Infections of Waldayer's ring
Dr. T. Balasubramanian M.S. D.L.O.
Normal flora gets established in the upper respiratory tract immediatly
after birth. Actinomyces, Fusobacterium & Nocardia are
acquired by 6 - 8 months of age. Later Bacteroids, Leptotrichia,
Propioniobacterium and candida also become established as part of
normal oral flora. Fusobacterium populations reach high numbers
after dentition and reach maximal number by 1 year of age.
During an episode of infection (viral/bacterial) the colonization of
gram negative organisms and Staph aureus increase by 70%. Many
organisms induce inflammation of Waldayer's ring. They are:
1. Bacterial - Aerobic
Infact some of thee infectious organisms are part of the normal oral
and pharyngeal flora; while others are external pathogens. Most
infections of waldayer's ring are polymicrobial and the infecting
organism work synergistically. One other feature of mixed
infection is the ability of organisms resistant to an antimicrobial
agent to protect an organism susceptible to the agent by production of
antibiotic degrading enzymes thus rendering the antibiotics used in the
Among all the bacterial infections affecting the waldayer's ring
streptococcal infections needs a prominent mention because of its
ability to produce such sequlae like Rheumatic heart disease and
Glomerular nephritis. Group A beta haemolytic streptococcus is
the common bacteria affecting the waldayers ring. Acute
streptococcal tonsillitis is a disease of childhood. The peak age
of incidence being between 5 - 6 years. Outbreaks of epidemic
proportions are common.
The history given by the patient determines whether the
patient is suffering from acute, recurrent or chronic tonsillitis.
The duration of illness is less than three weeks old. The patient
infact may not give any history of recent similar attacks.
Clinically these patients have:
2. sore throat
3. Foul smelling breath
4. Odynophagia (painful swallowing)
5. Tender enlarged upper deep cervical node belonging to the
jugulodigastric group. These nodes are palpable just below the
angle of the mandible.
6. In young children this condition is almost always associated with
enlarged adenoids which may cause nasal airway obstruction and
obstructive sleep apnoea syndrome.
7. Generally these pateints are lethargic and toxic.
Causative organisms of acute tonsillitis:
1. Streptococci pneumoniae (commonest)
4. H. Influenzae
Throat culture is a must to identify the presence of beta haemolytic
streptococci. The major disadvantage is that it takes a minimum
of 48 hours for the culture to be reported. There is also the
false negative results to contend with. Cultures must be
performed when the body temperature is more than 38.3 .C or when the
illness is characterised by sore throat. But a culture cannot
differentiate between acute and chronic infections.
Carrier states are common among false negative patients. These
patients can be identified by ASO titre assessment. A carrier
will have a positive culture for haemolytic streptococci with a
negative ASO titre.
Rapid tests for streptococci have been introduced among which rapid
strep test has prooved accurate and cost effective.
Therapy is directed at aerobic pathogens i.e. beta haemolytic
streptococci. Penicillins are the drug of choice.
Ampicillin / Amoxycillin in doses of 40 - 50 mg /kg body weight can be
used. Anaerobes have been shown to be involved in recurrent
tonsillitis hence clindamycin in considered in recurrent and resistant
Complications of tonsillitis:
3. Pharyngeal abscess
4. Otitis media
5. Septic foci leading on to subacure bacterial endocarditis, nephritis
or rhematic fever
6. Septicaemia (rare)
The duration of illness is more than 3 weeks. These patients have
milder symptoms when compared to those with acute tonsillitis.
Tonsils are enlarged. Tonsillar enlargement can be graded under 4
Grade 0: The tonsils are fully inside the pillars.
Grade 1: Tonsils found to be enlarged and out of its pillars
Grade 2: Tonsillar enlargement extends just up to half the distance of
Grade 3: Tonsillar enlargement up to the level of the uvula.
Grade 4: Tonsillar enlargement is so huge that they are virtually in
contact with each other i.e. Kissing tonsil.
