilу is the greyish-greenish raid which goes out outside
tonsilа is easily taken off, abandoning кровоточиві ulcers on his surface. A strong unpleasant
smell from a mouth is felt.
In a left submandibular area and above on a cutting edge m.sternocleіdomastoіdeus
package of dense, not almost sickly lymphatic knots.
Global analysis of blood: leucocytes 10.3 х 10 9/л, ESR - 19 мм/hr.
1. Diagnose. Basic forms of this disease (and,).
2. What does it differ by clinically from vulgar (lacunar, follicle) quinsies (а,б,в,г,д)?
3. Treatment.
Task N9.
Patient G. appealed yesterday to the district doctor with complaints about head pain,
indisposition, unpleasant feelings in a throat, insignificant increase of temperature of body (37.6
degrees).
At the review of pharynx a doctor exposed dim stagnant hyperemia, moderate edema of
mucus shell of tonsils and their handles, raids on the surface of tonsils as a net, that by places
swampy semilucent tape which was easily taken off was reminded. After days they were
dense with a smooth surface, greyish color with mother-of-pearl brilliance, was taken off with
labour.
1. Put a previous diagnosis.
2. Define motion of subsequent organizational and diagnostic measures.
3. Reference chart of treatment.

Task N10.
Patient D. yesterday in the evening delivered in the induction centre hospital in
connection with the acute increase for a day of temperature of body from 37.8 to 40.1 degrees,
by increasing pain in a throat which increased at swallowing of saliva and meal, was
accompanied by pain masticatory muscles, by nausea, vomits. The common state of health is
heavy.
At endoscopic research of pharynx the exposed moderately expressed hyperemia, edema,
cyanosys of mucus shell of left palatal tonsilа, oro- and nasopharynx. The surface of tonsilа is
covered by the raid of dirty gray color which goes beyond his scopes
(nasopharynx spreads on a mucus shell). On the left under the corner of lower jaw lymphatic
knot of dense consistency, sickly at palpation, by a size with egg of quail. The edema of
hypodermic cellulose of neck reaches to the collar-bone.
1. Put a previous diagnosis.
2. Define the criteria of degree of weight of disease after the sign of edema of
hypodermic cellulose of neck.
3. Name the basic clinical forms of disease (after intoxication and prevalence of
pathological process).
4. Treatment of this form of disease.

Task N11.
Beginning of disease of patient Is. it was characterized by acute pain in a throat, which
increased at swallowing, by the high temperature of body (40.3 degrees), chill, insignificant
hoarse of voice and labouring laryngeal breath.
Objectively: mucus shell of right palatal tonsilа, parts of nasopharynx, laryngopharynx,
vestibular department of larynx of the expressed red color, was swollen, reminds the lacquered
 26
surface. Hyperemia of mucus shell is acutely outlined.
A glottis is insignificantly narrowed, breathing is compensated.
On the cutting edge of the overhead and middle third m.sternocleіdomastoіdeus
megascopic and sickly at palpation лімфовузли.
There is leukocytosis (12.6 х 10 9/л) in a blood, ESR - 36 мм/hr.
1. Diagnose.
2. Most reliable complication from the side of the ENT organs at this disease?
3. Appoint treatment (chart).

Task N12.
For the inspection of the ENT organs at the patient D. otorhynolaringologist was invited
in connection with complaints about acute pain in a throat, which increased at swallowing so that
he answered from the use of meal (even liquid), temperature of body (39.8 degrees for С).
The common state of patient is heavy, pulse 108 after 1 min., rhythmic, tones of heart are
muffled, expressed intoxication of organism. on the skin of neck, thorax hemorrhage.
Blood test: red corpuscles 4.3 х 10 12/л, haemoglobin 125 г/л, amount of granulocytes
(neutrophils, basophils, eosinophils) 0.7 х 10 9/л.
Mesopharyngoscopy: the surface of tonsils has некротично-ulcerous character, covered
by the raid of dirty gray color. A process spreads on the mucus shell of soft palate, back wall of
oropharynx . Here and there in place of the torn away necrotic fabric there are the deep ulcers
covered by the grey-dirty raid.
1. What disease does a patient have?
2. Etiopathogenesis this illness?
3. What diseases (above all things) is it necessary to conduct a differential diagnosis
with?
4. Treatment of the exposed disease.
Task N13.
At a boy 5 years, which was on treatment the signs of defeat of overhead respiratory
tracts (acute pain in a throat, nasal voice, labouring nasal and laryngeal breath, high temperature
of body) appeared in child's infectious separation, in this connection he a few days was observed
otorhynolaringologist, which exposed the following: in the first days the mucus shell of pharynx,
in that number of palatal tonsils, was fire-red color; on the surface of tonsils separate rather
yellow points were selected, from the third day are raids of grey color, on a fourth day they
gained necrotic character. From a mouth is unpleasant smell. Expressed hyperemia and swelling
soft palate reached to borders of hard. Regional лімфовузли is megascopic, sickly at palpation.
Common state of health heavy (high temperature of body, intoxication, leukocytosis) the
Hа cheeks bright blush, pallor of skin in the area of nasolabial triangle.
1. Put a previous otorhynolaringologists diagnosis.
2. What complications can the defeat of mucus shell of overhead respiratory tracts at this
disease lead before?
3. Treatment of patient with the exposed pathology.

Task N14.
During 2th days in., student of 6th class, there was a general weakness, decline of
appetite, subfebrile temperature of body. Treated oneself by domestic facilities (decoction of
herbages). Hа 3th day the temperature of body rose to 39.3 degrees, appeared is moderate pain in
a throat, labouring nasal breath, unpleasant smell from a mouth.
A patient appealed to otorhynolaringologist, which at back rhynoscopy exposed
megascopic in a volume pharyngeal tonsil, without the signs of inflammatory process. Filling out
and megascopic in a volume other anatomic lymphoid formations of pharynx resulted in
difficulty of the nasal and mouth breathing. Hа palatal the tonsils exposed raid of light gray
color, that reminded such at diphtheria. He was easily taken off by a wadding tampon and was
 27
not springy at grinding of him between glass plates. The megascopic palpated, dense
consistency, unsickly cervical, neck and in a groin lymphatic knots. On motion of quinsy did not
cause introduction of antidiphtheritic whey of positive influence.
Blood: leukocytosis 11.7 х 10 9/л, ESR - 26 мм/hr, amount of monocytes - 65%.
1. Diagnose.
2. Etiology of this disease.
3. Clinical forms of this disease.
4. Treatment.

Task N15.
Hа 5th day disease by a quinsy lacunasарною, when basic its symptoms (pain in a throat,
high temperature of body) passed, sick К. appealed to otorhynolaringologist concerning
worsening of flow of illness - the temperature of body rose again (38.9 degrees, which was
accompanied by the laboured and sickly opening of mouth, mastication and swallowing of meal
practically became impossible, part of her got in a nose.
Objectively: limited opening of mouth, expressed salyvation, lockjaw masticatory
muscles. Hа levels of overhead part of front handle of right palatal tonsilа is thrusting out of hard
consistency, painfully at palpation. a tongue is displaced to the left, expressed hyperemia, edema
and limited mobility of soft palate. There are the lacunas exposed tracks of maintenance of
festering character in separate. At puncture of thrusting out of front handle a pus was not present.
A head is inclined to the right. The package of sickly lymphatic knots palpation in the region of
overhead part of right jugular chain.
1. Diagnose.
2. What fabrics are staggered, their localization?
3. What of you know the forms of this disease (а,б,в,)?
4. Treatment of this disease.
Task N16.
Patient An. grumbles about pain in a throat, slight swelling of soft fabrics of left half of
neck, difficulty at returning of head. At a necessity this act a patient returns her together with a
trunk. The temperature of body arrives at 38.7 degrees. the disease binds to the carried follicle
quinsy.
Objectively: it was swollen, infiltration of fabrics, pain in the left half of neck at its
palpation is more expressed, than in pharynx at swallowing of meal.
Blood test: leucocytes 12.7 х 10 9/л, ESR - 31 мм/hr.
Mesopharyngoscopy: displacement in all tonsilа in a mesial side, edema and infiltration
of fabrics surrounding him, moderately expressed lockjaw masticatory muscles on the left,
surplus salyvation.
1. Diagnose.
2. а) Localization of the fabric staggered by a pathological process;
б) Diagnosis and basic clinical differences of illness which develops at the defeat of
fabric outside from the lateral wall of pharynx.
3. Auxiliary method of research for clarification of the disease diagnosed by you.
4. Treatment.
Task N17.
In 9-monthly girl on the 5th day of nasopharyngitis the temperature of body rose to 38.2
degrees. She became uneasy, whining, answered from breast-feed, the nasal breathing became
worse acutely, the closed nasality appeared. Breathing through a mouth became worse in 2 days,
voice acquired an original hoarse tint. breathing of child some more freely, when she was in
horizontal position.
From the right side of neck (near the corner of lower jaw and cutting edge of sterno-
cleido-mastoideus sprout) the considerable swelling up a little of lymphatic knots is exposed.
Pharyngoscopic picture: mucus shell of pharynx of hyperaemic. From the right side of
 28
nasopharynx of thrusting out of wall of oval form, at the level of oro- and laryngopharynx it has
the rounded form. There is feeling of fluctuation at palpation by the ball-shaped probe of the
higher noted slight swelling.
Blood test: leucocytes 15 х 10 9/л, ESR - 40 мм/hr.
1. Diagnose.
2. By what to account for gradual descending character of difficulty of breathing (nasal,
laryngeal)?
3. What complications can arise up at this pathology?
4. Treatment.
Task N18.
Т., 45 years, during a supper (ate the grilled potato with meat) experienced pain at the
level of lower area of neck and overhead department of chest, which by a morning the second
day increased. A patient with labour swallows saliva, tea, milk. Dread appeared to do
swallowing motion or motion by a neck. At palpation of neck of signs of inflammatory process it
is not exposed in this area.
1. Diagnose.
2. Auxiliary methods of inspection.
3. Is there thought, that does this pathology most often meet in the first physiology
narrowing of gullet, so this or not?
4. Most expedient method of treatment of conceivable pathology.

Task N19.
Patient H., by age of 73 years, after the use of meat food exposed (established)
impossibility of swallowing of not only dishes of dense consistency but also liquids (milk, tea,
water). At an attempt to swallow the liquid of feeling of pain was not. Delivered in the ENT
separation on a 3th day after that happened.
At mesopharyngoscopy the exposed absence more than half of teeth of overhead and
lower jaw; there is accumulation of saliva in грушоподібних sines at hypopharyngoscopy.
At esophagoscopy (after sucking out from the gullet of saliva) at the level of the second
narrowing of gullet the piece of meat, which fully obturated him, is exposed. The overhead
department of gullet above him is some extended.
1. Put a previous diagnosis.
2. How is the symptom of accumulation of saliva in грушоподібних sines named?
Reasons of it?
3. Name the most frequent reasons of delay of extraneous bodies in a gullet (а,б,в).
4. Your attitude toward pushing through of bougie meat in a stomach. Обґрунтуйте this.

Task N20.
Patient of О. 46 years in society of acquaintances during an evening-party adopted the
considerable dose of alcohol, cold drinks. The next day experienced pain in a throat, difficulty of
swallowing of meal (even liquid). The temperature of body of to 37.8 degrees rose. A district
doctor, which a patient appealed to, diagnosed "quinsy", appointed the pills of biseptol, proper
diet. A patient did not execute recommendation of doctor in connection with impossibility of
swallowing.
With every hour pain increased in a throat and region of neck, the slight swelling in left
supraclavicular pit appeared. The temperature of body attained 39.6 degrees. A patient, not
trusting anymore to the district doctor, appealed independently to the ENT clinic, where and was
hospitalized.
Objectively: in left supraclavicular pit there is the slight swelling, infiltration of fabrics,
hyperemia of skin. Palpation of this area is acutely sickly. Temperature of body 39.9 degrees.
Swallowing of saliva is not possible acutely painfully.
Mesopharyngoscopy are the pathological changes are not exposed. Hypopharyngoscopy
 29
is the Jeckson'a symptom. Sciagraphy of neck is the extended prevertebral space.
1. Put a basic previous diagnosis.
2. Complication of basic disease.
3. What additional methods of research could be appointed by a doctor?
4. Most expedient method of treatment in this case.

Answer 1
1. Quinsy is acute infectious disease with the local displays of inflammation of one or a
few components of lymphoid pharynx ring, more frequent all palatal tonsils.
2. Morbidity by a quinsy has the expressed seasonal character, epidemics are observed in
a fall-winter period, at a low temperature and high humidity of air.
bacteria, viruses, спірохети, mushrooms, can be 3. Exciters of quinsy. Among bacterial
agents a beta hemolytic streptococcus is most frequent, rarer is staphylococcus or their
combination.
Answer 2
1. Catarrhal quinsy.
2. Supercooling can cause the decline of temperature of tonsils, degenerative processes in
them, strengthening of semination of their surface by microbes, decline of phagocytosis of
microbes by leucocytes.
3. Possible transition of catarrhal in an or follicle quinsy lacunasарну.
4. At little children motion of catarrhal quinsy more heavy, than at adults.

Answer 3
1. Lacunar quinsy.
2. With a follicle quinsy (rather yellow or rather yellow-white follicles which suppurated
and are under a mucus shell come forward above the surface of mucus shell of tonsilа), with
diphtheria of pharynx ( on the surface of tonsilа dirty gray color the fibrinous raid which spreads
for his scopes is taken off with labour, a hemorragic surface a stay after it).
3. Treatments: ліжковий or domestic mode without the physical loading; antibiotic
therapy (penicillin 500000 - 1000000 ODES each 4 hr. inwardly muscular); for the prophylaxis
of rheumatism appoint an aspirin 0.5 4 times per days during 10 days.

Answer 4
1. Follicle quinsy.
2. By mesopharyngoscopy.
3. it is Necessary to differentiate with a quinsy lacunasарною.
4. This utterance belongs M.P.Simanovskiy.

Answer 5
1. Phlegmonic quinsy.
2. Follicle quinsy, involvement in the process (suppuration) of deep follicles, melting of
them and паренхіми of tonsilа round them, formation of intratonsillar abscess (phlegmonic
quinsies).
3. Motion of paratonsillar abscess is stormy (high temperature of body, lockjaw
masticatory muscles, acutely laboured swallowing of meal, promoted salyvation, thrusting out,
fluctuation (more frequent in a supratonsillar area).
4. Openings of intratonsillar abscess; at relapse - tonsilectomy, antibiotic therapy.

Answer 6
1. Quinsy of nasopharynx tonsilа (viral genesis)
2. At adults conduct back rhynoscopy by a spatula and nasopharynx mirror; at small
 30
children by mesopharyngoscopy on to the indirect signs (flowline down of mucus-festering
excretions on the back wall of oropharynx , lymphoid granules on the same wall, red spots on a
soft palate); by lateral sciagraphy of nasopharynx.
3. Possible complications of quinsy of nasopharynx tonsilа: catarrhal or festering acute
middle otitis, retropharyngeal abscess, meningitis.

Answer 7
1. it is Possible to foresee the quinsy of tongue tonsilа.
2. Doctor used mesopharyngoscopy, and tongue tonsil it is possible to examine at
hypopharyngoscopy.
3. Quinsies after the sign of localization: nasopharyngeal (adenoids), tubal tonsils, palatal
tonsils, tongue tonsilа, laryngeal quinsy.
4. Possible complications of quinsy of tongue tonsilа: glossitis, abscessing root of
language, phlegmon of bottom of cavity of mouth, edema of mucus shell leafed.

Answer 8
1. Quinsy Simanovskiy-Vincent (ulcerous-pellicle). Basic forms: pseudopellicle;
ulcerous.
2. Exciters of disease: symbiosis of fusiform stick and спірохети of cavity of mouth.
3. At a ulcerative membranous quinsy: a) the common state of health suffers not enough;
b) duration of to a few Sundays; in) one-sidedness of changes in the region of pharynx; г)
exciters: symbiosis of fusiform stick and спірохети of cavity of mouth; д) favourable motion of
disease.
4. Treatments: rinse of pharynx by solutions of bactericidal action, greasing of surface by
tonsilа 10% solution of novarsenol in glycerin, antibiotic therapy (penicillin, ampicillin).

