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MINISTRY OF HEALTH CARE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF “ENT DISEASES”
CASE - TECHNOLOGY
SUBJECT: «Angina. Etiopathogenesis, clinic, diagnostics, differential diagnostics, treatment and prophylaxis.Tactic of General
Practitioner»
Case
To solve the problem, what tactic should keep GP in the cases of tonsillitis
Tashkent – 2015
MINISTRY OF HEALTH CARE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF “ENT DISEASES”
«APPROVED»
pro-rectorof educational work
prof.Teshaev O.R.
___________________
____ _____________ 2015 г
CASE - TECHNOLOGY
SUBJECT: «Angina. Etiopathogenesis, clinic, diagnostics, differential diagnostics, treatment and prophylaxis.Tactic of General
Practitioner»
Author: senior teacherAhundjanov N.O.
Pedagogical annotation
Subject: «Otorhinolaryngology»
Theme: « Angina. Etiopathogenesis, clinic, diagnostics, differential diagnostics,
treatment and prophylaxis.Tactic of General Practitioner.».
Aim of the case:
 Teach students to diagnostic criteria for tonsillitis
 Discuss the correct chose of antibiotics;
 To show main principles of differential diagnostics;
 To examine probable complications of tonsillitis;
 Teach students to compile sanitary measures
Planningresult–as a result of this case students gain next skills:
 Toevaluateandanalyzethesituation, and general condition of patients with tonsillitis
 To choose the algorithm of actions for correct tonsillitis
 If needed to provide first aid
 Send to hospital for treatment
 To be able to provide qualified rehabilitation measures
For successful decision of this case student must know :
 Anatomical and physiological features of throat in different age groups
 To know the etiology and pathogenetical links
 Diagnosing criteria;
 Classification of tonsillitis;
 The main clinical features , principles of diagnostic and treatment of tonsillitis.
 Clinical forms of tonsillitis, and principles of differential
 The main complications of tonsillitis;
 The principles of tonsillitis treatment;
 Indications for ENT doctor consultations.
Thegivencase reflects real situation in the conditions of primary unit channels of information
Main literature
1. «Ear ,nose , throatdiseases», V.T. Palchun, N.A. Preobrajensky, M.,Medicine 1980.
2. «Otorhinolaryngology», V.T. Palchun,A.I.Kryukov. Moscow «Litera», 1997y.
3. «Otorhinolaryngologyformedical high schools», Ovchinnikov M.., Medicine,1997y
4. Increasing effectiveness of antibacterial therapy in cases of suppurative inflammatory disease of throat A.I. Kryukov, N.L. Kupelskaya, G.N. Izotova. A.B. Turovskiy ,
Moscow 2007
Additional
1. www.medafarm.ru
2. www.tma.uz
3. www.medlincs.ru
Case characteristics
Thegivencasebelongstotheoreticalandplotline category it is volumetric and structured. This
is case -question.
By didactic aims this case is appear to be training, mind stimulating.
This case can be used in the next disciplines :ENT, Infectious diseases, emergency conditions
ICase
« Angina.Etiopathogenesis, clinic, diagnostics, differential diagnostics, treatment and
prophylaxis. Tactic of General Practitioner»
Preamble
Tonsillitis – acute inflammation of tonsils.
Tonsilltisistaldiease,characterized bylocalin flammatory changesof lymphoidtissueoftonsils. In 70 % ofcasesitis caused by group A streptococcus. AlsoitcanbecausedbySt. Aureus, by viruses , fungus, spirochetes etc. Differentirritants (thermic,
chemical and mechanical), reducing of general resistance can predisposetotonsillitis. Infectioncanenterfromoutsideormaybeasaresultofincreased virulence of microorganisms
which are always present in tonsil lacuna, oral cavity and in the throat. As the source of
infection can appear purulent diseases of nose andaccessory sinuses of nose, and caries.
Decisionofgivencasewillallowstudentstoreachthenext educational results:
 Toevaluateandanalysethesituation, and general condition of patients with tonsillitis
 To choose the algorithm of actions for correct tonsillitis
 If needed to provide first aid
 If needed send to hospital for treatment
 To be able to provide qualified rehabilitation measures
.
Situation.№1.Patient 25 yearsoldcomplainsonmalaise, sorethroat, increasedtemperature38,5С. Thediseasebegan 3 daysagoafter becoming too cold Pharyngoscopy: tonsils are
gently infiltrated,hyperemia ,yellowish patch on the tonsils . increased local lymph nodes,
