UKKIE – modul tht lbm 4 (tonsilitis): Mangbewok.tk - @simangbewok

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LBM 4 PAINFUL SWALLOWING

STEP 1

 Detritus : hasil eksudat yang berisi leukosit, bakteri, dan epitel yang

Detritus : hasil eksudat yang berisi leukosit, bakteri, dan epitel yang

terlepas di kanal berwarna bercak kuning.

 Kripte : muara saluran limfoid yang dapat

Kripte : muara saluran limfoid yang dapat terlihat pada tonsil

terlihat pada tonsil

STEP 2

1. 1. Anatomi, fisiologi, dan histologi faring dan

Anatomi, fisiologi, dan histologi faring dan tonsil?

tonsil?

2. 2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada

Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada

tenggorokan?

3. 3. Mengapa pasien demam dan mengalami penurunan nafsu makan?

Mengapa pasien demam dan mengalami penurunan nafsu makan?

4. 4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa

Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa

hiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan

mukosa hiperemis dan terdapat granul di posterior?

5. 5. Causa detritus dan kripte (definisi, patofis)?

Causa detritus dan kripte (definisi, patofis)?

6. 6. Obat warung apa yang kira-kira sudah

Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangi

dikonsumsi untuk mengurangi

gejala?

7. 7. Pemeriksaan penunjang untuk menegakkan diagnosis?

Pemeriksaan penunjang untuk menegakkan diagnosis?

8. 8. Penatalaksanaa

Penatalaksanaan yang tepat u

n yang tepat untuk pasien tersebut?

ntuk pasien tersebut?

9. 9. DD?

DD?

10. 10.Komplikasi yang dapat timbul dari diagnosis?

Komplikasi yang dapat timbul dari diagnosis?

STEP 3

1. 1. Anatomi, fisiologi, dan histologi faring dan

Anatomi, fisiologi, dan histologi faring dan tonsil?

tonsil?

ANATOMI

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

Nasofaring :

Batas depan : choanae

Atas : basis crania

Belakang : vertebra cervical yg

Belakang : vertebra cervical yg dipisahkan facia prevertebralis

dipisahkan facia prevertebralis

Bawah : palatum mole

Lateral : dinding medial leher

Ada bangunan



ostium tuba eusthacii, adenoid, recessus faring



OROFARING

Atas : nasofaring

Depan : cavum oris dan uvula

Belakang : vertebra cervical II-III

Lateral : dinding medial leher

Bawah : tepi atas epiglottis

Bangunan



tonsila palatine, fossa

tonsila palatine, fossa supra tonsilaris, tonsila lingualis

supra tonsilaris, tonsila lingualis



Laringofaring

Atas : orofaring

Depan : tepi blkg epiglottis

Belakang : dinding belakang orofaring

Bawah : porta esophagus

Ruang di sekitar faring:

 Retrofaring : ada mukosa

Retrofaring : ada mukosa faring, fossa faringobulbolaris, sering

faring, fossa faringobulbolaris, sering

tjd supurasi, jk pecah



abses retrofaring

 Parafaring : dibagi 2 ruangan oleh os.

Parafaring : dibagi 2 ruangan oleh os. Stiloid

Stiloid



pre dan post

stiloid

Pre stiloid : gampang tjd supurasi

Post : banyak pemb darah



TONSIL

Ada cincin waldeyer : tonsil palatine, tonsil faringeal, tonsil lingual, tonsil

tuba

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 Tonsil palatine : ada di fossa tonsil, dibatasi pilar anterior : m.

palatoglossus, posterior : m. palatofaringeus. Panjang 2-4 cm.

masing2 tonsil 10-30 kriptus. Lateral ; m. konstriktor faring superior,

anterior : m. palatoglossus, posterior : m. pakatofaringeus, superior :

palatum mole, inf : tonsil lingua.

Vaskularisasi : a. maksila eksterna, a. maksila interna, a. lingualis cab

a. lingua dorsal, a. faringeal ascenden

 Tonsil faringeal ; di dinding belakang nasofaring, tidak mempunyai

kripte

 Tonsil lingual : di dasar lidah, dibagi 2 oleh lig. glossoepliglotika

HISTOLOGI

Pada nasofaring mukosanya bersilia dan epitel mengandung sel goblet, sedangkan

orofaring dan laringofaring mukosa tidak bersilia.