Answer 9
1. Noncommunicative pellicle form of diphtheria of pharynx.
2. a) Quickly to take and send in a laboratory a stroke from the mucus shell of tonsils and
nose.
б) To send in the СЕС urgent report (by a telephone and mail). in) To send a patient in the
infectious separation. г) To bring to a 5 мл blood from a vein (before the conduct of
antidiphtheritic whey) for determination of reaction of passive hemagglutination along with
diphtherial diagnosticum.
3. Introductions of antidiphtheritic antitoxic whey: first dose a 20-40 thousand МО and
course dose a 40-80 thousand МО. Antibiotic therapy (antibiotics of wide spectrum of action),
glucose, vitamins.
Answer 10
1. Toxic diphtheria of pharynx of the ІІ degree.
2. Toxic diphtheria of the І-degree is the edema of hypodermic cellulose to the middle of
neck; ІІ degree - to the collar-bone, ІІІ degree - below collar-bones.
3. Noncommunicative, widespread, toxic (And, ІІ, ІІІ degree), hypertoxic diphtheria of
pharynx.
4. Antidiphtheritic antitoxic whey: 100-120 thousand МО first dose; 200-240 thousand
МО on the course of treatment; . Antibiotic therapy (antibiotics of wide spectrum of action),
glucose, vitamins.
Answer 11
1. Erysipelas of mucus shell of pharynx and larynx.
2. Most reliable complication is edema of mucus shell leafed, what can result in an
asphyxia.
3. Ampicillin 1.0 4 times per day inwardly muscular; antihistaminic preparations,
steroids, diet.
 31
Answer 12
1. Agranulocytosis. Agranulocytic quinsy.
2. Only reasoning of agranulocytosis is not present (does not exist). Agranulocytosis is
the special Agranulocytic reaction of haemopoesis on the irritation of infectious, toxic (including
medicinal - sulfonamides, medicines of pyrimidine row), radial and other nature.
3. Differential diagnosis must be above all things conducted with the Simanovskiy-
Vensan quinsy, aleycemic form of acute leucosis.
4. Treatments are conducted in the haematological or therapeutic separation. It is directed
on the removal of reason, on the fight against the second infection (antibiotics, rinses of throat by
solutions antiseptic), activation of the hematopoietic system (tezan 0.01 - 0.02 on a day,
penthoxill 0.2-0.3 on a day); ascorbic acid is appointed, cyanocobalamin, steroid and
replacement therapy by leukocyte mass.
Answer 13
1. Quinsy at a scarlatina.
2. To violation of respiratory function of nose, larynx, acute pyonecrotic middle otitides
and sinusities.
3. General antibiotic therapy, irrigation of mucus shell of mouth and pharynx by solutions
antiseptic, vitamin therapy.
Answer 14
1. Anginal form of infectious mononucleosis.
2. Diseases are caused by a virus (not quite known nature), the satellite of which there are
the bacteria of listerella.
3. Ferrous, anginal, febrile.
4. Appoint intramuscular the antibiotics of wide spectrum of action, disinfectant the rinse,
valuable feed, vitamins.
Answer 15
1. Paratonzillitis (front-overhead).
2. Staggered paratonzillar cellulose between the capsule of tonsilа and overhead part of
palatal lingual handle.
3. Forms of paratonzilitis (this on a creature the stage of process of inflammation): a)
edematous,b) infiltrative, c) abscessed.
4. Treatments of paratonzilitis conservative: antibiotic intramuscular, injection of him in
the staggered paratonzillar cellulose, compress of antibiotic with a 25% solution of Dimexid.

Answer 16
1. Lateral paratonsillar abscess.
2. a) A paratonzillar cellulose is struck (will fester) between the capsule of palatal tonsilа
and lateral wall of pharynx.
б) The Parapharyngeal abscess is localized outside lateral wall of pharynx near the corner of
lower jaw and on motion of sterno-cleido-mastoideus muscle; there can be Thrombophlebitis of
internal jugular vein, bleeding at erosion of wall of vessels.
3. For clarification of diagnosis it is necessary to execute diagnostic punction.
4. In connection with rareness of spontaneous breach and difficulty of opening of lateral
paratonsillar abscess execute tonsillectomy. After it antibiotic -, resolvent therapy.

Answer 17
1. Retropharyngeal abscess.
2. it is Possible to explain by distribution of pus from top to bottom (naso-, oro,
laryngopharynx).
3. Back mediastinitis, bleeding, intracranial complications, reflex stop of cardiac activity.
4. Surgical cut from top to bottom, nearer to the middle line. At deep abscesses there is
the not eliminated possibility of opening of abscess from the side of neck, (cut on the back edge
 32
of m.sternocleіdomastoіdeus, farther by a dull way to move up in a depth to appearance of pus).

Answer 18
1. Extraneous body (meat bone) of neck department of gullet.
2. Auxiliary methods of inspection: sciagraphy of gullet, esophagoscopy.
3. Hі. Most often extraneous bodies meet at the level of the jugular undercuting is the
overhead aperture of thorax ( Rozanov, Jackson et al) From the first narrowing often pushes the
3th designer of pharynx extraneous body downward. The Hа even undercuting is a chest narrow
enough road clearance (due to a trachea, gullet, vascular nerve bunches. Except for it, here is the
first bend of gullet to the right, related to the arc and descending department of aorta.
4. Most expedient method of delete of the uncomplicated extraneous body of neck
department of gullet - by esophagoscopy.
Answer 19
1. «Extraneous body» is the meat obstruction of pectoral department of gullet (second
narrowing).
2. Accumulations of saliva in грушоподібних sines is the Jeckson'a symptom. Ceiling by
the extraneous body of road clearance of gullet.
3. Most frequent reasons of delay of extraneous bodies in a gullet:
а) disparity of size of extraneous body with the road clearance of gullet (in a certain
place);
б) origin of reflex esophagospasm; in) acute edges (ends) of extraneous body.
4. Pushing through extraneous bodies in a stomach is not expedient from possibility of
injuring of gullet (for example, by a bone which is hidden in a meat obstruction).

Answer 20
1. Extraneous body of neck department of gullet. Trauma of back wall of gullet.
2. Complications is vertebral abscess, front mediastinitis.
3. Esophagoscopy, sciagraphy of neck and thorax.
4. Neck mediastinotomy.

І. Find right answer complete and for a question.

1. What must be done for establishment of diagnosis «acute pharyngitis»?

а) to collect anamnesis and execute epi-meso-hypopharyngoscopy
б) to appoint antibiotics
в) to appoint anaesthetic facilities
г) to explore the nasal breathing
д) to explore a vocal function
2. What department of pharynx more frequent all is attracted in an inflammatory process at
acute pharyngitis?
а) oropharynx
б) nasopharynx
в) laryngopharynx
3. What way do children have the infection of before spinal lymphatic knots by?
а) by the lymphatic ways of back departments of cavity of nose and nasopharynx
б) at the infectious diseases (measles, flu, scarlatina)
в) diseases of blood
 33
4. What diseases does it follow to conduct differential diagnostics of retropharyngeal abscess
with?
а) acute pharyngitis
б) paratonsillar abscess
в) hypertrophy of palatal tonsils
г) adenoids to vegetation
5. What heavy (mortal) complications can be caused by the not in good time exposed and not
cut retropharyngeal abscess?
а) festering meningitis
б) empyema of lights
в) festering mediastinitis, sepsis
6. Basic way of transmission of infection at quinsies?
а) air-drop
б) domestic
в) alimentary
7. What tonsils from a lymphoid ring most often light up at quinsies?
а) tubal
б) nasopharyngeal
в) palatal
г) tongue tonsil
8. About what is it possible to think, if at a catarrhal quinsy the state of patient became worse
acutely, did the temperature of body, chill rise, in a blood neutrophilic leukocytosis?
а) tonsillar sepsis
б) acute respirator disease
в) development of follicle quinsy
г) origin of paratonzilitis
д) forming of paratonzilar abscess
9. What character of raids at diphtheria?
а) the raids are thin, superficial
б) the raids are dense, dirty gray color, is heavily taken off, a surface is abandoned, that bleeds
в) yellow
г) it is easily taken off
10. Is there what character of pain at a paratonzilar abscess?
а) moderate, poured out
б) gives in teeth
в) pain one-sided, increases at swallowing of saliva, gives in an ear
11. What appears at the review of patients with paratonzilar abscesses on 4—5 time of
disease?
а) impossibility widely to open company (lockjaw masticatory muscles)
б) a patient opens a mouth widely
в) hyperemia of soft palate, handles, back wall of pharynx
г) increase and edema of palatal tonsils

II. Find all right answers for a question.

1. What principal reasons of origin of pharyngitis?
а) supercooling
б) viral infection
в) smoking
г) professional to harmfulness
д) tumours
е) nose-bleeds
2. Where is an inflammatory process at acute pharyngitis?
 34
а) in palatal tonsils
б) in nasopharynx
в) oropharynx
г) laryngopharynx
3. What will you appoint to the patient with acute pharyngitis?
а) antibiotics
б) sulfonamides
в) liquid food, that does not annoy pharynx
г) alkaline rinses
д) Faringosept, Falimint
е) warming compress on a neck
4. How to treat lateral pharyngitis?
а) cauterization
б) by trichloracetic acid
в) cryo
г) dissection by the scissors of hypertrophy adenoids fabric
д) rinse by solutions of antiseptics
5. What treatment do patients with a retropharyngeal abscess require?
а) warming compress on a neck
б) resolvent therapy
в) fortifying treatment
г) dissection of abscess
6. What is observed in oropharynx at a retropharyngeal abscess?
а) hyperemia of mucus shell of back wall of oropharynx
б) rounded, asymmetric thrusting out of back wall of oropharynx
в) hypertrophy of palatal tonsils
7. Why by a patient with acute primary is tonsilities appointed by hyposensitizing facilities in
complex treatment?
а) quinsies arise up on a background allergization of organism
б) it is the disease able exactly to cause allergization
в) for diminishment of main pain
8. What forms of diphtheria of pharynx are selected?
а) noncommunicative (easy)
б) widespread (toxic)
в) with the raids
г) without the raids
9. What complications arise up at patients which carried diphtheria, in 2—3 weeks and later?
а) edema leafed
б) bleeding
в) violation of breathing
г) paralysis of soft palate
д) myocarditis
10. What distinguish paratonsillar abscesses depending on localization?
а) front
б) lateral
в) overhead
г) back
д) middle
11. What are possible complication of paratonsillar abscess?
а) chronic tonsillitis
б) mediastinitis
в) sepsis
 35
г) phlegmon of neck
д) edema leafed

III Find an error in answers for a question.

1. Are there what basic changes of .спостерігаються on the mucus shell of back wall of
pharynx at acute pharyngitis?
а) dry crusts
б) hyperemia
в) it was swollen
г) slid
2. Tactic of doctor at the cold натічних abscesses of pharynx?
а) dynamic supervision
б) sciagraphy of neck department of spine
в) periodic puncture of abscess
г) specific treatment
3. What quinsy?
а) acute infectiously-allergic disease of organism with an inflammatory process in palatal tonsils
б) acute inflammation of pharynx
4. What microorganisms more frequent cause a quinsy?
а) staphylococcus
б) streptococcus
в) pneumococcus
5. Name the sources of infection at quinsies?
а) eczema
б) sick man
в) self-infection
6. How enough for the disease by a quinsy only infected agent?
а) no, the decline of reactivity of organism is needed yet
б) enough
7. What departments of palatal tonsils is struck at quinsies?
а) surface of tonsils and lacunas
б) parenchyma
в) capsule of tonsils
8. What basic symptoms of quinsy?
а) insomnia
б) pains in a throat
в) head pain
г) broken
д) pain in joints
е) promoted temperature
9. What appears in the blood of patients by a quinsy?
а) neutrophilic leukocytosis
б) thrombocytopenia
в) ESR a speed-up
10. What classification of acute tonsilities is offered by an academician Soldatov?
а) primary, second (at the acute infectious diseases and diseases of the system of blood)
б) easy, middle weight, heavy
11. What are abolitions of motion of quinsy lacunar in from catarrhal one?
а) in the degree of intoxication of organism
б) in the presence of raids on tonsils
в) in the increase of palatal tonsils
 36
12. What is included in the chart of treatment of acute primary tonsilities?
а) hormonal preparations
б) antibiotics
в) antiseptics
г) salicylates
д) hyposensitizing facilities
13. Are there bacillicarriers of diphtheria?
а) no
б) it is
14. Name the most characteristic symptoms at diphtheria:
а) glassy edema of soft palate, tongue
б) increase of регіонарних lymph nodes
в) distribution of raids outside palatal tonsils
г) брудно-сірий color of raids which are heavily taken off
15. Can diphtheria of pharynx flow without the raids?
а) can
б) no
16. What is based on the diagnosis «diphtheria»?
а) increase of regional lymph nodes
б) by the presence of widespread raids
в) results of research of strokes from pharynx
17. What will you do to the child in the grave condition, to which the set diagnosis quinsy
lacunar and is not diphtheria of pharynx eliminated?
а) you will enter a antidiphtheritic whey, will take strokes from pharynx on the bacillus Lefler
б) you will enter antibiotics anaesthetic, rinses of mouth
18. Why do patients more frequent have anterior and superior paratonsilar abscesses?
а) here many Lymphatic vessels
б) here anymore lacunas
в) they are deeper and winding
г) here many cellulose, that is easily infected

Situation tasks for verification of eventual level of knowledges.

Task N1.
Quinsy is the disease is known from ІV - V age to our era; prevalence of her is large,
especially in countries with the low level of socio-economic development. The disease has
polietiological character.
1. Give determination, that exposes maintenance of concept of quinsy as disease.
2. Role of seasonality in development of epidemics of quinsies which factors more
frequent all do influence on it?
3. Name the groups of exciters of quinsies, most frequent and reliable from them?

Task N2.
At the patient Ch. feeling of being tearing to pieces, dryness, extraneous body in a throat,
indisposition appeared on a day next after the common supercooling. After it he marked pain in a
throat (which irradiate in a left ear) and joints of lower extremities. The common state of health
is satisfactory.
Objectively: size of palatal tonsils achieves the first degree; the moderately expressed
hyperemia of their mucus shell spreads on front and back handles. Lymphatic knots near the
cutting edge of m. sternocheіdomastoіdeus single, by a size with small bean, soft consistency,
unsickly at palpation.
 37
1. Put a diagnosis, clinical form of disease.
2.How does a temperature factor (for example; supercooling of organism) on
development of pathological process in tonsils influence (as a result of experimental and clinical
researches)?
3. Possible transition of this clinical form in other? If so, in which?
4. Motion of this clinical form at little children (comparative with adults): and) more
heavy?,) more easy?
Task N3.
Patient Sh. grumbles about acute pain in a throat, high temperature of body (40.2
degrees), which is accompanied by a chill, broken, head pain, indisposition, pain in joints and
heart.
Motion of disease is stormy. Blood test: leucocytes 18 х 10 9/л, neytrophillic change to
the left, ESR - 48 мм/hr.
Mesopharyngoscopy: palatal tonsils megascopic, acutely hyperemic, filling out, lacunas
extended, filled by rather yellow-white maintenance which on the surface of tonsils forms tapes,
that the Regional lymphatic knots megascopic, acutely sickly at palpation, are easily deleted.
1. Diagnose.
2. With what diseases above all things is it necessary to conduct differential diagnosis,
their basic mesopharyngoscopic signs?
3. Treatment.
Task N4.
Hа second day after supercooling of organism at a patient Is. the temperature of body of
to 38.8 degrees rose, head pain, muscular pain, in the region of stomach and loin, pain, in a
throat appeared (increased at swallowing of saliva and meal). Common state of health of middle
weight.
Blood test: leucocytes 13.2 х 10 9/л, ESR - 32 мм/hr, change of formula of blood to the
left.
At research of pharynx the exposed hyperemia of palatal tonsils, through their epithelium
examine with x-rays whiter-rather yellow humps by a size with pin head. The surface of tonsilа,
after the utterance of prominent otorhynolaringologist, reminds "star sky".
1. Diagnose.
2. By what ендоскопічного method diagnosed?
3. What pathology is it necessary to differentiate this disease with?
4. What scientist does the utterance belong to "star sky"?