painful during palpation .Blood test:НЬ - 90 г/л, RC - 3,5х1012/л,WC - 10,5х10^9, ESR-20
мм/hour. Urinetest:weight - 1018, protein - аЬs, WC -2-3
Questions and tasks
1. What is your diagnosis with foundation?
2. How do you think with which disease it should be differentiated ?
3. What is the tactic of GP.
Task:on the basis of analyses should be given primary diagnose, carry out necessary
methods of diagnostics to make a right decision for the further management of patient with
tonsillitis
II. Methodical indications for students
2.1 Problem :
Choose the tactics of GP and defining the necessity of hospitalization of patients with tonsillitis in conditions of rural medical point
2.2. Problems
1. To analyse the appearance
2. To analyse anamnesis, to find out the etiological factor
3. To carry out examinations
4. Necessary methods of diagnostics
5. To analyse the results and provide differential diagnose
6. To make a decision in the conditions of rural medical point
2.3. Decisionalgorithm
1. To analyse of appearance includes :
- examination of skin and mucous membranes
- face(eyes, tongue)
2. To analyse the anamnesis
- adoptive diseases
- social and family anamnesis
- duration and character of disease
3. Analysis of examination
- Ps, blood pressure , temperature
- oropharyngoscopy
- mesopharyngoscopy
- palpation of local lymph nodes
4. To choose of necessary methods of diagnostics
- Blood and urine test
- biochemical blood test
- bacteriological sow
5. To analyse the results and provide differential diagnose with:
- diphteria
- paratonsillarabscess
6. To make a decision in the conditions of rural medical point
- treatment if needed
- emergency hospitalization
- to provide first aid
Instruction for decision of practical situation
List of situation analyses
Stages of work
Recommendations and advices
1. examination of the case
А cursory examination of the case. Read it , do
not attempt to analyse the situation immediately
2. Examination with the given situation
Read it one more time and underline the main
data.
Try to characterize the situation. Define what is
important and what is not.
3. Revelationandfoundationofthemainprob- problem:
lem
Choose the tactics of GP and defining the ne-
cessity of hospitalization of patients with tonsillitis in conditions of rural medical point .
4. Analysis of the situation
Answer next questions:
What are the most common diseases accompanied by high fever?
What diseases should be differentiated tonsillitis
from and what is the most common causative
agent of tonsillitis.
What kind of diagnostic methods should be
made in rural medical point and in hospital.
Consultation of what doctors do you need to
made a final diagnosis?
Define the further management of these patients
5. Choose and give a foundation for the List all the possible methods of solving this
methods of solving this problem.
problem on this occasion.
6. Developing and solving the problem
Diagnose and solve the problem in the conditions of rural medical point.
Instruction for team work in solving the practical situation and its’ analyses.
Stages of the work
Coordinate the opinions about the
situation and opinion.
Analyzeandevaluateoffered methods for solving the problem and
chose the best one.
Developmutuallyacceptablevariantofsolvingtheproblem and elaborate its’ further realization.
Prepare the presentation
Recommendations and advices
Discussand coordinate concepts of team members according to this situation and problem.
Discuss and evaluate offered variants and methods to
solve the problem, chose the priority way of solving the
problem.
Developmutuallyacceptablevariantofsolvingtheproblem
and elaborate its’ further realization..
Prove your diagnosis;
Prove your further actions.
Formalizetheresultsoftheworkinverbalformonthebehalfofthegroup.
Discussanddecidewhowillpresenttheresultsofthework: leaderorthewholeteamdividing the functions between the participants. Prepare
hand out data in the form illustrations, slides and multimedia
List of situation analyses
Stage
Content
examination with problem given А cursory examination of the case. Finding out im-
in the case
portant data
Answer next questions:
Analysis of the anamnesis , finding out etiological agent
Analysis of the situation
Analysis of the examination of the patient.
chose of necessary methods of diagnostics.
To analyze the results and provide differential diagnose.