Pada faring banyak jar limfoid untuk proteksi.

Ada palut lender/mucous blanket



di bagian nasofaring, di atas cilia, berfungsi

untuk menangkap partikel dari udara, mengandung lisozim. Bergerak ke posterior.

Terdapat otot2 sirkuler dan longitudinal.

 Sirkuler : m. konstriktor faring sup, media, inf



untuk konstriksi

 Longitudinal : m. stiloideus dan m. palatofaring

_

untuk melebarkan faring

dan mengangkat faring. Dipersarafi n IX.

Di palatum mole ada 5 pasang otot :

 M. levator veli palatine



menyempitkan isthmus faring, melebarkan tuba

eusthacii. Dipersarafi n X

 M. tensor veli palatine



mengencangkan anterior palatum mole dan

menyempitkan tuba eusthacii

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 M. azigos uvula



memperpendek dan menaikkan uvula

FISIOLOGI



Fungsi menelan

3 fase :

ORAL



bolus di mulut berjalan ke faring, volunteer

FARINGEAL



transfer bolus melewati faring, involunteer

ESOFAGEAL



bolus bergerak peristaltic dari esophagus keg aster,

involunteer

2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada

tenggorokan?

Invasi bakteri



pertahanan utama : tonsil , karena terdapat jaringan limfe



virulensi tinggi



inflamasi



tonsil edem



tonsil membentuk cincin ,

susah menelan



nutrisi berkurang , kelemahan . mengobstruksi tuba

eustacii juga



kurang oendengaran .

Bias juga menyebar menjadi otitis.

Sensasi terbakar



inflamasi tonsil dan mukosa di orofaring

Nafsu makan

Karena ada nyeri di tenggorokan , nyeri telan



nafsu makan menurun

Derajat tonsil:

T0

–

T4

Pada scenario



T4



sehingga mengobstruksi makanan, nyeri telan

Jika kronis



tidak ada nyeri telan

3. Mengapa pasien demam dan mengalami penurunan nafsu makan?

Di no 2

4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa

hiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan

mukosa hiperemis dan terdapat granul di posterior?

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 Hiperemis mukosa

_

ada peradangan, dilatasi pemb darah

 Detritus



adanya peradangan tonsil



penumpukan leukosit,

bakteri mati, epitel mati. Terlihat bercak kuning

 Kriptus



muara sal limfoid terisi detritus lama kelamaan tjd

pengerutan

 Granula

_

pembengkakan organ limfoid faring

Ada bakteri/virus



menginvasi mukosa faring, tjd inflamasi local,

kuman /bakteri mengikis epitel, jar. Limfoid bereaksi



pembendungan infiltrate leukosit PMN

Stadium awal : hiperemi, edema, sekresi banyak. Awal eksudat

serosa, menebal, kering menempel di dinding faring

Derajat tonsil

T0 : Tonsil sudah diambil

T1 : Normal

T2 : Pembesaran tonsil tidak sampai linea media

T3 : hipertrofi mencapai garis tengah



sesak napas

T4 : pembesaran tonsil lebih dari linea media, mengganggu deglutio

Es



tidak bersih



banyak bakteri



inflamasi pada tonsil

Chiki



MSG jd Iritan di tonsil ..

5. Causa detritus dan kripte (definisi, patofis)?

Tonsil dibungkus oleh kapsul di fossa tonsil , di tonsil banyak jar limfe yg

disebut folikel, tiap folikel pny kanal yang bermuara pada perm tonsil.

Muara tersebut terlihat muara yaitu kripte.

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Folikel peradangan



tonsil membengkak



membentuk eksudat yang

mengalir dalam kanal



keluar ke kripte



terlihat kotoran putih/ bercak

kuning (Detritus)

6. Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangi

gejala?