Task N5.
Patient A. during 5 days treated oneself independently concerning pain in a throat,
promoted temperature of body (to 38.6 degrees), by the reception of aspirin. The improvement
came as a result of it (the temperature of body went down, pain in a throat diminished). From a
6th day the higher noted symptoms increased, that induced a patient to appeal to
otorhynolaringologist, which estimated the common state of health of patient as satisfactory (the
temperature of body is a 38.1 degree, leukocytosis 11.3 х 10 9/л, ESR - 29 мм/hr).
Mesopharyngoscopy: palatal tonsils hyperemic, here and there on their surface point
humps of yellow, left tonsil filling out, tense, megascopic, sickly at palpation. Hа levels of
corner of lower jaw the sickly package of lymphatic knots palpation moderately.
1. Put a previous diagnosis.
2. How do you imagine stage-by-stage development of this disease?
3. Differential diagnosis him with a paratonsilar abscess?
4. Treatment.
Task N6.
At a 5-years-old boy the temperature of body of to 39.9 degrees, which was accompanied
by the symptoms of intoxication, rose suddenly (vomits, irritation of brain-tunics, intestinal
 38
disorders). The labouring nasal breath, pain, in the throat of irradiating in an ear, closed nasality
of voice, appeared in two days; excretions of серозно-mucus character from a nose, megascopic
лімфовузли, in the area of overhead third of jugular chain joined on a 3th day. In a blood is
moderate leukopenia.
ENT-organs: hyperemia and swelling mucus shell of nose, after its anemization general
nasal motions wide, breathing through a nose is acutely laboured. The overhead two third of
choans are covered hyperaemic, with an unequal surface by "fabric".
1. Your previous diagnosis.
2. What methods of research is it possible to define the defeat of nasopharynx by at adults
and at this patient?
3. Possible complications of disease which is diagnosed at a boy.

Task N7.
Patient by age 48 years appealed to the district doctor with complaints about the increase
of temperature of body (38.2 degrees), acute pain in a throat, which increased at swallowing of
meal, pulling out of language, talk. In a 34 annual age carried tonsillectomy.
A doctor examined the throat of patient (using a spatula here), diagnosed "quinsy",
appointed the proper treatment.
1. The defeat of what link (areas) of pharynx lymphoid ring can be foreseen, coming
information of anamnesis and complaints of patient from?
2. What method was used by a doctor at the review of throat at a patient? Expedient he in
this case? If no, what method it follows apply?
3. Name quinsies after the sign of their localization.
4. Possible complications of the diagnosed disease?

Task N8.
Patient In. appealed to the doctor with complaints about an unpleasant smell from a
mouth, indisposition, presence of the slight swelling in a left submandibular region, increase of
temperature of body (37.6), insignificant painfulness in a throat. The disease binds to work in the
environment of pesticide, by the insufficient use of meal of rich in vitamins (vegetables, fruit).
ENT-status: on left palatal tonsilу is the greyish-greenish raid which goes out outside
tonsilа is easily taken off, abandoning кровоточиві ulcers on his surface. A strong unpleasant
smell from a mouth is felt.
In a left submandibular area and above on a cutting edge m.sternocleіdomastoіdeus
package of dense, not almost sickly lymphatic knots.
Global analysis of blood: leucocytes 10.3 х 10 9/л, ESR - 19 мм/hr.
1. Diagnose. Basic forms of this disease (and,).
2. What does it differ by clinically from vulgar (lacunar, follicle) quinsies (а,б,в,г,д)?
3. Treatment.
Task N9.
Patient G. appealed yesterday to the district doctor with complaints about head pain,
indisposition, unpleasant feelings in a throat, insignificant increase of temperature of body (37.6
degrees).
At the review of pharynx a doctor exposed dim stagnant hyperemia, moderate edema of
mucus shell of tonsils and their handles, raids on the surface of tonsils as a net, that by places
swampy semilucent tape which was easily taken off was reminded. After days they were
dense with a smooth surface, greyish color with mother-of-pearl brilliance, was taken off with
labour.
1. Put a previous diagnosis.
2. Define motion of subsequent organizational and diagnostic measures.
3. Reference chart of treatment.
 39
Task N10.
Patient D. yesterday in the evening delivered in the induction centre hospital in
connection with the acute increase for a day of temperature of body from 37.8 to 40.1 degrees,
by increasing pain in a throat which increased at swallowing of saliva and meal, was
accompanied by pain masticatory muscles, by nausea, vomits. The common state of health is
heavy.
At endoscopic research of pharynx the exposed moderately expressed hyperemia, edema,
cyanosys of mucus shell of left palatal tonsilа, oro- and nasopharynx. The surface of tonsilа is
covered by the raid of dirty gray color which goes beyond his scopes
(nasopharynx spreads on a mucus shell). On the left under the corner of lower jaw lymphatic
knot of dense consistency, sickly at palpation, by a size with egg of quail. The edema of
hypodermic cellulose of neck reaches to the collar-bone.
1. Put a previous diagnosis.
2. Define the criteria of degree of weight of disease after the sign of edema of
hypodermic cellulose of neck.
3. Name the basic clinical forms of disease (after intoxication and prevalence of
pathological process).
4. Treatment of this form of disease.

Task N11.
Beginning of disease of patient Is. it was characterized by acute pain in a throat, which
increased at swallowing, by the high temperature of body (40.3 degrees), chill, insignificant
hoarse of voice and labouring laryngeal breath.
Objectively: mucus shell of right palatal tonsilа, parts of nasopharynx, laryngopharynx,
vestibular department of larynx of the expressed red color, was swollen, reminds the lacquered
surface. Hyperemia of mucus shell is acutely outlined.
A glottis is insignificantly narrowed, breathing is compensated.
On the cutting edge of the overhead and middle third m.sternocleіdomastoіdeus
megascopic and sickly at palpation лімфовузли.
There is leukocytosis (12.6 х 10 9/л) in a blood, ESR - 36 мм/hr.
1. Diagnose.
2. Most reliable complication from the side of the ENT organs at this disease?
3. Appoint treatment (chart).
Task N12.
For the inspection of the ENT organs at the patient D. otorhynolaringologist was invited
in connection with complaints about acute pain in a throat, which increased at swallowing so that
he answered from the use of meal (even liquid), temperature of body (39.8 degrees for С).
The common state of patient is heavy, pulse 108 after 1 min., rhythmic, tones of heart are
muffled, expressed intoxication of organism. on the skin of neck, thorax hemorrhage.
Blood test: red corpuscles 4.3 х 10 12/л, haemoglobin 125 г/л, amount of granulocytes
(neutrophils, basophils, eosinophils) 0.7 х 10 9/л.
Mesopharyngoscopy: the surface of tonsils has некротично-ulcerous character, covered
by the raid of dirty gray color. A process spreads on the mucus shell of soft palate, back wall of
oropharynx . Here and there in place of the torn away necrotic fabric there are the deep ulcers
covered by the grey-dirty raid.
1. What disease does a patient have?
2. Etiopathogenesis this illness?
3. What diseases is it necessary to conduct a differential diagnosis with?
4. Treatment of the exposed disease.

Task N13.
At a boy 5 years, which was on treatment the signs of defeat of overhead respiratory
 40
tracts (acute pain in a throat, nasal voice, labouring nasal and laryngeal breath, high temperature
of body) appeared in child's infectious separation, in this connection he a few days was observed
otorhynolaringologist, which exposed the following: in the first days the mucus shell of pharynx,
in that number of palatal tonsils, was fire-red color; on the surface of tonsils separate rather
yellow points were selected, from the third day are raids of grey color, on a fourth day they
gained necrotic character. From a mouth is unpleasant smell. Expressed hyperemia and swelling
soft palate reached to borders of hard. Regional лімфовузли is megascopic, sickly at palpation.
Common state of health heavy (high temperature of body, intoxication, leukocytosis) the
Hа cheeks bright blush, pallor of skin in the area of nasolabial triangle.
1. Put a previous otorhynolaringologists diagnosis.
2. What complications can the defeat of mucus shell of overhead respiratory tracts at this
disease lead before?
3. Treatment of patient with the exposed pathology.

Task N14.
During 2th days in., student of 6th class, there was a general weakness, decline of
appetite, subfebrile temperature of body. Treated oneself by domestic facilities (decoction of
herbages). Hа 3th day the temperature of body rose to 39.3 degrees, appeared is moderate pain in
a throat, labouring nasal breath, unpleasant smell from a mouth.
A patient appealed to otorhynolaringologist, which at back rhynoscopy exposed
megascopic in a volume pharyngeal tonsil, without the signs of inflammatory process. Filling out
and megascopic in a volume other anatomic lymphoid formations of pharynx resulted in
difficulty of the nasal and mouth breathing. Hа palatal the tonsils exposed raid of light gray
color, that reminded such at diphtheria. He was easily taken off by a wadding tampon and was
not springy at grinding of him between glass plates. The megascopic palpated, dense
consistency, unsickly cervical, neck and in a groin lymphatic knots. On motion of quinsy did not
cause introduction of antidiphtheritic whey of positive influence.
Research of blood: leukocytosis 11.7 х 10 9/л, ESR - 26 мм/hr, amount of monocytes -
65%.
1. Diagnose.
2. Etiology of this disease.
3. Clinical forms of this disease.
4. Treatment.

Task N15.
Hа 5th day disease by a quinsy lacunasарною, when basic its symptoms (pain in a throat,
high temperature of body) passed, sick К. appealed to otorhynolaringologist concerning
worsening of flow of illness - the temperature of body rose again (38.9 degrees, which was
accompanied by the laboured and sickly opening of mouth, mastication and swallowing of meal
practically became impossible, part of her got in a nose.
Objectively: limited opening of mouth, expressed salyvation, lockjaw masticatory
muscles. Hа levels of overhead part of front handle of right palatal tonsilа is thrusting out of hard
consistency, painfully at palpation. a tongue is displaced to the left, expressed hyperemia, edema
and limited mobility of soft palate. There are the lacunas exposed tracks of maintenance of
festering character in separate. At puncture of thrusting out of front handle a pus was not present.
A head is inclined to the right. The package of sickly lymphatic knots palpation in the region of
overhead part of right jugular chain.
1. Diagnose.
2. What fabrics are staggered, their localization?
3. What of you know the forms of this disease (а,б,в,)?
4. Treatment of this disease.
Task N16.
 41
Patient An. grumbles about pain in a throat, slight swelling of soft fabrics of left half of
neck, difficulty at returning of head. At a necessity this act a patient returns her together with a
trunk. The temperature of body arrives at 38.7 degrees. the disease binds to the carried follicle
quinsy.
Objectively: it was swollen, infiltration of fabrics, pain in the left half of neck at its
palpation is more expressed, than in pharynx at swallowing of meal.
Blood test: leucocytes 12.7 х 10 9/л, ESR - 31 мм/hr.
Mesopharyngoscopy: displacement in all tonsilа in a mesial side, edema and infiltration
of fabrics surrounding him, moderately expressed lockjaw masticatory muscles on the left,
surplus salyvation.
1. Diagnose.
2. а) Localization of the fabric staggered by a pathological process;
б) Diagnosis and basic clinical differences of illness which develops at the defeat of
fabric outside from the lateral wall of pharynx.
3. Auxiliary method of research for clarification of the disease diagnosed by you.
4. Treatment.
Task N17.
In 9-monthly girl on the 5th day of nasopharyngitis the temperature of body rose to 38.2
degrees. She became uneasy, whining, answered from breast-feed, the nasal breathing became
worse acutely, the closed nasality appeared. Breathing through a mouth became worse in 2 days,
voice acquired an original hoarse tint. breathing of child some more freely, when she was in
horizontal position.
From the right side of neck (near the corner of lower jaw and cutting edge of sterno-
cleido-mastoideus sprout) the considerable swelling up a little of lymphatic knots is exposed.
Pharyngoscopic picture: mucus shell of pharynx of hyperaemic. From the right side of
nasopharynx of thrusting out of wall of oval form, at the level of oro- and laryngopharynx it has
the rounded form. There is feeling of fluctuation at palpation by the ball-shaped probe of the
higher noted slight swelling.
Blood test: leucocytes 15 х 10 9/л, ESR - 40 мм/hr.
1. Diagnose.
2. By what to account for gradual descending character of difficulty of breathing (nasal,
laryngeal)?
3. What complications can arise up at this pathology?
4. Treatment.
Task N18.
Т., 45 years, during a supper (ate the grilled potato with meat) experienced pain at the
level of lower area of neck and overhead department of chest, which by a morning the second
day increased. A patient with labour swallows saliva, tea, milk. Dread appeared to do
swallowing motion or motion by a neck. At palpation of neck of signs of inflammatory process it
is not exposed in this area.
1. Diagnose.
2. Auxiliary methods of inspection.
3. Is there thought, that does this pathology most often meet in the first physiology
narrowing of gullet, so this or not?
4. Most expedient method of treatment of conceivable pathology.

Task N19.
Patient H., by age of 73 years, after the use of meat food exposed (established)
impossibility of swallowing of not only dishes of dense consistency but also liquids (milk, tea,
water). At an attempt to swallow the liquid of feeling of pain was not. Delivered in the ENT
separation on a 3th day after that happened.
At mesopharyngoscopy the exposed absence more than half of teeth of overhead and
 42
lower jaw; there is accumulation of saliva in грушоподібних sines at hypopharyngoscopy.
At esophagoscopy (after sucking out from the gullet of saliva) at the level of the second
narrowing of gullet the piece of meat, which fully obturated him, is exposed. The overhead
department of gullet above him is some extended.
1. Put a previous diagnosis.
2. How is the symptom of accumulation of saliva in грушоподібних sines named?
Reasons of it?
3. Name the most frequent reasons of delay of extraneous bodies in a gullet (а,б,в).
4. Your attitude toward pushing through of bougie meat in a stomach. Обґрунтуйте this.

Task N20.
Patient of О. 46 years in society of acquaintances during an evening-party adopted the
considerable dose of alcohol, cold drinks. The next day experienced pain in a throat, difficulty of
swallowing of meal (even liquid). The temperature of body of to 37.8 degrees rose. A district
doctor, which a patient appealed to, diagnosed "quinsy", appointed the pills of biseptol, proper
diet. A patient did not execute recommendation of doctor in connection with impossibility of
swallowing.
With every hour pain increased in a throat and region of neck, the slight swelling in left
supraclavicular pit appeared. The temperature of body attained 39.6 degrees. A patient, not
trusting anymore to the district doctor, appealed independently to the ENT clinic, where and was
hospitalized.
Objectively: in left supraclavicular pit there is the slight swelling, infiltration of fabrics,
hyperemia of skin. Palpation of this area is acutely sickly. Temperature of body 39.9 degrees.
Swallowing of saliva is not possible acutely painfully.
Mesopharyngoscopy are the pathological changes are not exposed. Hypopharyngoscopy
is the Jeckson'a symptom. Sciagraphy of neck is the extended prevertebral space.
1. Put a basic previous diagnosis.
2. Complication of basic disease.
3. What additional methods of research could be appointed by a doctor?
4. Most expedient method of treatment in this case.

Answers for tests and tasks for verification of initial level of knowledges
And. 1th, 2th, 3th, 4-б, 5-in, 6th, 7-in, 8th, 9-б, 10-in, 11th.
ІІ. 1-а,б, in, г; 2-б, in, г; 3-in, г, д; 4th,, in, д; 5-б, in, г; 6th,; 7th,; 8th,; 9-г, д; 10- and,, in, г;
11-б, in, г, д;
ІІІ. 1th, 2th, 3-б, 4-in, 5th, 6-б, 7-in, 8th, 9-б, 10-б, 11-in, 12th, 13th, 14-б, 15-б, 16th,
17-б, 18th.

Answers for situation tasks for verification of eventual level of knowledges.

Answer 1
1. Quinsy is acute infectious disease with the local displays of inflammation of one or a
few components of lymphoid pharynx ring, more frequent all palatal tonsils.
2. Morbidity by a quinsy has the expressed seasonal character, epidemics are observed in
a fall-winter period, at a low temperature and high humidity of air.
bacteria, viruses, спірохети, mushrooms, can be 3. Exciters of quinsy. Among bacterial
agents a beta hemolytic streptococcus is most frequent, rarer is staphylococcus or their
combination.
Answer 2
1. Catarrhal quinsy.
2. Supercooling can cause the decline of temperature of tonsils, degenerative processes in
 43
them, strengthening of semination of their surface by microbes, decline of phagocytosis of
microbes by leucocytes.
3. Possible transition of catarrhal in an or follicle quinsy lacunasарну.
4. At little children motion of catarrhal quinsy more heavy, than at adults.