To make a decision in the conditions of rural medical
point
Problem foundation
Foundation of the main problem and its’ constituents
The ways of alternative decisions Form the possible alternatives in this case.
Developing and solving the prob- Elaboration and foundation of concrete decision in this
lem
case
III.
VARIANT OF SOLVING THE CASE WITH THE TEACHER
IVCASE – SEMINAR EDUCATION
4.1 THE MODEL
Theme
Quantity of hours
Form of the studies
Tonsillitis
Quantity of students: 10
Seminardevotedtoextendanddeepeningtheknowledge
in management the patients with tonsillitis
Plan
Preamble
Actualization of knowledge
Work with case in mini groups
Results presentation
Discussion, evaluation and selection of the best
strategy
Conclusion.
Aimofthestudy:extendanddeepeningtheknowledge in management the patients with tonsillitis. Developingtheabilitytoevaluate, analyze, choosethemanagementtactics, rehabilitation
for the patients with tonsillitis in the condition of rural medical point
Teacher tasks:
Results:
- extendanddeepeningtheknowledge - evaluate and analyze general conditions of the pain management the patients with ton- tients with tonsillitis
sillitis
- choose the algorithm for diagnosing the disease
- to teach the correct algorithm of ac- - develop the skills of making independent decisions
tions in the cases of tonsillitis
in the cases of tonsillitis in conditions of rural medi- to teach the skill of first medical aid cal point .
- to develop the skills of making in- - develop the algorithm of the action to provide first
dependent decisions in the cases of medical aid if it is needed
tonsillitis in conditions of rural medical point .
Education methods
Case-stages , discussion, practical methods
Educational resources
Form of study
Conditions of study
Monitoring and evaluation
Stages and
contents of
the work
Preparation
stage
Case, methodical indications
Individual, frontal work in groups
Auditory with technical equipment
observation, survey, presentation, evaluation
Technological map of the study based on the case
Actions of:
Teacher
Students
Explainswhat “Case” is – its’ stagesandits’
influenceonprofessionalknowledge.
Giveshandoutdataandintroducewith the algorithm of the actions for correct analyze
the situation. Gives the task to analyze and
write down the results into the “list of situation analyses”
Iintroducing
1.1. namethesubject, plan, its’ aim, andexinto the sub- pectationresults
ject
1.2. introduce the schedule of the day and
(10-15 min)
the evaluation criteria
IImain stage 2.1. givesafoundationofthesubjectits’ actual60 min
ity. Carry out the survey to activate the
knowledge of the students:
List the main reasons of tonsillitis?
What complications may occur in the cases
of late diagnostics?
2.2. divides students into the groups. Reminds them the content and the tasks of the
case
2.3. gives task and ensure that students have
understood
What diseases should be differentiated tonsillitis from and what is the most common
causative agents of tonsillitis..
Methods of diagnostic in the conditions of
rural medical
Tactics of management and treatment of
such patients
2.4. coordinateandconsults, direct the educational process
Evaluatetheresultofindividual
2.5.
organizespresentationsontheresultofsolvingthecase. Discussion.
Listen
Study the case and fill the list
of analyses independently
Listen and write down important data
Answer and ask questions
Divides into the groups
Discussandmakejointanalysesofindividualproblemformalize thae main aspect
of
the
problem.
Formtheresultofthework
Presentsthewaysofproblemsolution
10-15
minquestinsafterpresentations , selectionofthebestvar-
IIIsizing up
the result ,
analyses and
evaluation 20
min
Organizer gives question and reminds the
subject
2.6. Organizer- algorithm of GP actions in
this case
2.7. Report his way of solution the case
3.1. summarizetheresultofmadework, announce the marks of individual and team
work
Analyzesandevaluatethegroup, note positive
and negative moments.
3.2. underlinethesenseofthecase – andits’ influence on developing of future specialists
iant
Develop
discuss
uniform
system,
Listen.
May make a self-appraisal,
or evaluate other students
Tell their opinion
Appendix № 1.
Thetheoreticalpart
«Angina.Etiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention.
Tactics of GP»
The pharynx is that part of the digestive tube which is placed behind the nasal cavities, mouth, and larynx. It is a musculomembranous tube, somewhat conical in form, with