Hanya mengatasi simptomnya saja

Paracetamol, ibuprofen

Antibiotic

7. Pemeriksaan penunjang untuk menegakkan diagnosis?

 CT Scan

 MRI

 Biopsi

 Darah rutin : leukositosis, Hb turun

 Uji swab



untuk mengetahui bakteri

8. Penatalaksanaan yang tepat untuk pasien tersebut?

 Farmakologi : antibiotic cefadroxil 1 minggu, analgesic, antipiretik,

kortikosteroid

 Non farma : edukasi, minum air putih, pengontrolan makanan

GOLONGAN ANTIBIOTIK ? GENERASI?

SEDIAAN…..

9. DD?

TONSILITIS

 Tonsillitis akut

o

Viral : haemophillus influenzae

o

Bacterial : streptococcus beta hemoliticus

 Tonsillitis membranacea

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Demam, nyeri kepala, nyeri telan, badan lemas

o

T. septic



strep hemoliicus

o

T. angina plaut Vincent



bakteri spirochaeta

o

T. karena kelainan darah



leukimia

o

Proses spesifik luas dan TB

 Kronis



Tonsilitis diphteri

Dari sal pernapasan atas, usia 10 th

Ada 3 gejala :

Local : membrane semu, pembesaran limfe / bull neck

Sistemik : Demam, nyeri kepala, nyeri telan, badan lemas

Eksotoksin : jantung



miokarditis

Diagnose : gejala local, px mikrobiologi

10.Komplikasi yang dapat timbul dari diagnosis?

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STEP 7

1. Anatomi, fisiologi, dan histologi faring dan tonsil?

Nasopharynx

The upper portion of the pharynx, the nasopharynx, extends from the base of the skull to the upper surface of the soft palate. It includes the space between the internal nares and the soft palate and lies above the oral cavity. The adenoids, also known as the pharyngeal tonsils, are lymphoid tissue structures located in the posterior wall of the nasopharynx. The nasopharynx, oropharynx, and laryngopharynx or larynx can be seen clearly in this sagittal section of the head and neck.

Polyps or mucus can obstruct the nasopharynx, as can congestion due to an upper respiratory infection. The eustachian tubes, which connect the middle ear to the pharynx, open into the nasopharynx. The opening and closing of the eustachian tubes serves to equalize the barometric pressure in the middle ear with that of the ambient atmosphere. The anterior aspect of the nasopharynx communicates through the choanae with the nasal cavities. On its lateral walls are the pharyngeal ostia of the auditory tube, somewhat triangular in shape, and bounded behind by a firm prominence, the torus tubarius or cushion, caused by the medial end of the cartilage of the tube that elevates the mucous membrane. Two folds arise from the cartilaginous opening:

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the salpingopharyngeal fold, a vertical fold of mucous membrane extending from the inferior part of the torus and containing the salpingopharyngeus muscle

the salpingopalatine fold, a smaller fold extending from the superior part of the torus to the palate and containing the levator veli palatini muscle. The tensor veli palatini is lateral to the levator and does not contribute the fold, since the origin is deep to the cartilaginous opening.

Behind the opening of the auditory tube is a deep recess, the pharyngeal recess (also referred to as the fossa of Rosenmüller). On the posterior wall is a prominence, best marked in childhood, produced by a mass of lymphoid tissue, which is known as the pharyngeal tonsil. Superior to the pharyngeal tonsil, in the midline, an irregular flask-shaped depression of the mucous membrane sometimes extends up as far as the basilar process of the occipital bone, this is known as the pharyngeal bursa.

Oropharynx

The oropharynx lies behind the oral cavity, extending from the uvula to the level of the hyoid bone. It opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall, between the Palatoglossal arch and the Palatopharyngeal arch, is the palatine tonsil. The anterior wall consists of the base of the tongue and the epiglottic vallecula; the lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars; the superior wall consists of the inferior surface of the soft palate and the uvula. Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the glottis when food is swallowed to prevent aspiration. The oropharynx is lined by non-keratinised squamous stratified epithelium.