The anterior pillars are congested. The jugulodigastric nodes are
enlarged and tender.
Types of chronic tonsillitis:
Chronic follicular tonsillitis:
In these patients the tonsillar enlargement is associated with the
presence of prominent inflammed follicles. Whitish material can
be seen extruding from the follicles when the anterior pillars are
pressed with a tongue depressor. This is known as the squeeze
test. A positive squeeze test always indicate the diagnosis of ch
follicular tonsillitis. Inflammation and blockage of crypta magna
in these pateints lead on to the formation of Quincy or peritonsillar
Chronic parenchymatous tonsillitis:
In these patients tonsils are enlarged but the follicles are not
prominent. Infection is found within the substance of the tonsil.
Infection in patients with chronic tonsillitis is always poly microbial
with a predominence of gram negative and anaerobic organisms.
Surgery is commonly indicated in these patinets.
Causes membranous tonsillitis. Membranous exudate are seen over
tonsils and soft palate, followed by its distant toxic effects.
It is caused by corynebacterium diphtheria. Three different
strains of diphtheria have been identified, they are Gravis,
Intermedius and Mitis. These organisms grow in Loeffler's media
or Tellurite agar. These organisms ferment glucose. This
infection is rare these days because of the success of universal
Multiplication of organism leads to production of toxins which cause
epithelial necrosis with collection of polymorphs and fibrin leading
formation of false membranous formation (because it consists of
necrotic layer of mucosa, where as true membrane is superimposed over
the intact mucosa).
1. The child is very quiet
4. Head ache
On examination a greyish / yellowish thick membrane on one or both
tonsils extending up to the soft palate and uvula. The membrane
can be removed leaving a raw under surface. Massive cervical
adenitis is also seen i.e. Bull neck.
Diagnosis is by :
Signs and symptoms
Throat swab for culture and sensitivity
Lymphocyte count is raised
Albuminuria is seen
Schick test is postive
Acute streptococcal tonsillitis
Infectious mono nucleosis
The patient is kept in isolation for 2 weeks
If myocarditis has set in patient must be kept in bed rest till the ECG
The patient must have 3 negative swabs before discharge
Anti diphthertic serum must be administered in acute cases:
- for mild cases 20,000 units
- moderate cases 40,000 units - 80,000 units
Half dose is given as intra muscular injection
and the other half as intra venous injections.
Injection penicillin is administered in doses of 5 - 10 lakhs
Tracheostomy is done in patient's with stridor.
1. Myocarditis & circulatory failure
2. Peripheral neuritis with palatal palsy
3. Ocular muscle palsy
4. Peripheral neuritis
Differences between acute diphtheria and acute
Acute follicular tonsillitis
1. Occurs in individuals between 6 -20 yrs
Occurs in individuals under 10 years of age
2. H/O attacks of recurrent tonsillitis
H/O exposure to diphtheria
3. Pain is severe
Pain is mild
4. Toxemia absent
5. Dirty white pseudo membrane limited to tonsil only
and can be removed with no raw areas after removal
Membrane extensive on tonsil, uvula, and soft
palate. Can only be removed with difficulty, underlying raw area
is seen on removal.
6. Throat swab shows streptococci
Swab shows c. diphtheria
7. Schick test negative
Schick test positive
Complications of tonsillitis:
The complications of tonsillitis can be
classified under non suppurativve and suppurative complications.
Non suppurative complications are
1. Scarlet fever
2. Rhematic fever
3. Post streptococcal glomerular nephritis
Suppurative complications include all abscesses
is secondary to acute streptococcal tonsillitis / pharyngitis with
production of toxins by the bacteria. It is characterised by
1. Erythematous rash
2. Severe lymphadenitis
3. Sore throat
4. Erythematous tonsils
6. Membrane is present over the tonsils and is friable
7. Strawberry tongue
Copyright drtbalu 2007