Answer 3
1. Lacunar quinsy.
2. With a follicle quinsy (rather yellow or rather yellow-white follicles which suppurated
and are under a mucus shell come forward above the surface of mucus shell of tonsilа), with
diphtheria of pharynx ( on the surface of tonsilа dirty gray color the fibrinous raid which spreads
for his scopes is taken off with labour, a hemorragic surface a stay after it).
3. Treatments: ліжковий or domestic mode without the physical loading; antibiotic
therapy (penicillin 500000 - 1000000 ODES each 4 hr. inwardly muscular); for the prophylaxis
of rheumatism appoint an aspirin 0.5 4 times per days during 10 days.

Answer 4
1. Follicle quinsy.
2. By mesopharyngoscopy.
3. it is Necessary to differentiate with a quinsy lacunasарною.
4. This utterance belongs M.P.Simanovskiy.

Answer 5
1. Phlegmonic quinsy.
2. Follicle quinsy, involvement in the process (suppuration) of deep follicles, melting of
them and паренхіми of tonsilа round them, formation of intratonsillar abscess.
3. Motion of paratonsillar abscess is stormy (high temperature of body, lockjaw
masticatory muscles, acutely laboured swallowing of meal, promoted salyvation, thrusting out,
fluctuation (more frequent in a supratonsillar area).
4. Openings of intratonsillar abscess; at relapse - tonsilectomy, antibiotic therapy.

Answer 6
1. Quinsy of nasopharynx tonsilа (viral genesis)
2. At adults conduct back rhynoscopy by a spatula and nasopharynx mirror; at small
children by mesopharyngoscopy on to the indirect signs (flowline down of mucus-festering
excretions on the back wall of oropharynx , lymphoid granules on the same wall, red spots on a
soft palate); by lateral sciagraphy of nasopharynx.
3. Possible complications of quinsy of nasopharynx tonsilа: catarrhal or festering acute
middle otitis, retropharyngeal abscess, meningitis.

Answer 7
1. it is Possible to foresee the quinsy of tongue tonsilа.
2. Doctor used mesopharyngoscopy, and tongue tonsil it is possible to examine at
hypopharyngoscopy.
3. Quinsies after the sign of localization: nasopharyngeal (adenoids), tubal tonsils, palatal
tonsils, tongue tonsilа, laryngeal quinsy.
4. Possible complications of quinsy of tongue tonsilа: glossitis, abscessing root of
language, phlegmon of bottom of cavity of mouth, edema of mucus shell leafed.

Answer 8
1. Quinsy Simanovskiy-Vincent (ulcerous-pellicle). Basic forms: pseudopellicle;
ulcerous.
2. Exciters of disease: symbiosis of fusiform stick and спірохети of cavity of mouth.
 44
3. At a ulcerative membranous quinsy: a) the common state of health suffers not enough;
b) duration of to a few Sundays; in) one-sidedness of changes in the region of pharynx; г)
exciters: symbiosis of fusiform stick and спірохети of cavity of mouth; д) favourable motion of
disease.
4. Treatments: rinse of pharynx by solutions of bactericidal action, greasing of surface by
tonsilа 10% solution of novarsenol in glycerin, antibiotic therapy (penicillin, ampicillin).

Answer 9
1. Noncommunicative pellicle form of diphtheria of pharynx.
2. a) Quickly to take and send in a laboratory a stroke from the mucus shell of tonsils and
nose.
б) To send in the СЕС urgent report (by a telephone and mail). in) To send a patient in the
infectious separation. г) To bring to a 5 мл blood from a vein (before the conduct of
antidiphtheritic whey) for determination of reaction of passive hemagglutination along with
diphtherial diagnosticum.
3. Introductions of antidiphtheritic antitoxic whey: first dose a 20-40 thousand МО and
course dose a 40-80 thousand МО. Antibiotic therapy (antibiotics of wide spectrum of action),
glucose, vitamins.

Answer 10
1. Toxic diphtheria of pharynx of the ІІ degree.
2. Toxic diphtheria of the І-degree is the edema of hypodermic cellulose to the middle of
neck; ІІ degree - to the collar-bone, ІІІ degree - below collar-bones.
3. Noncommunicative, widespread, toxic (And, ІІ, ІІІ degree), hypertoxic diphtheria of
pharynx.
4. Antidiphtheritic antitoxic whey: 100-120 thousand МО first dose; 200-240 thousand
МО on the course of treatment; . Antibiotic therapy (antibiotics of wide spectrum of action),
glucose, vitamins.

Answer 11
1. Erysipelas of mucus shell of pharynx and larynx.
2. Most reliable complication is edema of mucus shell leafed, what can result in an
asphyxia.
3. Ampicillin 1.0 4 times per day inwardly muscular; antihistaminic preparations,
steroids, diet.
Answer 12
1. Agranulocytosis. Agranulocytic quinsy.
2. Only reasoning of agranulocytosis is not present (does not exist). Agranulocytosis is
the special Agranulocytic reaction of haemopoesis on the irritation of infectious, toxic (including
medicinal - sulfonamides, medicines of pyrimidine row), radial and other nature.
3. Differential diagnosis must be above all things conducted with the Simanovskiy-
Vensan quinsy, aleycemic form of acute leucosis.
4. Treatments are conducted in the haematological or therapeutic separation. It is directed
on the removal of reason, on the fight against the second infection (antibiotics, rinses of throat by
solutions antiseptic), activation of the hematopoietic system (tezan 0.01 - 0.02 on a day,
penthoxill 0.2-0.3 on a day); ascorbic acid is appointed, cyanocobalamin, steroid and
replacement therapy by leukocyte mass.
Answer 13
1. Quinsy at a scarlatina.
2. To violation of respiratory function of nose, larynx, acute pyonecrotic middle otitides
and sinusities.
3. General antibiotic therapy, irrigation of mucus shell of mouth and pharynx by solutions
 45
antiseptic, vitamin therapy.
Answer 14
1. Anginal form of infectious mononucleosis.
2. Diseases are caused by a virus (not quite known nature), the satellite of which there are
the bacteria of listerella.
3. Ferrous, anginal, febrile.
4. Appoint intramuscular the antibiotics of wide spectrum of action, disinfectant the rinse,
valuable feed, vitamins.
Answer 15
1. Paratonzillitis (front-overhead).
2. Staggered paratonzillar cellulose between the capsule of tonsilа and overhead part of
palatal lingual handle.
3. Forms of paratonzilitis (this on a creature the stage of process of inflammation): a)
edematous,b) infiltrative, c) abscessed.
4. Treatments of paratonzilitis conservative: antibiotic intramuscular, injection of him in
the staggered paratonzillar cellulose, compress of antibiotic with a 25% solution of Dimexid.

Answer 16
1. Lateral paratonsillar abscess.
2. a) A paratonzillar cellulose is struck (will fester) between the capsule of palatal tonsilа
and lateral wall of pharynx.
б) The Parapharyngeal abscess is localized outside lateral wall of pharynx near the corner of
lower jaw and on motion of sterno-cleido-mastoideus muscle; there can be Thrombophlebitis of
internal jugular vein, bleeding at erosion of wall of vessels.
3. For clarification of diagnosis it is necessary to execute diagnostic punction.
4. In connection with rareness of spontaneous breach and difficulty of opening of lateral
paratonsillar abscess execute tonsillectomy. After it antibiotic -, resolvent therapy.

Answer 17
1. Retropharyngeal abscess.
2. it is Possible to explain by distribution of pus from top to bottom (naso-, oro,
laryngopharynx).
3. Back mediastinitis, bleeding, intracranial complications, reflex stop of cardiac activity.
4. Surgical cut from top to bottom, nearer to the middle line. At deep abscesses there is
the not eliminated possibility of opening of abscess from the side of neck, (cut on the back edge
of m.sternocleіdomastoіdeus, farther by a dull way to move up in a depth to appearance of pus).

Answer 18
1. Extraneous body (meat bone) of neck department of gullet.
2. Auxiliary methods of inspection: sciagraphy of gullet, esophagoscopy.
3. Hі. Most often extraneous bodies meet at the level of the jugular undercuting is the
overhead aperture of thorax ( Rozanov, Jackson et al) From the first narrowing often pushes the
3th designer of pharynx extraneous body downward. The Hа even undercuting is a chest narrow
enough road clearance (due to a trachea, gullet, vascular nerve bunches. Except for it, here is the
first bend of gullet to the right, related to the arc and descending department of aorta.
4. Most expedient method of delete of the uncomplicated extraneous body of neck
department of gullet - by esophagoscopy.
Answer 19
1. «Extraneous body» is the meat obstruction of pectoral department of gullet (second
narrowing).
2. Accumulations of saliva in грушоподібних sines is the Jeckson'a symptom. Ceiling by
the extraneous body of road clearance of gullet.
 46
3. Most frequent reasons of delay of extraneous bodies in a gullet:
а) disparity of size of extraneous body with the road clearance of gullet (in a certain
place);
б) origin of reflex esophagospasm; in) acute edges (ends) of extraneous body.
4. Pushing through extraneous bodies in a stomach is not expedient from possibility of
injuring of gullet (for example, by a bone which is hidden in a meat obstruction).

Answer 20
1. Extraneous body of neck department of gullet. Trauma of back wall of gullet.
2. Complications is vertebral abscess, front mediastinitis.
3. Esophagoscopy, sciagraphy of neck and thorax.
4. Neck mediastinotomy.

Theme 2:
1. Chronic pharyngitis : forms, diagnosis, treatment.
2. Actinomycosis pharynx, kandydomykoz, farynholeptotryhoz : Etiology, Symptoms,
Diagnosis, Treatment.
3. Adenoydnыe razraschenye : diagnosis, treatment.
4. Hypertrophy nasopharyngeal, lingual and palatal tonsils: diagnosis, treatment.
5. Classification of Chronic tonzylytov.
6. Comorbidities, linking with Chronic tonsillitis.
7. Diagnosis Chronic tonsillitis, probable signs.
8. Chronic tonsillitis without of exacerbation, diagnosis, treatment.
9. Differential diagnosis hypertrofyy palatal tonsils with Chronic tonsillitis.
10. Differential diagnosis tonzylohennoho with sepsis and septic termonevrozom second
origin.
11. Conservative Treatment of Chronic tonsillitis (scheme by L.A.Lukovskyy,
A.Y.Kolomyychenko, VVKischuk).
12. Indications and Contraindications to tonsillectomy.
13. Indications and Contraindications to half-surgical methods of Treatment of Chronic
tonsillitis.
Basic literature:
1. A Pocket Guide to the Ear. Albert L. Menner, M.D. Otolaryngologist in Private
Practice, Elmira, NY, USA, 2003.- 44 Illustrations.- 140 p.
2. Current Diagnosis & Treatment in Otolaryngology ”Head & Neck Surgery, 2nd
Edition. / Anil K. Lalwani.
3. Head and Neck Surgery - Otolaryngology (2-Volume Set), 3rd edition, (October 15,
2001): by Byron J., Md. Bailey (Editor), Karen H., Md. Calhoun (Editor), Gerald B., Md. Healy
(Editor), Harold C., Iii, Md. Pillsbury (Editor), Jonas T., Md. Johnson (Editor), M. Eugene, Jr.,
Md. Tardy (Editor), Robert K, Md. Jackler (Editor), Anthony Pazos (Illustrator), Chri Gralapp
By Lippincott Williams & Wilkins Publishers.- 190 p.
4. Head & Neck Surgery - Otolaryngology, 4th Edition / Editors: Bailey, Byron J.; Johnson,
Jonas T.; Newlands, Shawn D.
5. Otolaryngology: Basic Science and Clinical Review /Editor: Thomas R.Van De Water,
Ph.D., Associate editor: Hinrich Staecker, M.D., Ph.D.- Thieme, New York • Stuttgart.- 2006.-
728 p.
Additional literature:
6. Head and Neck Manifestations of Systemic Disease /October 8th, 2007 by adil.- 728
Views.- Posted in Medicine, Surgery, ENT, Nursing, Pathophysiology, General Surgery.-
2007- 608 p.
 47
7. The Harvard Medical school guide to healing your sinuses / Ralph B. Metson, M.D.
with Steven Mardon / McGraw-Hill Companies, Inc., 2005.- 207 p.
8. Hearing: anatomy, physiology, and disorders of the auditory system /Second
Edition/ A.R.Moller.- School of Behavioral and Brain Sciences University of Texas at Dallas.-
Texas.- 307 p.

Distributing of marks which can be got by a student

At mastering of theme №1 from rich in content to the module №2а for educational
activity to the student estimation for 4th is proposed by a ball (traditional) scale which is then
converted in marks as follows:

Estimation Marks
“5” 5 marks
“4” 4 marks
“3” 3 marks
“2” 0 marks

MODULE
Content module 3
Practical lessons number 12
Subject : Chronic pharyngitis. Chronic tonsillitis. Hypertrophy nasopharyngeal, lingual
and palatal tonsils. Farihgoleptotrihosis. Kahdidamikosis. Aktihomikosis.
And the relevance of the topic:
Doctors should be able to prescribe appropriate treatment and prevent the development of
complications in farintіtah, tonsillitis and sore throats. Severe pathology in children to age 3
years have retropharyngeal abscess, which in the case of delayed diagnosis and treatment can
lead to severe stenosis of the larynx, asphyxia, pneumonia aspіratsіynoї, medіastinіtu, sepsis, in
which the prognosis is very serious.

1. Learn to make the diagnosis of chronic pharyngitis, tonsillitis, paratonsillar abscess,

retropharyngeal abscess (= III).
2. Learn the principles of diagnosis and differential diagnosis of chronic diseases of these
(= III).
3. Learn especially conservative treatment (= III).
4. Learn the basic types of surgical interventions in the surgical treatment of diseases of
the pharynx (= III).
5. Learn basic methods of preventing diseases of the pharynx (= III)

Tests and tasks to check the source of knowledge

I. Find the complete and correct answer to the question.
1. Who’s more often suffer with hypertrophy of palatine tonsills?
a) child
b) middle-aged
c) older people
2. Which diseases can be a sharp increase in the palatal almonds?
a) flu
b) blood diseases
c) measles
g ) scarlet fever
3. Which instrument is carried tonzilotomiya ?
a) a scalpel
 48
b) a pair of scissors
c) tonzilotomom
g ) polypouses loop
4. What are the main complaints of patients with adenoid II-III degree?
a) violation of nasal breathing
b) fever
c) weakness
d) difficulty in swallowing
5. What characterizes the form of compensated chronic tonsillitis ?
a) there are local signs of inflammation, retromandibular lymphadenitis
b) increased migdaliny
c) there are no signs of local inflammation
g ) the back wall of the pharynx gіperemovana
d ) swelling of the tongue
6. What are the main symptoms of chronic catarrhal pharyngitis ?
a) high temperature
b) a sharp pain in the throat
a ) scratchy feeling, pain in the throat
g ) hemoptysis
7. What is chronic atrophic pharyngitis on the back of the throat ?
a) mucosa is dry, brilliant, subtle
b) a large number of rare sputum
c) mucosal hyperemia
d) hypertrophic follicles
8. What form of chronic pharyngitis easier to be treated ?
a) atrofіchna
b) Bluetongue
c) hypertrophic
9. What do I need to take a study to confirm the diagnosis " faringomіkoz "?
a) a swab from the throat
b) a piece of cork
c) the content gaps tonsil

II. Search for all the correct answers to the question.

1. Which people are more often chronic pharyngitis ?
a) in individuals with persistent violation of nasal breathing
b) in diseases of the cardiovascular system, gastrointestinal tract
c) in liver disease, dive, blood formation organs
g ) Are pre-conscription age
d ) children who suffer diathesis
e) pregnant women
2. What morphological changes were observed in the mucosa with hypertrophic pharyngitis ?
a) epithelial desquamation
b) partial disappearance of epithelium
c) destruction of the mucous glands
d) increase rows epithelium
d ) kіsti and folds
e) vasodilation
3. Which places are located cover keratinizing epithelium in farynhomikoz?
a) palatine migdaliki
b ) the back wall of the pharynx
c) the side bolsters of the pharynx
 49
 g ) the inner surface of the cheeks
d ) vestibule of mouth
4. Under which it is desirable to tonzilektomy anesthesia in children under 10 years old ?
a) endotrahealnim anesthesia
b) local infiltration anesthesia
c) epіduralnoyu anesthesia
5. What methods to stop bleeding after tonzilektomії you know ?
a) tamponade niche migdalikіv
b) vessel ligation in the wound
c) Inserting a tampon between Ends
g ) the external carotid artery ligation
d ) rinsing the mouth with 3 % hydrogen peroxide solution
6. What prevention of chronic tonsillitis ?
a) a balanced diet
b) quenching
c) sanitation fires infection (teeth, nose, sinuses)
d) use of immunomodulators
d ) physiotherapy ( UHF, laser )
e ) washing the gaps tonsils
7. Which violations have been reported in children with hypertrophic tonsils II-III degree?
a) breathing
b) food intake
c) first
d) Sleep
d ) appetite
8. What can not be held tonzilektomiyu hypertrophy of the palatine tonsils?
a) Possible bleeding
b) violation in voice
c) Scarring Pillar Palatal
d) decreasing the body's defenses
d ) immunological deficiencies
9. What diseases should be diagnosed differentsionny adenoid vegetations ?
a) foreign body nasopharynx
b) bending forward bulkhead
c) Juvenile nasopharyngeal fibroma
g ) hypertrophy of the posterior ends of inferior turbinates
d ) choanal polyp