Laryngopharynx

The laryngopharynx, (Latin: pars laryngea pharyngis), is the caudal part of the pharynx; it is the part of the throat that connects to the esophagus. It lies inferior to the epiglottis and extends to the location where this common pathway diverges into the respiratory (larynx) and digestive (esophagus) pathways. At that point, the laryngopharynx is continuous with the esophagus posteriorly. The esophagus conducts food and fluids to the stomach; air enters the larynx anteriorly. During swallowing, food has the "right of way", and air passage temporarily stops. Corresponding roughly to the area located between the 4th and 6th cervical vertebrae, the superior boundary of the laryngopharynx is at the level of the hyoid bone. The laryngopharynx includes three major sites: the pyriform sinus, postcricoid area, and the posterior pharyngeal wall. Like the oropharynx above it, the laryngopharynx serves

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The vascular supply to the hypopharynx includes the superior thyroid artery, the lingual artery and the ascending pharyngeal artery. The primary neural supply is from both the vagus and glossopharyngeal nerves. The vagus nerve provides a branch termed "Arnolds Nerve" which also supplies the external auditory canal, thus hypophayrngeal cancer can result in referred otalgia. This nerve is also responsible for the ear-cough reflex in which stimulation of the ear canal results in a person coughing.

 Pharyngeal lymphatic ring(waldeyer lymphatic ring): 1. inner ring

2. outer ring

Applied anatomy of pharynx, Wang Peihua, Department of Otorhinolaryngology, 9th people’s hospital, School of medicine, Shanghai Jiaotong University.

Tonsils are lymphoepithelial organs at the opening of the upper aerodigestive tract. From above downwards, they can be divided into

1. pharyngeal tonsil, adenoid, which lies on the roof and posterior wall of the nasopharynx

2. tubal tonsil which lies around the eustachain tube

3. palatine tonsil which lies between the anterior and posterior faucial pillars 4. lingual tonsil which lies at the base of the tongue

These lymphoid organs developed from the epithelium of the primitive oronasal cavity, the mesenchymal stroma and lymphoid cells then infiltrate these areas. Although the tonsils are present at embryonal stage, they only acquire their typical structure in thepostnatal period. They begin increasing rapidly in size between the first and third year of life, with peaks in the third and seventh year. They involute slowly at early puberty. In contrast to other lymphoid aggregates, tonsils do not filter lymph.

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The palatine tonsil is supplied by the facial artery, ascending pharyngeal artery, lingual artery and the maxillary artery. Venous drainage is by the lingual and pharyngeal veins.

2. Mengapa pasien merasakan seperti sensasi terbakar dan nyeri telan pada

tenggorokan?

Bacteria and virus enter the body through the nose and mouth

Bateria and viruses are filtered in the tonsils

tonsils work by surrounding bacteria and virus with white blood cells

Precipitating factors • Age • Sex • Race • Unhealthy Lifestyle • Environment Predisposing Factors • Cold • loss of sleep • constipation

infection and inflammation causes enlarge tonsils

Signs

 Red and swollen tonsils and uvula

 Redness of throat

 Presence of purulent materials

 Tenderness on the jugulodiagastric Symptoms

 Sore throat

 Dysphagia

 Fever

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emedicine.medscape.com

3. Mengapa pasien demam dan mengalami penurunan nafsu makan?

Virus; Bacteria; Group A – beta hemolytic streptococcusActivation of macrophages by IFN-γ production of endogenous pyrogen IL-1, IL-4, IL-6, TNF-αendogenous pyrogens enter the systemic circulation and penetrate hematoencephalic barrier reacts to the hypothalamusEffects of endogenous pyrogen on hypothalamic cytokines causethe production of arachidonic acidand prostaglandins Prostaglandins stimulate the cerebral cortex (behavioral response) leptin causes stimulation of the hypothalamussuppressed appetite.

ACUTE TONSILLO PHARYNGITIS EXUDATIVE, CAPITOL MEDICAL CENTER COLLEGES INC., CORRAL, Priscilla Chantal M.

4. Apa interpretasi dari pemeriksaan orofaringeal : tonsil : T4/T4, mukosa

hiperemis, kripte melebar +/+, detritus +/+ dan pada faring ditemukan

mukosa hiperemis dan terdapat granul di posterior?