the base upward, and the apex downward, extending from the under surface of the skull to
the level of the cricoid cartilage in front, and that of the sixth cervical vertebra behind.
The cavity of the pharynx is about 12.5 cm. long.
The cavity of the pharynx may be subdivided from above downward into three
parts: nasal, oral, and laryngeal.
The lower part of oral cavity and the adjacent walls of the pharynx have an clusters of
lymphoid tissue which form some isolated lymphatic organs. So, we have the palatine
tonsil(1,2), the pharyngeal tonsil(3), the lingual tonsil(4) and an clusters of lymphoid tissue posterior to the ostiumpharingeumtubaeauditivae known as tonsil of the torus tubarius(5,6). Yet, at the pillars
and adjacent parts of pharyngeal mucosa there are many lymphatic follicules.These lymphatic structures protect the entrance of the respiratory and digestive tract. They are named
as pharyngeal
lymphatic ring or Waldeyer’s ring.
Blood supply of the pharynx is realized predominantly by the external carotid artery
branches.
Physiology of the pharynx.
Pharynx performs the following important functions:
1) swallowing and sucking
2) voice and speech production
3) breath
4) protection when eating and breathing.
Angina - an acute inflammation of the tonsils of the pharynx.
Angina is common name for acute infectious disease in lymphoid tissue of pharynx,
in most cases, the tonsils. In the majority of cases of angina the basic etiological role belongs to the beta-hemolytic streptococcus group A (70% of cases). Staphylococcus aureus,
viruses, spirochetes, fungi, etc. can also be the reason of angina. Contributing moments are
various stimuli (thermal, chemical and mechanical) with a decrease in total body resistance. The infection can be introduced from the outside or is due to increased virulence
of microorganisms residing in the gaps of the tonsils, oral cavity and pharynx. The source
of infection can also be a festering diseases of the nose and paranasal sinuses, caries teeth,
etc.
CLASSIFICATION of Angina.
A lot of classifications of angina were offered. In clinical practice, the most widespread classification of Preobrajenski, which includes the following forms of angina: catarrhal, follicular, lacunar, fibrinous, hermetic (gangrenous), mixed forms.
Etiological classification of angina.
Nonspecific
In acute infectious
Flora (main)
diseases
Streptococcus
a) B-hemolytic
streptococcus gr.A
b) epidemic
streptococcus
Staphylococcus
a) aureus
b) white
Diphtheria
Tuberculosis
Scarlet fever
Syphilis
Measles
Fuso
spirochetosis
Rubella
Infectious
mononucleosis
Kandidomikousis
Influenza and adenovirus
Glanders
Catarrhal angina
In blood diseases
and
hemorrhagic
diathesis
Leukemia (lymphocytic leukemia)
Agranulocytosis
Pneumococcus
Rod bacteriums
a) E.coli
b) Pseudomonas
Proteus
Infectious granulomatous and specific pathogens
Brucellosis
Tularemia
Alimentary - toxic
aleukia
Patients initially complain to dryness and soreness of the throat. Temperature is
somewhat high in adults ,high temperature, vomiting, headache,and fatigue are often occur in young children. The disease usually ends in 3-4 days.
Pharyngoscopy findings: heavily reddened swollen tonsils, their surface is covered with a
mucous discharge. Mucosa around the tonsils are more or less hyperemic. In more severe
cases, there are petechial hemorrhages in the mucosa.
Lacunar angina.
An inflammation of the mucous membrane covering the tonsils and lining the crypts
or follicles of the gland.
Etiology.—This occurs most frequently between the ages of ten and twenty-five,
while it is rare in infants and after middle life. Exposure to wet and cold, especially after
overheating or undue use of the voice, is a common exciting cause. It occurs most frequently in the spring. Bad hygienic surroundings, especially where the sewerage is defective, allowing the escape of sewer-gas, is also thought to be a fruitful cause. An effort has
been made, with some success, to show that there is some relation existing between rheumatism and this disease.
Measles, scarlet fever, and diphtheria, of the infectious fevers, play some part as a
causal factor in this lesion.
Pathology.—The lacunae are filled with a cheesy substance, consisting of epithelial