III. Find an error in the answers to the question.

1. That there are treatments for hypertrophic pharyngitis ?
a) Grease pharynx Lugol solution
b) moxibustion hypertrophic mucosa solution of silver nitrate
c) moxibustion Trichloroacelic acid
g ) galvanokaustika
d ) kriodestruktsyya
2. What is included in the complex therapy for symptomatic atrophic pharyngitis ?
a) alkaline inhalations, rinse
b) Grease pharynx solution kolargolu
c) Oil inhalation
d) the lubricant pharynx iodo- glycerol
 50
Chronic tonsillitis
At the very outset, it must be mentioned that the mere size of the tonsils is no indication
regarding the state of their health. Enlarged tonsils may be physiological from response to
infection and small tonsils may be diseased and contracted due to fibrosis.
Besides, tonsils normally hypertrophy at the ages of two, five and thirteen. At the age of
two, the child learns to walk, gets out of the house and mixes with other playmates from whom
he catches cross infection. At the ages of five, he goes to school and mixes with still larger
number of children and at the age of thirteen when he enters adolescence, the lymphphoid tissues
all over the body hypertrophies in response to the stress and strain of puberty. However, we do
not mean to imply that the size of the tonsils should be disregarded altogether. By and large,
hypertrophied tonsils are diseased unless proved otherwise.
Aetiology. Chronic tonsillitis results from repeated attacks of acute tonsillitis and
pharyngitis. Therefore the aetiology of chronic tonsillitis is more or less the same as that of the
acute one to which the student should refer. Besides, heredity also seems to play a part. The
bacteriology is generally mixed, a gram positive coccus mixed up with a gram negative bacillus.
Clinical features. There is history of repeated attacks of sore throat which are due to
attacks of acute tonsillitis superimposed on chronic state of infection. During the acute attack,
the symptoms and signs are the same as hi an ordinary case of acute tonsillitis. In the intervals,
the patient may have no complaints. As time goes on, the interval between the attacks which
were several month in the initial stages, go on diminishing so that a time may come when the
patient is never free of symptoms. In other cases, in the interval, the tonsils may give rise to
complaints which may really be on account of their large size. Thus there may be thick voice,
dry cough, Eustachian catarrh from poor function of the soft palate or there may be difficulty in
breathing and swallowing.
Not infrequently the patient is unaware of the state of his tonsils but his attention is drawn
to his throat by some careful physician for complaints situated at a distance from the tonsils.
Such complaints may lie in the ears, the chest, the abdomen, the cardiovascular system, the
urinary system or the locomotor system; details of this have already been given in the section on
symptomatology.
On examination, if the patient comes during an acute attack there are all the signs of the
acute disease. If the patient comes in the interval between the attacks, there may be absolutely no
sign from which a conclusion of chronic tonsillitis may be drawn.
But more often, on the subsidence of an acute attack, the tonsils do not come back
absolutely to normal.
Under such circumstances, they appear to be hypertrophied and such hypertrophy is more
apparent during a fit of coughing or gagging.
Sometimes the tonsils may appear shrunken due to fibrosis. The mouths of the crypts are
easily visible and the surface of the tonsil is irregular. The colour of the tonsils is also somewhat
deeper than that of the soft palate which serves as a good background for comparison.
On pressing the tonsils through the anterior pillar by means of a second tongue depressor,
fluid pus may by expressed from the crypts, particularly the crypta magna. Sometimes
epithelium gets abraded from opposing lips of the mouth of a crypt which then become adherent.
As a result, shed off epithelium, dead micro-organisms and leucocytes collect in the crypt.
This gives the blocked crypt the yellowish white appearance of a cyst. This is called a
"retention cyst" and is taken as a sure sign of chronic tonsillitis. The tonsillar lymph glands are
easily palpable.
In children, adenoids accompany chronic tonsillitis, and then symptoms and signs of both
get superimposed upon each other.
The pathology of tonsils is closely associated with the rest of the respiratory and the
gastrointestinal tracts. Tonsillitis may be primary and pathology in other parts of these tracts
secondary, or vice versa, and always before removing the tonsils, the operator must be careful to
 51
ensure that the case of chronic tonsillitis he is dealing with, is not secondary but is primary,
because if tonsillitis is secondary, the patient is going to get worse after operation.
However, hi a long-standing case where the complaints in the tonsils and parts of the
respiratory and gastrointestinal tracts have co-existed for a number of years and the patient
cannot lay the blame on any particular region as being the primary site, more benefit will ensue
by removing the septic tonsils than by retaining them.
Treatment. Once it has been decided that the tonsils are infected, and that they have
undergone irrepairable damage, nothing but good can come out of their removal. It is a fact that
in no other region of the body is the operative treatment so beneficial as in the case of the tonsils
provided proper indications exist. It is a great misfortune that unhealthy tonsils do not often give
rise to very incapacitating symptoms so that their removal becomes more or less a matter of
option for the patient. This leads to un-due delay in their removal with consequent reduction in
the amount of benefit which would otherwise have ensued had the tonsils been removed in time.
If infected tonsils are left in the throat for any length of time, they often given rise to
inflammatory mischief elsewhere, e.g., in the nose, the paranasal sinuses, the ears and the chest
efc., with the unavoidable misfortune that their removal will not give 100% benefit and when
changes have occurred in these other regions, the benefit is correspondingly less.
There is practically no medicinal treatment During the acute attacks medicines may be
given as outlined in the section on acute tonsillitis, but they seldom do anything more than
suppress the attack and another attack follows sooner or later.
Tonics, vitamins, anabolic agents and local remedies are all temporising. They are worthy
of trial in doubtful cases where the examiner cannot definitely decide in favour of chronic
infection, but once a definite decision of chronic infection has been taken and it has been
assessed that tonsils cannot come back to a permanent state of health, they should be removed as
soon as the first opportunity makes itself available.
Recently the operation has suffered a set-back on account of pro-miscuous* surgery
where indications have not been correctly weighed. Chances of faulty decisions are quite
obvious in a busy out-patient department or a general practitioner's clinic where the examiner has
not got the necessary time available to fit all the evidence in favour of or against removal.
Thus in an unquestioned case of chronic infection in the tonsils the only dependable
treatment is tonsillectomy, /.«., complete removal of both the tonsils. In the words of a wise man
"Healthy tonsils should never be removed and diseased tonsils should always be removed" is the
golden rule to follow. This brings us to the question: "when to remove the tonsils"?.
Indications for tonsillectomy. At the very outset, it must be made plain that whatever
indication may there be for the removal of the tonsils, chronic infection in the tonsils themselves
must be inferred from history and clinical examination. It is not enough to remove them merely
on the suspicion or theoretical knowledge that infection in the tonsils and/or upper respiratory
tract can give rise to the condition it is intended to-cure, for example that chronic joint pains are
very often due to infection in the upper respiratory tract, and therefore in every such case tonsils
should not be removed.
It is true that such a disease generally starts after infection in the upper respiratory tract or
may be kept up by the same, yet in a given case it may not be so. Even if it starts after a sore
throat, the tonsils might have recovered from the infection and the joint pains may be kept up by
infection elsewhere, e.g., in the teeth or the sinuses.
The gist of the matter is that tonsils must be chronically infected before it is decided to
remove them. Subject to the above provision the indications for tonsillectomy are:
A. Local: 1. Repeated attacks of acute tonsillitis. These should preferably have lasted not
less than two years and the intervals in between the attacks should not have been longer than
three months.
2. Even one attack of peritonsillar abscess, about three months after the attack has healed.
3. Simple tumours and very early malignant growths of the tonsils and foreign bodies
embeded in them.
 52
4. Tonsil remnants from a previous tonsillectomy if they give rise to symptoms.
B. Neighbourhood:
5. Cervical adenitis particularly of the upper region.
6. Repeated attack of rhinitis and sinusitis following attacks of tonsillitis. If the attacks of
nasal infection precede the tonsillar infection, the tonsillitis is secondary and the tonsils should
not be removed unless such infection has lasted for a long time and it is presumed that the tonsils
have undergone irreparable damage even though secondary to rhinitis, etc.
7. Chronic tubal catarrh and suppurative otitis media.
8. Chronic pharyngitis, dyspepsia, mesenteric adenitis, cholecystitis, appendicitis,
etc.
9. Repeated attack of laryngitis, bronchitis, lung infection, asthma and other respiratory
diseases secondary to tonsils.
C. Systemic:
10. Rheumatism in the muscles and joints, getting worse during the attacks of tonsillitis.
11. Myo-and endocarditis,
12. Glomerulonephritis.
13. Pyreria of uncertain origin (P. U. O.), a low state of health, anaemia and lack of
vigour.
D. Mechanical:
14. Obstruction to breathing and swallowing.
15. Persistent dry cough due to a foreign body feeling in the • throat. In such cases, a
thorough investigation should be carried out to find out any other cause for cough before
accusing the tonsils.
16. Thick speech.
E. Miscellaneous:
17. Diphtheria carriers, three months after the attacks.
18. Some cases of thyroid enlargement and infectious fevers of the upper respiratory
tract.
19. Pulmonary tuberculosis in association with chronic tonsillitis. In such cases, the lung
lesion must be treated first and when it has healed, the tonsils should be removed under local
anaesthesia.
Centra-Indications
(A) Absolute.
1. Allergic rhinitis and asthma until and unless there is convencing evidence of tonsillar
infection.
2. Bleeding diseases e.g. leukaemias, purpuras, aplastic anaemia and haemophilia.
3. Epidemic of poliomyelitis.
4. Acute tonsillitis.
(B) Relative contra-indications.
1. Age less than five years and more than forty years. However, they can be removed
under compulsion e.g. on the advice of the attending family doctor or the request of the parents.
2. Singers, teachers and others whose livelihood depends on voice production should be
explained that they may have to train their voice afresh after removal of the tonsils.
3. Pregnancy and menstrual period.
4. Size alone, until and unless it produces symptoms.
5. Organic diseases e.g. active pulmonary tuberculosis, severe diabetes, gross hyertension
(Ordinarily, systolic blood pressure should be below 160mm Hg for tonsillectomy).
6. Upper respiratory infection.
7. In severely anaemic patients, haemoglobin below 60%.
Investigations: These are principally directed toward excluding the contraindications
given above. Thus the following investigations should be carried out before operation.
 53
1. The temperature should be taken to exclude the possibility of an acute attack. Mild
temperature does not matter but high temperature contraindicates immediate surgery.
2. Bleeding .and coagulation time to exclude a bleeding disease. The normal bleeding
time is two to four minutes and coagulation time four to six minutes. In some hospitals a routine
bleeding and coagulation time is not taken but more reliance is placed on a personal and/or
family history of a bleeding disease. History of bleeding at the time of circumcision and falling
off of the deciduous teeth gives workable guidance. History of excessive bleeding with minor
trauma should also be taken.
3. Haemoglobin percentage. This should preferably be not less than 60%.
4. Total and differential leucocyte count.
5. Blood pressure: In all patients above the age of twenty-five.
6. Urine examination: It should be free from sugar except in traces.
7. X-ray of paranasal sinuses and chest to exclude sinusitis and pulmonary tuberculosis.
As regards both these diseases, refer to the details given above.
Premedication.
It consists of atropine in children and morphia and atropine, or pethidine and atropine in
adults.
Anaesthesia.
The anaesthesia may be general or local. In all children, general anaesthesia should
always be given. In adults also general anaesthesia is preferable but in case of a contraindication
to general anaesthesia and secondly, if the patient so prefers, local anaesthesia should be given.
General anaesthesia should be administered with endotracheal intubation. Intubation is
not necessary in children when tonsils have to be removed with guillotine. In children to be
operated upon by dissection method, intubation is necessary. In adults the tonsils are always
removed by dissection and so when general anaesthesia is administered, intubation is essential.
General anaesthesia is the domain of the anaesthetist. The operator may have to give local
anaesthesia himself. The usual premedication is given and the throat is sprayed with cocaine-
adrenaline solution three times at five minutes' intervals.
Each tonsil bed is then infiltrated with about 15 c.c. of 1% novocain or xylocaine solution
to which a few drops of adrenaline 1/1000 have been added. 5 c.c. of the solution is injected at
three points, the upper pole, the middle and -the lower pole, through the anterior faucial pillar.
This makes the tonsil bulge medially.
The tonsils can now be removed with the patient sitting in the upright position in a chair
by the dissection method. It is still better to give the patient about 15 mgm. of largactil and 100
mgm. of pethidine intravenously and remove the tonsils with the patient lying on the back in the
same position as under general anaesthesia.
Methods of removal: Tonsils may be removed by four methods
1. The guillotine method.
2. The dissection method.
3. Cryo-surgical method.
4. Laser surgical method.
The guillotine method: In former days, the guillotine was a great favourite. The method is
employed principally in children in whom it is presumed that there is no adhesion-formation
between the tonsils and their surroundings.
The child is not intubated and the adenoids can be removed by just administering geneial
anaesthesia to the child by the mouth with a Doyne's gag. Before the child recovers from
anaesthesia, both the tonsils and the adenoids canbe removed and the whole process does not
take more than a minute. Bleeding is free for a short time and then stops. The advantage of the
method Is that it is quick. No ligature is applied. The disadvantages are that the guillotine may
leave behind a part of the tonsil or may remove something more than the tonsil. "Remove the
tonsil, the whole tonsil and nothing but the tonsil" is the only rule. Secondly the bleeding vessels
are not ligatured, and there is great risk of post-operative bleeding
 54
Dissection method.
This method is being used all over the world. In this method the tonsil is removed in a
planned manner,.slowly and steadily dissecting it out from its bed. It can be done under general
or local anaesthesia and in children or adults.
If general anaesthesia is used, the patient is intubated.
He lies on the operation table on the back with a pillow under the shoulders and head
extended. The operator sits or stands on the head side of the table. A Boyle-Davis gag is applied
and an assistant holds it up and keeps the head extended.
Alternatively, the assistant can be replaced by a suspension .apparatus. Light is thrown on
to the patient's throat. The tonsil is held near the upper pole by means of a tonsil-holding forceps,
a Luc's forceps or a vulsellum.
With tonsil scissors or with a tonsil-knife, an incision is given along the anterior pillar
from just aboye the lower pole towards the upper pole and as close to the medial border of the
pillar as possible. The incision cuts just the mucous membrane and is carried round and above
the upper pole and is then carried downwards along the posterior faucial pillar. Having given the
incision, the tonsil is palled medially 'and a dissector, generally Gwynne's-Evan's or Negus'
pushes the peritonsillar tissues away from the tonsil and thus dissects them out.
The dissection is started at the upper pole and proceeds downwards. The reason for
choosing the upper pole to begin with, is that there is lot of areolar tissue around this pole and by
dissection it is easy to find the proper plane of cleavage between the tonsil and the superior
constrictor.
Finding the proper plane is highly important. If one dissects medially to this plane, part of
the tonsil will be left behind and the patient will end up with tonsil remains in tonsilar fossa. If
one dissects lateral to this plane, part of the superior constrictor will be removed and there will
be a lot of fibrous tissue development in the fossa.
Moreover, under both conditions, serious haemorrhage will occur. As one proceeds with
dissection, any space created in the tonsil fossa is packed with pieces of gauze. This serves two
purposes, first it stops bleeding by pressure and secondly it dissects the tonsil out by blunt gauze
dissection and helps in sticking to the plane between the tonsil and the surrounding tissues. The
field is kept dean by occasional suction.
On reaching the lower pole, a cut is made with scissors in the mucosa round the lower
pole and dissection completed with the dissector. No part of the lingual tonsil should be
removed.
Many surgeons apply the tonsil snare reaching the lower pole. The tonsil snare first
crushes & then cut the lower pole which is said to reduce bleeding, but it does not dissect out the
tonsil so cleanly as the tonsil dissector.
Having completed the dissection, the gauze pieces are removed one by one and any
bleeding points worth ligaturing are caught and ligatured. The procedure is repeated on the
opposite side. It is advisable to remove one tonsil and procure complete haemostasis of the side
before proceeding on to the dissection of the other side. Bleeding at the time of operation may
be:
1. Arterial.
This is spurting with the pulse, blood is bright red in colour. Near the upper pole it is
from branches of the greater palatine artery; near the middle from tonsillar artery and near the
lower pole from branches of the dorsalis linguae artery.
2. Venous.
This is welling up Uke a spring. The blood is dark in colour. The usual bleeder is the
para-tonsillar vein.
3. Capillary.
This is oozing from a surface and not from a point. The fossa fills up slowly and not
rapidly as in the case of arterial or venous bleeding.
 55
Arterial and venous bleeding needs ligaturing; capillary bleeding needs mild pressure
with a swab.
A pack given round the tube above the larynx (epilaryngeal pack) keeps that patient
deeply under anaesthesia by not allowing him to breath air round the tube and also not allow the
blood to go into the lungs.
There are several methods of applying ligature. Many surgeons use the tonsil needle but
the writers have preference for slip-knot.
In children, when the tonsils have been removed, the patient is reintubated through the
oral route and then adenoidectomy is performed. Some people intubate the patient through the
mouth and remove the adenoids before removing the tonsils. This method has the advantage of
not pushing sepsis from the nose into the lungs as may happen if intubation is performed through
the nose, but it adds to the difficulties of the surgeon by occupying some space in the already
narrow throat.
When the tonsils and the adenoids have been removed and there is not note-worthy
bleeding, the patient is put on the side and the head is lowered so that any blood, mucus, or
vomitus flow out instead of going inside. When the patient has appreciably recovered from
anaesthesia and the cough reflex has returned, he can be shifted to the ward.
The method of dissection under local anaesthesia is similar to that under general
anaesthesia. At the end of the operation, the patient is returned to the ward in an upright position.
Post-operative care.
The wound in the throat takes roughly two weeks to heal. On account of the peculiar site
of operation, no dressing can be applied with the result that bleeding, no matter how mild is
naturally to be expected. Moreover, the operation site is open to infection from inspired air and
food; thirdly, the constant action of the pharyngeal muscles does not allow enough rest to the
wound. The postoperative management will, therefore, resolve itself into
1) avoidance of bleeding
2) avoidance of infection and
3) avoidance of trauma.
On having been received in the ward from the operation theatre, the patient is put on the
side with head low, if the operation has been performed under general anaesthesia. This position
is maintained till recovery from anaesthesia in order that blood or mucus etc., in the throat
should flow outward rather than inward, when the head is raised and the feet are lowered.
If tonsillectomy has been performed under local anaesthesia, the patient is given a back
rest from the very start. A strict watch is kept for any serious bleeding; minor amount of bleeding
which does not call for any special postoperative management, occurs in the almost every case.
Frequent swallowing movements by a semiconscious patient may indicate bleeding worth
taking note of.
To check on serious bleeding/the patient's puke is recorded every 15 minutes for the first
2 hours and half an hour for the next 6 hours.
A rising pulse rate indicate bleeding worth taking note of. In most cases this is
accompanied by blood appearing through the nose or mouth in sufficient amount and bright red
in colour.
The blood pressure, if checked, will also show a steady fall. If so, something must be
done.
Postoperative bleeding may occur within the first 24 hours and between the fifth and the
tenth days; details of these are given hereafter.
To avoid infection, the patient is given routine antibiotics for the first four or five days.
Most people do not agree with routine administration of such drugs but it is the writers' opinion
that they do ward of several complications and make the patient's convalescence easy for him.
To avoid trauma, the patient is given light, fluid or semi-solid, easily digestible diet for
two weeks after the operation. In the early days, this may be sweet and cold for example ice-
 56
cream or ice milk particularly in summer, giving place within two or three days to semi-solid diet
like jelly, sago, custard etc., followed by pudding made out of rice flour (fimi), etc.
On the fourth or fifth day the patient may take a little soup to which some salt (but no
chillies) has been added. The patient may also take bread soaked in milk, or soup.
Reversion to normal diet should be slow and steady and the process completed in about
two weeks. During this time, the patient is also given cold gargles two to three times a day to
keep the mouth clean. It is a characteristic of the operation that, due to diet restriction, the patient
loses weight in the post-operative period, but rapidly makes it up on going back to normal diet. If
the bowels do not open by the fourth day, light laxative or enema may be given.
The patient should be warned that removal of tonsils is no guarantee against sore throat
which injudicious diet may excite.
For a few days after tonsillectomy, the tonsil fossae are covered with whitish slough
which disappears slowly in about 10-14 days' time. This appearance should not be confused with
diphtheria, ft gives rise to no special symptoms, e.g., those of frank sepsis or severe toxaemia.
Cryo-surgical method
Cryo-tonsillectomy: The name of the procedure cryo-tonsillectomy is not semantically
correct as not all of the mass of lymphoid tissue is removed but accurate word would be cryo-
genic subtotal tonsillectomy.
Cryo-tonsillectomy is performed for selective patients of small to moderately enlarged
tonsils under local anaesthesia. Necrosis of the tonsils results from rapid deep freezing of the
tissue. Due to anaesthesia of the regional nerve caused by freezing this procedure becomes
relatively painless.
Necrosis of the tissue occurs within hours and is completed within several days. The
necrosed tissue sloughs off leaving behind granulating base which is said to be relatively
resistant to infection. It has been suggested that freezing may produce auto-immune, antigen-
antibody reaction by virtue of alteration in the tissue proteins. The technique is relatively free
from bleeding since intracapillary thrombosis takes place due to freezing.
Patient feels post-operative pain but intensity of pain is not severe. The pain can be
relieved by simple medication.
It is suggested that this procedure should not be carried out in enlarged tonsils, since post-
operative oedema of remaining tonsillar tissue results in airway obstruction. It is not possible to
perform cryo-tonsillectomy in children without general anaesthesia.
Advantages over conventional surgical tonsillectomy:
1. Hospitalization is not necessary.
2. No risk of general anaesthesia.
3. No postoperative incapacitation.
4. No postoperative bleeding.
Disadvantages.
1. The time requiring is relatively longer than conventional Surgery.
2. Cryo-probe and accompanying delivery system needs substantial investment.
3. The remnants become infected again.
4. It is not possible to carry out in children without general anaesthesia.
Complications:
1. Bleeding: Since our early days as students, we have been hearing the dread of bleeding
in tonsillectomy. This may have been true in those days but it appears rather misplaced now-a-
days. Improved methods of operation and anaesthesia have, reduced this complication to rare
occurrence. In former days, factors encouraging bleeding were the use of guillotine and
anaesthesia without intubation which did not allow of planned haemostasis after removal of the
tonsils. But now-a-days, the patient is intubated, the tonsils are dissected out and after dissection,
the bleeding points are caught at leisure and ligatured, thus reducing the incidence of bleeding
after tonsillectomy.
Post-tonsillectomy bleeding may be:
 57
I. Primary
II. Reactionary
III. Secondary.