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Standardized tonsillar hypertrophy grading scale. (0) Tonsils are entirely within the tonsillar fossa. (1+) Tonsils occupy less than 25 percent of the lateral dimension of the oropharynx as measured between the anterior tonsillar pillars. (2+) Tonsils occupy less than 50 percent of the lateral dimension of the oropharynx. (3+) Tonsils occupy less than 75 percent of the lateral dimension of the oropharynx. (4+) Tonsils occupy 75 percent or more of the lateral dimension of the oropharynx.

Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg. 1998;118:69 –73.

Widen crypt:

The human palatine tonsils (PT) are covered by stratified squamous epithelium that extends into deep and partly branched tonsillar crypts, of which there are about 10 to 30. The crypts greatly increase the contact surface between environmental influences and lymphoid tissue.

The tonsillar crypts often provide such an inviting environment to bacteria that bacterial colonies may form solidified "plugs" or "stones" within the crypts. In particular, sufferers of chronic sinusitis or post-nasal drip frequently suffer from these overgrowths of bacteria in the tonsillar crypts.[medical citation needed] these small whitish plugs, termed

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Barnes, Leon (2000). Surgical Pathology of the Head and Neck (2nd ed. ed.). CRC Press. p. 404.

Detritus:

Infiltration of bacteria on the epithelial tissue lining the tonsils will cause an inflammatory reaction in the form of the release of polymorphonuclear leukocytes to form detritus. This detritus is a collection of leukocytes, dead bacteria and epithelial apart. Clinically this detritus filling kripte tonsils and appear as yellowish spots.

Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.

Granule in the posterior wall:

Acute pharyngitis Looks at mucosal thickening and hypertrophy of the lymph nodes underneath and behind the posterior pharyngeal arch (lateral band). The existence of the uneven mucosa of the posterior wall of the so-called granular.

Staf Pengajar Ilmu Penyakit THT FKUI. Buku Ajar Ilmu Kesehatan Telinga Hidung Tengorok Kepala Leher Edisi ke 6 Cetakan ke 1, Balai Penerbit FKUI, Jakarta, 1990.

5. Causa detritus dan kripte (definisi, patofis)?

6. Obat warung apa yang kira-kira sudah dikonsumsi untuk mengurangi

gejala?

7. Pemeriksaan penunjang untuk menegakkan diagnosis?

Diagnosis of tonsillitis is based on a medical history and a physical exam of the throat. An accurate medical history is needed to find out whether tonsillitis is recurrent, which may affect treatment choices.

If your symptoms suggest strep throat, your doctor may want to confirm this diagnosis by doing a throat culture. Strep throat is more likely if 3 or 4 of the following signs or symptoms are present:

Fever

White or yellow spots or coating on the throat and/or tonsils (tonsillar exudates) Swollen or tender lymph nodes on the neck

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If a strep infection is suspected, your doctor may do a rapid strep test or a throat culture or both. Both of these tests can be done in a doctor's office. You may want to discuss the advantages and disadvantages of each test to see which test is appropriate.

The results of these tests will determine whether antibiotic treatment is needed. These results combined with an accurate medical history will be considered in deciding whether surgery to remove the tonsils (tonsillectomy) is recommended.

If the Epstein-Barr virus, which can cause mononucleosis, is suspected as a cause f or the tonsillitis, a test for mononucleosis may be done.

http://www.emedicinehealth.com/tonsillitis-health/page6_em.htm

8. Penatalaksanaan yang tepat untuk pasien tersebut?

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Tonsilitis

The most active phase of tonsils is between age 3 to 10 years and after that involution begins. Although hyperplasia of tonsils is not a disease, these organs are found to have a higher incidence of pathogenic bacteria around the poorly-drained tonsillar crypts resulting in tonsillitis. Majority of childhood tonsillitis are caused by group A £]-haemolytic streptococcus (GABHS). Its frequency and serious consequences such as acute rheumatic fever and glomerulonephritis make this an important infection. Viral causes are also common including coxsackievirus, herpesvirus and Epstein-Barr virus. However, it was found that with recurrent attacks of tonsillitis, the type and number of organisms changes from a commensal to greater varieties of bacteria and thus requiring different broad-spectrum antibiotics. Therefore the use of throat culture to arrive at the diagnosis is inaccurate.

