Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
A Rare Cause of Tonsillitis Dr. Stanley Voigt, Dr. Peter Rappo, & Dr. Mark A Vecchiotti Tufts Medical Center Figure 1. Abstract We present a unique Case of a 10 year-old boy with Trichotillomania who presented to Tufts Medical Center Floating Hospital for Children Pediatric Otolaryngology clinic upon referral from his primary care physician for noted hair within his tonsils & halitosis. Trichotillomania is an impulse control disorder that involves strong urges to pull out one’s own hair and in some cases eat it. The patient had been pulling out his hair for 2 years and ingesting the hair with development of bilateral tonsilloliths. These hairs were partially removed in the clinic setting and the patient required eventual operative management in the form of bilateral tonsillectomy. A review of trichotillomania as well as our management of this unique condition is discussed. Right Tonsil Tonsilloliths Left Tonsil Figure 2. Trichotillomania Trichotillomania (ICD9-code 312.39, ICD10F63.3) is a medical/psychiatric condition characterized by the compulsive need to pull or twirl hair, usually from the scalp, but potentially also from the eyelashes, eyebrows, or pubic area. [10]. Patients with Trichotillomania exhibit hair loss of different lengths. This is distinctively different from those patients who have Alopecia, where the hair loss is even and to the scalp line, or fungal infection, where the scalp is rough and scaly. Anxiety and depression are also commonly associated with Trichotillomania. Patients report that pulling of hair leads to pleasure, satisfaction, or relief of stress. During childhood, boys and girls have an equal incidence of Trichotillomania. Negative stressors can also cause an increase in hair pulling. [11] Treatment options are varied but the efficacy of such treatment and results are mixed. Habit reversal training (HRT) has had the highest rate of success in treating Trichotillomania. [12, 13] The individual is trained to recognize the impulses that lead to hair pulling along with teaching to redirect the impulse. Biofeedback and Cognitive Behavioral Therapy have also been employed. [12] Since Trichotillomania is associated with both obsessive compulsive disorder and anxiety, selective serotonin re-uptake inhibitors (SSRI's) have been employed, but with limited success. As in the case of ADHD, combination of dual therapy with both medication and behavioral therapy would appear to be a logical combination. Other holistic approaches such as yoga, relaxation therapy, homeopathy, naturopathy and herbal medications have been employed, but without convincing scientific validation. Contact Stanley Voigt Tufts Medical Center Email: [email protected] Phone: 617-636-7878 Photo of hair lodged within right tonsillar crypt after in-office removal Figure 3. Given the cryptic nature of the palatine tonsils, they tend to be prone to retention of foreign body or exfoliated epithelial cells within the tonsil termed tonsilloliths. [5] This creates the optimal environment for the activity of anaerobic bacteria in the upper airway and patients therefore may develop what is termed Chronic Caseous Tonsillitis. Tonsilloliths are rare in the pediatric population and are more commonly seen in the 20-77 age group [7] The exact pathogenesis of tonsilloliths is unknown however potential etiologies have been proposed. Examination of tonsilloliths frequently reveal carbonates and phosphates of calcium and magnesium.[6] This is thought to be a result of chronic inflammation of the tonsils leading to scarring and fibrosis of the tonsillar ducts and crypts. This then leads to retention of epithelial debris and further bacterial invasion and colonization of the tonsils. Calcification results from the deposition of inorganic salts secreted by the salivary glands. [7] Tonsilloliths are usually managed conservatively with salt water gargles or expression by the patient. With larger tonsilloliths attempts can be made to remove them in the office setting. Pulsating water jet can be used in a cooperative patient to clean the pockets of debris mechanically. [8,9] Tonsilloliths that cause symptoms such as foreign body sensation, otalgia or halitosis refractory to medical management or in our unique case where the patient was at risk for recurrence of his tonsilloliths and resultant tonsillitis, the patient should be offered surgical management in the form of tonsillectomy. [9] He underwent bilateral tonsillectomy without issue and future therapeutic interventions for management of his trichotillomania will include behavioral therapy and the use of an SSRI medication to reduce anxiety. A behavioral approach called symptom substitution in which the patient will substitute one neuromotor activity for another (squeezing a soft rubber ball with his hand rather than twirling his hair) will also be recommended. (Kaplan 2012). Finally, counseling for the mother around her own personal anxiety and resistance to medical follow-up will be pursued. References 1. Dal Rio et al. Relationship between the presence of tonsilloliths and halitosis in patients with chronic caseous tonsillitis. British Dental Journal. 2008; 26;204(2):E4. 2. Abbey K, Kawabata I. Computerized three-dimensional reconstruction of the crypt system of the palatine tonsil. Acta Otolaryngol 1988; 454: 39-42. 3. Ansai T & Takehara T. Tonsillolith as a halitosis-inducing factor. British Dental Journal. 2005; 198(5): 263-4. 4. Stoodley P et al. Tonsillolith: Not just a stone but a living biofilm. Otolaryngology-Head and Neck Surgery. 2009; 141: 316-321. 5. Parsek MR, Singh PK. Bacterial biofilms: an emerging link to disease pathogenesis. Annu Rev Microbiol 2003;57:677–701. 6. Thirunavukkarasu, AB et al. Persistent Earache Due to Tonsillolith. Indian pediatrics. 2012; 49: 144-5. 7. Thakur JS et al. Giant Tonsillolith causing odynophphagia in a child: a rare case report. Cases Journal. 2008; 1: 50. 8. Pruet CW, Duplan DA: Tonsil concretions and tonsilloliths. Otolaryngol Clin North Am 1987; 20:305. 9. Flint PW et al. Pharyngitis and Adenotonsillar Disease in Cummings Otolaryngology. Fifth Edition. Philadelphia: Elsavier. 2010. 10. Harrison JP & Franklin ME. Pediatric Trichotillomania. Curr Psychiatry Rep. 2012; 14(3): 188-196. 11. Stemberger RMT, Thomas AM, Mansueto CS, Carter JG. Personal toll of trichotillomania: behavioral and interpersonal sequelae. J Anxiety Disord. 2000; 14:97– 104. 12. Franklin ME, Flessner CA, Woods DW, et al. The Child and Adolescent Trichotillomania Impact Project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr. 2008; 29:493–500 13. Gupta, S & Gargi PD. Habit Reversal Training for Trichotillomania. International Journal of Trichology. 2012; 4(1): 39-41. Adolescent with severe trichotillomania Title: Trichotillomania. 29 September 2003 via Wikimedia Commons 14. Trichotillomania. 29 September 2003. Created by Robodoc (original uploader) (de.wiki) [Public domain], via Wikimedia Commons http://commons.wikimedia.org/wiki/File%3ATrichotillomania_1.jpg 15. Mahajan, P & Johnson, LD. Foresee Your Next Patient: Trichobezoars. Consultant for Pediatricians, May 2012. pp. 148-149. 16. Kaplan, A. Update on Trichotillomania. Psychiatric Times, May 14, 2012.