I. Primary haemorrhage: This occurs at the time of operation and bleeding is controlled
by applying ligatures to the bleeding points.
II. Reactionary haemorrhage: This occurs within the first 24 hours after operation and
more so within the first eight hours. It is called reactionary, because following general
anaesthesia the blood pressure may rise or following local anaesthesia there may be reactive
vasodilatation When the effect of adrenaline passes off.
Reactionary bleeding may be moderate or severe. Moderate bleeding needs attention. The
patient should be given some sedative to allay anxiety; morphia is very good for this purpose but
it should not be given to children.
The patient should be made to sit upright.
The face and neck should be fomented with ice. The throat should be inspected and if
there is any blood clot in any tonsillar fossa, it should be removed and the fossa pressed with a
swab soaked in 6 vols. % hydrogen peroxide or 10% protargol.
For severe bleeding, the patient should be re-anaesthetised in the operation theatre,
intubated and the bleeding point stitched in a planned manner.
In rare instances either at the time of original operation or after reactionary haemorrhage,
if there is generalised oozing from the fossa, a pack of gauze should be inserted into the fossa
and-pillars stitched over it for 24 hours.
Also rarely, blood transfusion may be required.
III. Secondary haemorrhage occurs between the fifth and the tenth days generally. It is
due to infection in the tonsillar fossa and forcible detachment of crusts which may be on account
of a bout of coughing or taking of some solid food. It may also be moderate or severe.
When moderate, its treatment is the same as for moderate reactionary haemorrhage.
When severe, it does not allow of ligaturing of the bleeding points because the whole fossa is
friable and artery forceps cannot be applied. The best plane would be tying-in a pack and given
blood transfusion, which is very rarely needed. Antibiotics should be given.
2. Pain in the ear. This may occur from otitis media following tonsillectomy or the pain
may be just referred from the tonsil fossa mostly the latter. The treatment is on general lines.
3. Insufficiency of the palate. This may occur immediately after the operation from
stretching of or trauma to the palate during operation, or it may be remote from too radical
removal of the tonsils giving place to fibrosis after some months.
The result is excessive nasal twang in the voice (rhiholalia aperta) and regurgitation of
fluids through the nose. The immediate insufficiency soon recovers with Vitamin 'B' injections
and palatal exercises, e.g., repeatedly blowing up a balloon but the remote in-sufficiency is
difficult to cure. It may need pharyngoplasty.
4. Several infective complications have been described, e.g., in the lungs, pharyngeal
space, blood etc., but they are very rare now-a-days.
5. A common complication is fever lingering on for many days after the operation. In our
opinion, this is due to the attack by the malarial parasite in patients who harboured the same. The
parasite attacks "on accounts of lowered resistance following the operation. The treatment is as
for malaria.
6. In patients in whom the operation is performed for the relief of heart, kidney or joint
disease, such disease exacerbates after the operation on account of the release of a large number
of the causative micro-organisms into the circulation at the time of operation. Such an
exacerbation is a proof of the association of chronic tonsillitis with heart, kidney or the joint
condition in the particular patient. In due course, it settles down never to return or return in a
very mild form.
7. Inefficient removal.
 58
This may be too much or too little. In the former case, the surroundings may be injured-
soft palate, uvula, tongue, pharyngeal muscles etc. In the latter case, tonsil remnants are left
behind. Sometimes these remnants produce symptoms e.g., irritation in throat giving rise to
cough etc., or recurrent infection particularly if they are left behind with one or more crypts e.g.,
the crypta magna. Such remnants deserve surgical removal, or dealing with cryo-surgery.
Conservative treatment of chronic tonsillitis:
Sometimes chronic tonsillitis has to be treated conservatively e.g., when the indications
for their removal are not clear cut or when there is any contraindication to then- removal or, for
instance, the patient cannot attend a hospital where their removal can be undertaken. Under these
and similar circumstances, the following treatment can be givea
1. General. The patient should be instructed to lead a regular life free from worries and
anxiety. He should have regular hours of rest and exercise and should take balanced diet rich hi
proteins and vitamins. He should avoid excess of all sorts.
2. Tonics may be prescribed e.g., preparation of iron, liver, arsenic, vitamins and
anabolicsi.
3. The patient's general health should receive appropriate attention e.g., obesity,
rheumatism, diabetes, etc.
4. Local treatment should be instituted on the following lines:
I. Gargles e.g., saline, soda bicarb, antiseptic mouth washes etc.
II. Throat paints e.g., Mandl's, guaicol glycerin, resorcin glycerin etc.
III. Lozenges to suck e.g., penicillin lozenges, tyrozets.
5. The crypts may be sucked, off and on by the medical attendant with a sucker, or
alternatively, the patient himself may express out infected matter from the crypts.
6. Antibiotics may .be prescribed, assisted if necessary, by culture and sensitivity test of
the thraot swab.
7. Any infection round-about the throat should be vigorously treated Ј.&, in the nose and
paranasal sinuses, mouth, teeth and gums and in the respiratory or the gastrointestinal tracts.
8. The patient should avoid:
I. Too much spices and condiments.
II. Thermal trauma to the throat e.g., too hot or too cold eatables.
III. Smoking and drinking,
IV. Pickles, citrous fruits and other sour eatables,
V. Cold and dust,
VI. Abuse of voice,
VII. Other patients suffering from nose and throat infection.

Chronic Pharyngitis
This may result from repeated acute attacks or the patient may have no memory of such
attack. By and large, the aetiology of chronic pharyngitis resembles that of the acute stage. The
patient is generally stout and plethoric and about middle-aged smoker. Males are affected more
often than females. Chronic pharyngitis is nearly always secondary to infection elsewhere, for
example in the nose paranasal sinuses, chest and abdomen.
Clinical features.
There may be no symptoms referable to the throat and the discovery of chronic
pharyngitis may be an accidental finding on routine examination of the patient for some other
trouble. When symptoms are present, they generally take the form of a little discomfort in the
throat, a feeling of foreign body, dry cough, thick voice or nasal obstruction. There may be much
hawking or gagging. In more severe cases, there may be actual pain hi the throat which may even
be referred to the ears.
If there is concomitant Eustachian catarrh, there may be a complaint of deafness.
Not infrequently there may be voice changes.
 59
Often there are symptoms referable to the nose, the throat and the digestive system.
On examination a stout middle-aged patient, generally male and looking rather well-fed
has got a throat which is narrow in comparison to the thickness of the neck. The whole
pharyngeal wall appears to be thick and hypertrophic. It may be a bit congested and there is
excess of thick secretion on it. The patient's throat is hyper-irritable and he may start gagging on
merely opening the mouth, much less to bear the touch of a tongue depressor. The uvula appears
hypertrophic and the movements of the palate appear clumsy. The tonsils may be somewhat
prominent. The mucous membrane may be wet from over-secretion of mucus or in very late
cases it may be dry from atrophy of the mucous glands.
In some cases the lateral band present in posterior pharyngeal wall are very much
hypertrophied from chronic infection and appear as distinct bands in the throat. This is called
lateral pharyngitis (This appearance may also sometimes be seen as a compensatory
phenomenon following tonsillectormy.)
In other cases, there may be hypertrophy of lymph follicles under the mucous membrane
of the pharynx appearing like granulations. This condition is called granular pharyngitis. These
granules are very irritating to the throat and produce dry cough. They generally result from nasal
or sinus infection or are a compensatory phenomenon following tonsillectomy.
Treatment.
This is general and local. The general treatment consists of advising the patient on a
proper way of life, good dietary habits and regulation of life as regards exercise and sleep. The
cause should be investigated and treated: thus smoking, anaemia, rheumatism, diabetes,
dyspepsia etc., should receive appropriate attention. If the patient is habitually constipated, this
should be relieved. If the voice is affected appreciably, the patient requires lessons in correct
voice production (elocution).
Too much emphasis on local treatment may be harmful. Some simple spray or lozenges
are often enough. The patient should adhere to saline or soda bicarb gargles morning and
evening. The authors have great respect for alum; a pinch of dry and powdred alum added to
saline or soda bicarb solution is often reported to be very beneficial by the patient. Orodental
hygiene should be scrupulously ensured. Mandl's throat paint is given for chronic cases. If there
are granules in the throat, they should be painted with 25% silver nitrate solution twice a week.
Galvanocautery in the treatment of granular pharyngitis is not recommended. The gist of
the matter is that general treatment should receive priority over local treatment and removal of
the cause, if discovered is all important.