Clinically, the patients presented with sorethroat, fever and malaise. Physical examination may nor may not show enlarged tonsils, but exudates, erythema are seen. Cervical lymph nodes may be enlarged and tender.

Definition of recurrent acute tonsillitis is varible. We take more than 4 episodes in one year or 7 episodes in 1 year, 5 episodes per year for 2 years or 3 episodes per year for 3 years .

Recurrent acute tonsillitis and chronic tonsillitis can give rise to peritonsillar abscess. Further spread of the infection beyond the peritonsillar space and lateral aspect of tonsillar fossa can lead to parapharyngeal space abscess. In addition, children under age 3 with tonsillitis are more susceptible to retropharyngeal space infection. Affected children will present as irritability, fever, difficulty in breathing and torticollis.

The most common drug used to treat tonsillitis is amoxicillin. But with increasing resistance, the use of beta-lactamase inhibitor i.e. augmentin or unasyn may be needed. Only 32% responds to medical treatment with 6 months prophylaxis or a prolonged course of 30-days antibiotics.

Decision for surgical intervention in patients with recurrent tonsillitis should be individualized. When treating paediatric patients, surgeon should have good communication with parents and provide full explanation of the procedure. Always ask for family history of bleeding tendency and other medical problems. Cervical XR should be done for children with Down's syndrome.

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Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the following problems:

 repeated bouts of tonsillitis;

 hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea;

 repeated attacks of purulent otitis media;

 suspected hearing loss due to serous otitis media that has occurred in association with enlarged tonsils and adenoids;

 and some other conditions, such as an exacerbation of asthma or rheumatic fever. emedicine.medscape.com

1. Infection:

Recurrent, acute tonsillitis (>6 episodes per year or 3 episodes per year >2 years) Recurrent acute tonsillitis associated with other conditions

Cardiac valvular disease associated with recurrent streptococcal tonsillitis Recurrent febrile seizures

Chronic tonsillitis that is unresponsive to medical therapy associated with Halitosis

Persistent sore throat Tender cervical adenitis

Streptococcal carrier state unresponsive to medical therapy Peritonsillitis abscess

Tonsillitis associated with abscessed cervical nodes

Mononucleosis with severely obstructing tonsils that is unresponsive to medical therapy 2. Obstruction:

Excessive snoring and chronic mouth breathing Obstructive sleep apnoea or sleep disturbances Adenotonsillar hypertrophy associated with Cor pulmonale

Failure to thrive Dysphagia

Speech abnormalities

Craniofacial growth abnormalities Occlusion abnormalities

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Suspected neoplasia-asymmetric tonsillar hypertrophy

There are different methods of tonsillectomy including the use of a cold knife, hot knife, diathermy, laser and harmonic scalpel. The operation lasts for about one hour. Postop, the patients recover rapidly and can resume tonsillar diet immediately. Most important is to look out for post-op bleeding. Postoperative haemorrhage ranges from 0.5-2%. No significant immunological consequence has ever been documented. Changes in speech or velopharyngeal insufficiency are mainly temporary. In general, nearly all our patients can be discharged safely from hospital three days after the operation.

Tonsillectomy Complications:

 Peritonsillar abscess.

 Acute otitis media.

 Lancefield's GABS can cause rheumatic fever, Sydenham's chorea, glomerulonephritis and scarlet fever.

 Streptococcal infection may cause a flare-up of guttate psoriasis.

 Enlarged and chronically infected tonsils interfere with children's sleep.

 Complications of tonsillectomy include otitis media and haemorrhage which can be very difficult, especially where there is an undiagnosed bleeding tendency such as haemophilia. Altered taste sensation has been reported.

 Patients who have had tonsillectomy are more susceptible to bulbar poliomyelitis. Smithard A, Cullen C, Thirlwall AS, et al; Tonsillectomy may cause altered tongue sensation in adult patients. J Laryngol Otol. 2009 May;123(5):545-9. Epub 2008 Jul 30.

BACTERIA vs VIRAL

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