VI action -oriented basis

Chronic tonsillitis
At the very outset, it must be mentioned that the mere size of the tonsils is no indication
regarding the state of their health. Enlarged tonsils may be physiological from response to
infection and small tonsils may be diseased and contracted due to fibrosis.
Besides, tonsils normally hypertrophy at the ages of two, five and thirteen. At the age of
two, the child learns to walk, gets out of the house and mixes with other playmates from whom
he catches cross infection. At the ages of five, he goes to school and mixes with still larger
number of children and at the age of thirteen when he enters adolescence, the lymphphoid tissues
all over the body hypertrophies in response to the stress and strain of puberty. However, we do
not mean to imply that the size of the tonsils should be disregarded altogether. By and large,
hypertrophied tonsils are diseased unless proved otherwise.
Aetiology.
Chronic tonsillitis results from repeated attacks of acute tonsillitis and pharyngitis.
Therefore the aetiology of chronic tonsillitis is more or less the same as that of the acute one to
which the student should refer. Besides, heredity also seems to play a part. The bacteriology is
generally mixed, a gram positive coccus mixed up with a gram negative bacillus.
 60
Clinical features.
There is history of repeated attacks of sore throat which are due to attacks of acute
tonsillitis superimposed on chronic state of infection. During the acute attack, the symptoms and
signs are the same as hi an ordinary case of acute tonsillitis. In the intervals, the patient may have
no complaints. As time goes on, the interval between the attacks which were several month in
the initial stages, go on diminishing so that a time may come when the patient is never free of
symptoms. In other cases, in the interval, the tonsils may give rise to complaints which may
really be on account of their large size. Thus there may be thick voice, dry cough, Eustachian
catarrh from poor function of the soft palate or there may be difficulty in breathing and
swallowing.
Not infrequently the patient is unaware of the state of his tonsils but his attention is drawn
to his throat by some careful physician for complaints situated at a distance from the tonsils.
Such complaints may lie in the ears, the chest, the abdomen, the cardiovascular system, the
urinary system or the locomotor system; details of this have already been given in the section on
symptomatology.
On examination, if the patient comes during an acute attack there are all the signs of the
acute disease. If the patient comes in the interval between the attacks, there may be absolutely no
sign from which a conclusion of chronic tonsillitis may be drawn.
But more often, on the subsidence of an acute attack, the tonsils do not come back
absolutely to normal.
Under such circumstances, they appear to be hypertrophied and such hypertrophy is more
apparent during a fit of coughing or gagging.
Sometimes the tonsils may appear shrunken due to fibrosis. The mouths of the crypts are
easily visible and the surface of the tonsil is irregular. The colour of the tonsils is also somewhat
deeper than that of the soft palate which serves as a good background for comparison.
On pressing the tonsils through the anterior pillar by means of a second tongue depressor,
fluid pus may by expressed from the crypts, particularly the crypta magna. Sometimes
epithelium gets abraded from opposing lips of the mouth of a crypt which then become adherent.
As a result, shed off epithelium, dead micro-organisms and leucocytes collect in the crypt.
This gives the blocked crypt the yellowish white appearance of a cyst. This is called a
"retention cyst" and is taken as a sure sign of chronic tonsillitis. The tonsillar lymph glands are
easily palpable.
In children, adenoids accompany chronic tonsillitis, and then symptoms and signs of both
get superimposed upon each other.
The pathology of tonsils is closely associated with the rest of the respiratory and the
gastrointestinal tracts. Tonsillitis may be primary and pathology in other parts of these tracts
secondary, or vice versa, and always before removing the tonsils, the operator must be careful to
ensure that the case of chronic tonsillitis he is dealing with, is not secondary but is primary,
because if tonsillitis is secondary, the patient is going to get worse after operation.
However, hi a long-standing case where the complaints in the tonsils and parts of the
respiratory and gastrointestinal tracts have co-existed for a number of years and the patient
cannot lay the blame on any particular region as being the primary site, more benefit will ensue
by removing the septic tonsils than by retaining them.
Treatment.
Once it has been decided that the tonsils are infected, and that they have undergone
irrepairable damage, nothing but good can come out of their removal. It is a fact that in no other
region of the body is the operative treatment so beneficial as in the case of the tonsils provided
proper indications exist. It is a great misfortune that unhealthy tonsils do not often give rise to
very incapacitating symptoms so that their removal becomes more or less a matter of option for
the patient. This leads to un-due delay in their removal with consequent reduction in the amount
of benefit which would otherwise have ensued had the tonsils been removed in time.
 61
If infected tonsils are left in the throat for any length of time, they often given rise to
inflammatory mischief elsewhere, e.g., in the nose, the paranasal sinuses, the ears and the chest
efc., with the unavoidable misfortune that their removal will not give 100% benefit and when
changes have occurred in these other regions, the benefit is correspondingly less.
There is practically no medicinal treatment During the acute attacks medicines may be
given as outlined in the section on acute tonsillitis, but they seldom do anything more than
suppress the attack and another attack follows sooner or later.
Tonics, vitamins, anabolic agents and local remedies are all temporising. They are worthy
of trial in doubtful cases where the examiner cannot definitely decide in favour of chronic
infection, but once a definite decision of chronic infection has been taken and it has been
assessed that tonsils cannot come back to a permanent state of health, they should be removed as
soon as the first opportunity makes itself available.
Recently the operation has suffered a set-back on account of pro-miscuous* surgery
where indications have not been correctly weighed. Chances of faulty decisions are quite
obvious in a busy out-patient department or a general practitioner's clinic where the examiner has
not got the necessary time available to fit all the evidence in favour of or against removal.
Thus in an unquestioned case of chronic infection in the tonsils the only dependable
treatment is tonsillectomy, /.«., complete removal of both the tonsils. In the words of a wise man
"Healthy tonsils should never be removed and diseased tonsils should always be removed" is the
golden rule to follow. This brings us to the question: "when to remove the tonsils"?.
Indications for tonsillectomy.
At the very outset, it must be made plain that whatever indication may there be for the
removal of the tonsils, chronic infection in the tonsils themselves must be inferred from history
and clinical examination. It is not enough to remove them merely on the suspicion or theoretical
knowledge that infection in the tonsils and/or upper respiratory tract can give rise to the
condition it is intended to-cure, for example that chronic joint pains are very often due to
infection in the upper respiratory tract, and therefore in every such case tonsils should not be
removed.
It is true that such a disease generally starts after infection in the upper respiratory tract or
may be kept up by the same, yet in a given case it may not be so. Even if it starts after a sore
throat, the tonsils might have recovered from the infection and the joint pains may be kept up by
infection elsewhere, e.g., in the teeth or the sinuses.
The gist of the matter is that tonsils must be chronically infected before it is decided to
remove them. Subject to the above provision the indications for tonsillectomy are:
A. Local:
1. Repeated attacks of acute tonsillitis. These should preferably have lasted not less than
two years and the intervals in between the attacks should not have been longer than three
months.
2. Even one attack of peritonsillar abscess, about three months after the attack has healed.
3. Simple tumours and very early malignant growths of the tonsils and foreign bodies
embeded in them.
4. Tonsil remnants from a previous tonsillectomy if they give rise to symptoms.
B. Neighbourhood:
5. Cervical adenitis particularly of the upper region.
6. Repeated attack of rhinitis and sinusitis following attacks of tonsillitis. If the attacks of
nasal infection precede the tonsillar infection, the tonsillitis is secondary and the tonsils should
not be removed unless such infection has lasted for a long time and it is presumed that the tonsils
have undergone irreparable damage even though secondary to rhinitis, etc.
7. Chronic tubal catarrh and suppurative otitis media.
8. Chronic pharyngitis, dyspepsia, mesenteric adenitis, cholecystitis, appendicitis,
etc.
 62
9. Repeated attack of laryngitis, bronchitis, lung infection, asthma and other respiratory
diseases secondary to tonsils.
C. Systemic:
10. Rheumatism in the muscles and joints, getting worse during the attacks of tonsillitis.
11. Myo-and endocarditis,
12. Glomerulonephritis.
13. Pyreria of uncertain origin (P. U. O.), a low state of health, anaemia and lack of
vigour.
D. Mechanical:
14. Obstruction to breathing and swallowing.
15. Persistent dry cough due to a foreign body feeling in the • throat. In such cases, a
thorough investigation should be carried out to find out any other cause for cough before
accusing the tonsils.
16. Thick speech.
E. Miscellaneous:
17. Diphtheria carriers, three months after the attacks.
18. Some cases of thyroid enlargement and infectious fevers of the upper respiratory
tract.
19. Pulmonary tuberculosis in association with chronic tonsillitis. In such cases, the lung
lesion must be treated first and when it has healed, the tonsils should be removed under local
anaesthesia.
Centra-Indications
(A) Absolute.
1. Allergic rhinitis and asthma until and unless there is convencing evidence of tonsillar
infection.
2. Bleeding diseases e.g. leukaemias, purpuras, aplastic anaemia and haemophilia.
3. Epidemic of poliomyelitis.
4. Acute tonsillitis.
(B) Relative contra-indications.
1. Age less than five years and more than forty years. However, they can be removed
under compulsion e.g. on the advice of the attending family doctor or the request of the parents.
2. Singers, teachers and others whose livelihood depends on voice production should be
explained that they may have to train their voice afresh after removal of the tonsils.
3. Pregnancy and menstrual period.
4. Size alone, until and unless it produces symptoms.
5. Organic diseases e.g. active pulmonary tuberculosis, severe diabetes, gross hyertension
(Ordinarily, systolic blood pressure should be below 160mm Hg for tonsillectomy).
6. Upper respiratory infection.
7. In severely anaemic patients, haemoglobin below 60%.
Investigations: These are principally directed toward excluding the contraindications
given above. Thus the following investigations should be carried out before operation.
1. The temperature should be taken to exclude the possibility of an acute attack. Mild
temperature does not matter but high temperature contraindicates immediate surgery.
2. Bleeding .and coagulation time to exclude a bleeding disease. The normal bleeding
time is two to four minutes and coagulation time four to six minutes. In some hospitals a routine
bleeding and coagulation time is not taken but more reliance is placed on a personal and/or
family history of a bleeding disease. History of bleeding at the time of circumcision and falling
off of the deciduous teeth gives workable guidance. History of excessive bleeding with minor
trauma should also be taken.
3. Haemoglobin percentage. This should preferably be not less than 60%.
4. Total and differential leucocyte count.
5. Blood pressure: In all patients above the age of twenty-five.
 63
6. Urine examination: It should be free from sugar except in traces.
7. X-ray of paranasal sinuses and chest to exclude sinusitis and pulmonary tuberculosis.
As regards both these diseases, refer to the details given above.
Premedication.
It consists of atropine in children and morphia and atropine, or pethidine and atropine in
adults.
Anaesthesia.
The anaesthesia may be general or local. In all children, general anaesthesia should
always be given. In adults also general anaesthesia is preferable but in case of a contraindication
to general anaesthesia and secondly, if the patient so prefers, local anaesthesia should be given.
General anaesthesia should be administered with endotracheal intubation. Intubation is
not necessary in children when tonsils have to be removed with guillotine. In children to be
operated upon by dissection method, intubation is necessary. In adults the tonsils are always
removed by dissection and so when general anaesthesia is administered, intubation is essential.
General anaesthesia is the domain of the anaesthetist. The operator may have to give local
anaesthesia himself. The usual premedication is given and the throat is sprayed with cocaine-
adrenaline solution three times at five minutes' intervals.
Each tonsil bed is then infiltrated with about 15 c.c. of 1% novocain or xylocaine solution
to which a few drops of adrenaline 1/1000 have been added. 5 c.c. of the solution is injected at
three points, the upper pole, the middle and -the lower pole, through the anterior faucial pillar.
This makes the tonsil bulge medially.
The tonsils can now be removed with the patient sitting in the upright position in a chair
by the dissection method. It is still better to give the patient about 15 mgm. of largactil and 100
mgm. of pethidine intravenously and remove the tonsils with the patient lying on the back in the
same position as under general anaesthesia.
Methods of removal: Tonsils may be removed by four methods
1. The guillotine method.
2. The dissection method.
3. Cryo-surgical method.
4. Laser surgical method.
The guillotine method: In former days, the guillotine was a great favourite. The method is
employed principally in children in whom it is presumed that there is no adhesion-formation
between the tonsils and their surroundings.
The child is not intubated and the adenoids can be removed by just administering geneial
anaesthesia to the child by the mouth with a Doyne's gag. Before the child recovers from
anaesthesia, both the tonsils and the adenoids canbe removed and the whole process does not
take more than a minute. Bleeding is free for a short time and then stops. The advantage of the
method Is that it is quick. No ligature is applied. The disadvantages are that the guillotine may
leave behind a part of the tonsil or may remove something more than the tonsil. "Remove the
tonsil, the whole tonsil and nothing but the tonsil" is the only rule. Secondly the bleeding vessels
are not ligatured, and there is great risk of post-operative bleeding
Dissection method.
This method is being used all over the world. In this method the tonsil is removed in a
planned manner,.slowly and steadily dissecting it out from its bed. It can be done under general
or local anaesthesia and in children or adults.
If general anaesthesia is used, the patient is intubated.
He lies on the operation table on the back with a pillow under the shoulders and head
extended. The operator sits or stands on the head side of the table. A Boyle-Davis gag is applied
and an assistant holds it up and keeps the head extended.
Alternatively, the assistant can be replaced by a suspension .apparatus. Light is thrown on
to the patient's throat. The tonsil is held near the upper pole by means of a tonsil-holding forceps,
a Luc's forceps or a vulsellum.
 64
With tonsil scissors or with a tonsil-knife, an incision is given along the anterior pillar
from just aboye the lower pole towards the upper pole and as close to the medial border of the
pillar as possible. The incision cuts just the mucous membrane and is carried round and above
the upper pole and is then carried downwards along the posterior faucial pillar. Having given the
incision, the tonsil is palled medially 'and a dissector, generally Gwynne's-Evan's or Negus'
pushes the peritonsillar tissues away from the tonsil and thus dissects them out.
The dissection is started at the upper pole and proceeds downwards. The reason for
choosing the upper pole to begin with, is that there is lot of areolar tissue around this pole and by
dissection it is easy to find the proper plane of cleavage between the tonsil and the superior
constrictor.
Finding the proper plane is highly important. If one dissects medially to this plane, part of
the tonsil will be left behind and the patient will end up with tonsil remains in tonsilar fossa. If
one dissects lateral to this plane, part of the superior constrictor will be removed and there will
be a lot of fibrous tissue development in the fossa.
Moreover, under both conditions, serious haemorrhage will occur. As one proceeds with
dissection, any space created in the tonsil fossa is packed with pieces of gauze. This serves two
purposes, first it stops bleeding by pressure and secondly it dissects the tonsil out by blunt gauze
dissection and helps in sticking to the plane between the tonsil and the surrounding tissues. The
field is kept dean by occasional suction.
On reaching the lower pole, a cut is made with scissors in the mucosa round the lower
pole and dissection completed with the dissector. No part of the lingual tonsil should be
removed.
Many surgeons apply the tonsil snare reaching the lower pole. The tonsil snare first
crushes & then cut the lower pole which is said to reduce bleeding, but it does not dissect out the
tonsil so cleanly as the tonsil dissector.
Having completed the dissection, the gauze pieces are removed one by one and any
bleeding points worth ligaturing are caught and ligatured. The procedure is repeated on the
opposite side. It is advisable to remove one tonsil and procure complete haemostasis of the side
before proceeding on to the dissection of the other side. Bleeding at the time of operation may
be:
1. Arterial.
This is spurting with the pulse, blood is bright red in colour. Near the upper pole it is
from branches of the greater palatine artery; near the middle from tonsillar artery and near the
lower pole from branches of the dorsalis linguae artery.
2. Venous.
This is welling up Uke a spring. The blood is dark in colour. The usual bleeder is the
para-tonsillar vein.
3. Capillary.
This is oozing from a surface and not from a point. The fossa fills up slowly and not
rapidly as in the case of arterial or venous bleeding.
Arterial and venous bleeding needs ligaturing; capillary bleeding needs mild pressure
with a swab.
A pack given round the tube above the larynx (epilaryngeal pack) keeps that patient
deeply under anaesthesia by not allowing him to breath air round the tube and also not allow the
blood to go into the lungs.
There are several methods of applying ligature. Many surgeons use the tonsil needle but
the writers have preference for slip-knot.
Chronic Pharyngitis
This may result from repeated acute attacks or the patient may have no memory of such
attack. By and large, the aetiology of chronic pharyngitis resembles that of the acute stage. The
patient is generally stout and plethoric and about middle-aged smoker. Males are affected more
 65
often than females. Chronic pharyngitis is nearly always secondary to infection elsewhere, for
example in the nose paranasal sinuses, chest and abdomen.
Clinical features.
There may be no symptoms referable to the throat and the discovery of chronic
pharyngitis may be an accidental finding on routine examination of the patient for some other
trouble. When symptoms are present, they generally take the form of a little discomfort in the
throat, a feeling of foreign body, dry cough, thick voice or nasal obstruction. There may be much
hawking or gagging. In more severe cases, there may be actual pain hi the throat which may even
be referred to the ears.
If there is concomitant Eustachian catarrh, there may be a complaint of deafness.
Not infrequently there may be voice changes.
Often there are symptoms referable to the nose, the throat and the digestive system.
On examination a stout middle-aged patient, generally male and looking rather well-fed
has got a throat which is narrow in comparison to the thickness of the neck. The whole
pharyngeal wall appears to be thick and hypertrophic. It may be a bit congested and there is
excess of thick secretion on it. The patient's throat is hyper-irritable and he may start gagging on
merely opening the mouth, much less to bear the touch of a tongue depressor. The uvula appears
hypertrophic and the movements of the palate appear clumsy. The tonsils may be somewhat
prominent. The mucous membrane may be wet from over-secretion of mucus or in very late
cases it may be dry from atrophy of the mucous glands.
In some cases the lateral band present in posterior pharyngeal wall are very much
hypertrophied from chronic infection and appear as distinct bands in the throat. This is called
lateral pharyngitis (This appearance may also sometimes be seen as a compensatory
phenomenon following tonsillectormy.)
In other cases, there may be hypertrophy of lymph follicles under the mucous membrane
of the pharynx appearing like granulations. This condition is called granular pharyngitis. These
granules are very irritating to the throat and produce dry cough. They generally result from nasal
or sinus infection or are a compensatory phenomenon following tonsillectomy.
Treatment.
This is general and local. The general treatment consists of advising the patient on a
proper way of life, good dietary habits and regulation of life as regards exercise and sleep. The
cause should be investigated and treated: thus smoking, anaemia, rheumatism, diabetes,
dyspepsia etc., should receive appropriate attention. If the patient is habitually constipated, this
should be relieved. If the voice is affected appreciably, the patient requires lessons in correct
voice production (elocution).
Too much emphasis on local treatment may be harmful. Some simple spray or lozenges
are often enough. The patient should adhere to saline or soda bicarb gargles morning and
evening. The authors have great respect for alum; a pinch of dry and powdred alum added to
saline or soda bicarb solution is often reported to be very beneficial by the patient. Orodental
hygiene should be scrupulously ensured. Mandl's throat paint is given for chronic cases. If there
are granules in the throat, they should be painted with 25% silver nitrate solution twice a week.
Galvanocautery in the treatment of granular pharyngitis is not recommended. The gist of
the matter is that general treatment should receive priority over local treatment and removal of
the cause, if discovered is all important.

VII System training tasks to check the final level of knowledge.

I. Find the complete and correct answer to the question.

a) middle-aged
b) older people
2. Which diseases can be a sharp increase in the palatal almonds?
a) flu
 66
b) blood diseases
c) measles
g ) scarlet fever
3. Which instrument is carried tonzilotomiya ?
a) a scalpel
b) a pair of scissors
c) tonzilotomom
g ) polypouses loop
4. What are the main complaints of patients with adenoid II-III degree?
a) violation of nasal breathing
b) fever
c) weakness
d) difficulty in swallowing
5. What characterizes the form of compensated chronic tonsillitis ?
a) there are local signs of inflammation, retromandibular lymphadenitis
b) increased migdaliny
c) there are no signs of local inflammation
g ) the back wall of the pharynx gіperemovana
d ) swelling of the tongue
6. What are the main symptoms of chronic catarrhal pharyngitis ?
a) high temperature
b) a sharp pain in the throat
a ) scratchy feeling, pain in the throat
g ) hemoptysis
7. What is chronic atrophic pharyngitis on the back of the throat ?
a) mucosa is dry, brilliant, subtle
b) a large number of rare sputum
c) mucosal hyperemia
d) hypertrophic follicles
8. What form of chronic pharyngitis easier to be treated ?
a) atrofіchna
b) Bluetongue
c) hypertrophic
9. What do I need to take a study to confirm the diagnosis " faringomіkoz "?
a) a swab from the throat
b) a piece of cork
c) the content gaps tonsil

II. Search for all the correct answers to the question.

1. Which people are more often chronic pharyngitis ?
a) in individuals with persistent violation of nasal breathing
b) in diseases of the cardiovascular system, gastrointestinal tract
c) in liver disease, dive, blood formation organs
g ) Are pre-conscription age
d ) children who suffer diathesis
e) pregnant women
2. What morphological changes were observed in the mucosa with hypertrophic pharyngitis ?
a) epithelial desquamation
b) partial disappearance of epithelium
c) destruction of the mucous glands
d) increase rows epithelium
d ) kіsti and folds
 67
e) vasodilation
3. Which places are located cover keratinizing epithelium in farynhomikoz?
a) palatine migdaliki
b ) the back wall of the pharynx
c) the side bolsters of the pharynx
 g ) the inner surface of the cheeks
d ) vestibule of mouth
4. Under which it is desirable to tonzilektomy anesthesia in children under 10 years old ?
a) endotrahealnim anesthesia
b) local infiltration anesthesia
c) epіduralnoyu anesthesia
5. What methods to stop bleeding after tonzilektomії you know ?
a) tamponade niche migdalikіv
b) vessel ligation in the wound
c) Inserting a tampon between Ends
g ) the external carotid artery ligation
d ) rinsing the mouth with 3 % hydrogen peroxide solution
6. What prevention of chronic tonsillitis ?
a) a balanced diet
b) quenching
c) sanitation fires infection (teeth, nose, sinuses)
d) use of immunomodulators
d ) physiotherapy ( UHF, laser )
e ) washing the gaps tonsils
7. Which violations have been reported in children with hypertrophic tonsils II-III degree?
a) breathing
b) food intake
c) first
d) Sleep
d ) appetite
8. What can not be held tonzilektomiyu hypertrophy of the palatine tonsils?
a) Possible bleeding
b) violation in voice
c) Scarring Pillar Palatal
d) decreasing the body's defenses
d ) immunological deficiencies
9. What diseases should be diagnosed differentsionny adenoid vegetations ?
a) foreign body nasopharynx
b) bending forward bulkhead
c) Juvenile nasopharyngeal fibroma
g ) hypertrophy of the posterior ends of inferior turbinates
d ) choanal polyp

1. That there are treatments for hypertrophic pharyngitis ?

a) Grease pharynx Lugol solution
b) moxibustion hypertrophic mucosa solution of silver nitrate
c) moxibustion Trichloroacelic acid
g ) galvanokaustika
d ) kriodestruktsyya
2. What is included in the complex therapy for symptomatic atrophic pharyngitis ?
a) alkaline inhalations, rinse
b) Grease pharynx solution kolargolu
 68
c) Oil inhalation
d) the lubricant pharynx iodo- glycerol

Case studies to verify the final level of knowledge.

Exercise N1.
Patient L. appealed to the otolaryngologist with complaints of discomfort in the throat in
the form of dry, slight tingling and pain, Dirt. Causes of the disease the patient is unaware.
Mezofaringoskopіya : cone formation of up to 3 mm yellow- cream color. Formation on
the surface of tonsils tightly soldered to subordinates fabrics. Ha -site disposal can be observed
mucosal damage.
1. Name exposed disease ?
2. The causative agent of the disease?
3. Differentsionny diagnosis of this disease with lacunar tonsillitis ?
4. Treatment.

Exercise N2.
Patient M. complains discomfort in the throat, stinky smell from the mouth. Over 3 years
treated periodically about angina (1-2 times a year ). Ent status: palatine tonsils are enlarged first
degree, in their gaps of a small amount of pus ( found during Clicking on the tonsils through his
front shackle ). Front bow hyperemic with thickened edges, extremities top of the front and rear
arches swollen. Regional lymph nodes are enlarged, not pain.
In light blood leukocytosis (9.2 x 10 9 / L ).
1. Diagnose Narrow form of the disease.
2. What are the most popular among practitioners classification (author, clinical forms of
the disease.
3. Is it possible to form a diagnosis of one of the most characteristic signs of the disease ?
4. The treatment for this patient (fixed assets, schemes).

Exercise N3.
In a patient to, for 8 years observed angina ( 2-3 times a year ), recurrent acute quinsy.
The last 5 years is at a dispensary in rheumatology office.
Ent status : palatine tonsils are enlarged, second degree, glued with front Ends scars.
Mucosa duzhekchhyperemic front, thickened edges, swollen edge arches in the upper part
thereof. When pressing a spatula on a palatal migdalik ( through the front shackle ) of the
lacunae follows purulent fluid with an unpleasant odor.
At the top of the front bow right palatine tonsils scars - the result of repeated
interventions in paratonzilyarnih abscesses. In the upper part of the jugular chain of moderately
painful palpable lymph nodes.
1. Diagnosis. Specify the form of the disease.
2. Which of the following signs of the disease is: a) reliable b) unreliable ?
3. Assign treatment.
4. a ) indication for surgery?
    b) contraindication to surgery?

Exercise N4.
Continuous subfebrilіtet may be due :
1. common chronic infection ;
2. campfire infection ;
3. endocrine hyperthermia ;
4. vegetative neurosis.
 69
Thus subfebrilіtet may be infectious ( hronіosepsis ) and noninfectious (endocrinopathies,
thermoneurosis ) origin.
Hronіosepsis may be due to chronic tonsillitis, carious teeth, pielity, cholecystitis,
inflammation of female genitalia, to a lesser extent - chronic suppurative otitis, sinusitis and
other diseases.
1. Spend difdіagnoz tonzilogenic sepsis from sepsis of other origin.
2. Spend difdіagnoz tonzilogenic subfebrіlіty from sepsis, which is associated with
disorders of thermoregulation - thermoneurosis.
3. Make a short description of the process piramidonovoy sample.

Exercise N5.
Have you boy 9 years reports sharply Nasal obstruction him, nasal discharge, disturbed
sleep, memory loss, retarded learning from their classmates, frequent bilateral catarrh of the
middle ear and low-grade fever body.
Objective examination : Boy behind general physical development of peers, the affected
configuration of the facial skull, sluggish appearance, mіmіka poor, nasolabial folds smoothed.
Front rhinoscopy. After anemization nasal mucosa - general progress relatively wide
nasal, nasal breathing is virtually absent.
Orofaringoskopіya. The hard palate is narrowed and elongated top, constitutes the so-
called Gothic vault. When pressing on the tongue spatula soft palate behind the posterior wall of
the nasopharynx.
1. Put the previous diagnosis.
2. Auxiliary examination methods.
3. How to explain memory loss and mental activity in patients with diagnosed pathology?
4. What rises physical development in this disease ?
5. Development of ear pathology depends on... ?

Exercise N6.
Have a three year old son said that he had 2 for years labored breathing through the
mouth and nose ( at least ). Over the last year mouth breathing worsened considerably at night
during sleep snoring occurs periodically coughing attacks. 6 months ago there was something
difficulty swallowing food, changed voice ( snuffles ).
Objectively: the nasal mucosa pink, common nasal passage is not changed hoany free
breathing through the nose is moderately difficult. The magnitude of palatine tonsils approaching
to third degree mucosa their pink color, surface Gorny, soft consistency with clearly defined
crypts. Breathing through the mouth is difficult.
1. Diagnose.
2. How to determine the degree of increase in palatine tonsils?
3. With what diseases it is necessary to (primarily ) to conduct differentsionny diagnosis?
4. Treatment.

Exercise N7.
Citizen P. accidentally drank 30ml colorless, transparent liquid. followed by any
vomiting, sharp pain and smoking in the throat, severe salivation, slight shortness of breath
guttural.
After 3 hours, P. contacted the ENT department of the CRL, where at pharyngoscope,
indirect laryngoscopy revealed hyperemic, swollen, covered with dry, dense, white scabs of the
mucous membrane of the pharynx, epiglottis, vocal cords unreal. Title fluid victim knows.
1. Early diagnosis.
2. Intended nature drunk P. liquid ? Ha which is based this conclusion ?
3. Providing ambulance.
 70
Answer:
Answer 1
1. Leptotrichosis.
2. Bacterial microorganism - Leptotryx buccalіs, saprofіt emptiness in the mouth.
3. Lacunar tonsillitis accompanied by high fever, signs of inflammation tonsils, its bloom.
4. Rinse antiseptic, lubricant conical formations zinc chloride, galvanocaustics, krіovpliv.
When combined with chronic tonsillitis lepotrihozu - tonzilektomіyu operate.

Answer 2
1. Chronic tonsillitis compensated (if there are only local signs of the disease, which are
described in the problem).
2. Classification proposed I.B.Soldatovim (compensated and dekompensirovanaya form
of chronic tonsillitis) classification proposed LA Lukovskim (compensated, and subcompensated
decompensated chronic tonsillitis).
3. None of the objective signs of chronic tonsillitis is not patognomonіchnoyu. For the
diagnosis of the disease required a cumulative assessment of all symptoms.
4. Treatment of this form of tonsillitis conservative: washing and disinfectant crypts,
0.1% sodium levamіzolu immunomodulator, filling gaps crypts refractory pastes that contain
antibiotics, corticosteroids, etc., are widely used physiotherapy techniques: ^ quartz-quartz-tube-
quartz, UHF, ultrasound, low-energy laser.

Answer 3
1. Chronic tonsillitis dekompensirovany (local signs of disease + defeat other organs and
systems).
2. a) reliable
1. presence of pus in the gaps; signs:
2. exacerbation (recurrence of angina paratonzilіtіv);
3. pathological changes arches palatine tonsils.
b) related
1. value tonsils, their consistency; signs:
2. unpleasant smell from the mouth;
3 increase in regional lymph nodes.
3. The patient shown tonzilektomiya.
4. a) indication to tonzilektomii:
1. chronic tonsillitis dekompensirovanye;
2. in the absence of a thorough and successful technical properly conducted 2 courses of
treatment compensated form of tonsillitis.
b) contraindication to tonzilektomії:
1) local: a - temporary, would - permanent (absolute).
2) common: a - time; would - permanent (absolute).

Answer 4
1. Using two samples - washing gaps and massage tonsils. a) washing with antiseptic
solutions lacunae - tonzilogennomu sepsis when the body temperature drops b) massage palatine
tonsils - tonzilogennomu sepsis when there is a "jump" temperature.
2. When tonzilogennomu sepsis: irregular fluctuations of the height of the temperature
curve, the data analyzes of blood, urine - results are typical of the inflammatory process,
affecting overall health. Thermoneurosis accidentally turns, general health suffers, monotonous
nature of the temperature curve. There are other signs of vegetative neurosis: sweating, general
neurotic reactions.
3. 3 days before the break every hour (from 6.00 to 21.00) measures the body temperature
of the patient.
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Following 3 days of bed he sticks mode:
- The first day of the test measures the body temperature every hour,
- On the second day give drink pyramidon 0.5% solution (in 6 hours - 3 tablespoons, after
every hour to 21.00 1 tablespoon total of 300 mL).
The sample is considered positive (confirms tonzilogenny sepsis) if the body temperature
drops in the same day after receiving pyramidon.

Answer 5
1. Adenoid nasopharyngeal razrascheniya migdalika.
2. Palpation vatotrimachem (special probe with a rectangular wound on the end of wool)
lateral radiographs of the nasopharynx, accounting indirect (side) symptoms - when pressed with
a spatula on the tongue behind the soft palate from the posterior wall of the nasopharynx,
depending on the size of the adenoids.
3. Nasal obstruction leads to venous stasis in the meninges, increased intracranial
pressure, and as a result - memory loss and mental activity.
4. Reduction in the overall physical development associated with impaired nasal
breathing and nutrition, especially in neonates and infants (in which the possible development of
"adenoid cachexia").
5. Development of ear pathology depends on the mechanical blockage of the auditory
tube and the spread of the inflammatory process in the Eustachian tube.

Answer 6
1. Hypertrophy of tonsils.
2. The distance between the edge of the front bow tonsils and tongue conditionally
divided into 3 parts. Tonsils increase by 1/3 of this distance corresponds to hypertrophy of the
first degree, 2/3 - second degree; surface tonsils comes to tab - III degree.
3. Primarily differentsionny hypertrophy diagnosed with hypertrophic tonsils spend form
of chronic tonsillitis (history of angina, objective evidence of inflammation tonsils), tumor
tonsils (one-way process, the increased density of tonsils, enlarged regional lymph nodes).
4. Treatment. restorative therapy, climate, vitamin; grease tonsils, Lugol's solution, 3.2%
solution of silver nitrate; tonzilotomі.

Answer 7
1. Chemical burns of the mucous membrane of the pharynx and larynx.
2. Based on the fact that the scabs on the mucosa dry, dense, white (coagulation necrosis)
can be assumed that chemical burns caused by acid.
3. Ambulance: urgent throat and stomach lavage antidotes: water with the addition of
milk of lime, powdered chalk, magnesia, anti-inflammatory, antiedematous therapy, sparing diet.