cells and various micrococci, and, protruding from the crypts, give the tonsil a spotted appearance; the mucous membrane between the crypts is bright red, and bathed with a
creamy pus, sometimes resembling a membrane, and may be mistaken for diphtheria,
though the ease with which it may be wiped off should allay all doubts as to its character.
Sometimes calcareous degeneration occurs, and limy or chalky deposits fill the lacunae.
Symptoms.—This is more severe than the catarrhal form, and is usually ushered in
with a chill, followed by rather a high grade of fever considering the local character of the
disease. During the initiatory stage the patient complains of aching all over the body, and
one who is subject to the disease will diagnose his own case before there is much local
trouble.
The throat soon becomes sore and stiff, the pain extending to the ear; the tonsil or
tonsils are red, angry-looking, with yellowish spots, the cheesy exudate showing from the
crypt. Swallowing is difficult, and respiration is more or less impaired; the lymphatics are
generally involved. The tongue is coated with a dirty fur, the breath is offensive, and the
secretions markedly arrested, the skin being dry, urine scanty, and bowels constipated; the
temperature frequently reaches 103° f or 104° f. The disease reaches its height by the
fourth or fifth day, then gradually declines, the patient being convalescent by the end of
the second week.
Follicular Tonsillitis.
An inflammation of the mucous membrane covering the tonsils and lining the crypts
or follicles of the gland.
This is more severe than the catarrhal form, and is usually ushered in with a chill, followed by rather a high grade of fever considering the local character of the disease. During
the initiatory stage the patient complains of aching all over the body, and one who is subject to the disease will diagnose his own case before there is much local trouble.
The throat soon becomes sore and stiff, the pain extending to the ear; the tonsil or
tonsils are red, with yellowish spots, the cheesy exudate showing from the crypt. Swallowing is difficult, and respiration is more or less impaired; the lymphatics are generally involved. The tongue is coated with a dirty fur, the breath is offensive, and the secretions
markedly arrested, the skin being dry, urine scanty, and bowels constipated; the temperature frequently reaches 39° or 40°. The disease reaches its height by the fourth or fifth day,
then gradually declines, the patient being convalescent by the end of the second week.
When the pain will be intensified.Sometimes accompanied by discomfort symptoms.
There are some patients will be accompanied by tinnitus and hearing loss in chronic tonsillitis is generally because .Acute tonsillitis repeated recurrence, so will some.
Chronic tonsil boring hypertrophy and fibrosis. Hypertrophic tonsillitis will have different
degrees of swelling, lymphatic tissue significantly hyperplasia and lymphoid follicles. Will
obviously increase in lymphoid tissues increases, there will be numerous plasma cells, but
also slightly some inflammatory exudate.And fibrous tonsillitis, there will be a lot of fibrous connective tissue hyperplasia, tonsil volumewill be reduced, lymphoid tissue will
shrink or even disappear. Crypt export obstruction then a Xiang shaped expansion.
Tonsillitis phlegmonousous.
Angina phlegmonous. Is complication of one of the anginas described above forms is
more often and develops in 1-2 days after the angina has ended. Process more often unilateral, is characterized by a sharp pharyngalgia at a swallowing, a headache, a cold fit, sensation of weakness, delicacy, a nasonnement, a masticatory spasm of masseters, a fervescence up to 38-39 degrees, a unpleasant smell from a mouth, plentiful allocation of a saliva.
SYMPTOMS:
Unlike tonsillitis, which is more common in the pediatric age group, PTA has a more
even age spread — from children to adults. Symptoms start appearing two to eight days
before the formation of an abscess. Progressively worsening, unilateral sore throat and
pain during swallowing usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area, fever, malaise, headache and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and halitosis are also common. While these signs may
be present in tonsillitis itself, a PTA should be specifically considered if there is limited
ability to open the mouth (trismus).
InShort:

Severe unilateral pain in the throat;

Pyrexia above 103 degree F (39ºC);

UnilateralEarache;

Odynophagia and difficulty swallowing saliva;

Change in voice — muffled voice, “hot potato” voice;

Intense salivation and dribbling,Thickened speech, Foetororis, Halitosis;

Painintheneck;

Malaise, Headache, Rigor.
Trismus is common. Physical signs include redness and edema in the tonsillar area of
the affected side and swelling of the jugulodigastric lymph nodes. The uvula may be displaced towards the unaffected side. Odynophagia (pain during swallowing), and ipsilateral
earache also can occur.
PTA usually arises as a complication of an untreated or partially treated episode of
acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue and is hence susceptible to formation of
abscess. PTA can also occur de novo. Both aerobic and anaerobic bacteria can be causative. Commonly involved species include streptococci, staphylococci and hemophilus.
Treatment is surgical incision and drainage of the pus, thereby relieving the pain of
the pressed tissues. Antibiotics are also given to treat the infection. Internationally, the infection
is
frequently
penicillin
resistant,
so
it
is
now
common
to
treat
with clindamycin.[1] Treatment can also be given while a patient is under anesthesia, but
this is usually reserved for children or anxious patients.
Complications:

Retropharyngealabscess;

Extension of abscess in other deep neck spaces leading to airway compro-
mise. See Ludwig'sangina;

Septicaemia;

Possible necrosis of surrounding deep tissues;

Inrarecases, mediastinitis.
Retropharyngealabscess
Most commonly seen in infants and young children, retropharyngeal abscess (RPA)
is an abscess located in the tissues in the back of the throat behind the posterior pharyngeal
wall (the retropharyngeal space). Because RPA's typically occur in deep tissue, they are
difficult to diagnose by physical examination alone. RPA is a relatively uncommon illness,
and therefore may not receive early diagnosis in children presenting with stiff
neck, malaise, difficulty swallowing, or other symptoms listed below. Early diagnosis is
key, while a delay in diagnosis and treatment may lead to death. Parapharyngeal space
communicates with retropharyngeal space and an infection of retropharyngeal space can
pass down behind the oesophagus into mediastinum. RPA's can also occur in adults of any
age.
RPA can lead to airway obstruction or sepsis - both life-threatening emergencies. Fatalities normally occur from patients not receiving treatment immediately and suffocating prior to knowing that anything serious was wrong.
RPA
is
usually
caused
by
a
bacterial
infection
originating
from
the nasopharynx, tonsils, sinuses, adenoids or middle ear. Any Upper Respiratory Infection (URI) can be a cause. RPA can also result from a direct infection due to penetrating
injury or a foreign body. RPA can also be linked to young children who do not have adequate dental care or brush their teeth properly.
SYMPTOMS:
Symptoms may include stiff neck (limited neck mobility or torticollis), some form
of palpable neck pain (may be in "front of the neck" or around the Adam's
Apple), malaise, difficulty swallowing, fever, stridor, drooling, croupy cough or enlarged
cervical lymph nodes. Any combination of these symptoms should arouse suspicion of
RPA.
TREATMENT:
RPA's frequently require surgical intervention. A tonsillectomy approach is typically
used to access/drain the abscess, and the outcome is usually positive. Surgery is done
without general anesthesia since there is risk of rupture of abscess during intubation for
anesthesia. In complex cases, tracheotomy may be required to prevent upper airway obstruction caused by edema in the neck.
High dose of Intravenous antibiotics are required in order to control the infection and
reduce the size of the abscess prior to surgery.
Chronic retropharyngeal abscess is usually secondary to tuberculosis and the patient
needs to be started on anti tubercular therapy as soon as possible.
Diagnosis:
CT is the definitive diagnostic test.
X ray of the neck 80% of the time shows swelling of the retropharyngeal space. If
the retropharyngeal space is more than half of the size of the C2 vertebra, it may indicate
retropharyngeal abscess.
Acute necrotizing ulcerative gingivitis (ANUG) or necrotizingulcerative gingivitis
(NUG) is a sub-classification of necrotizingperiodontal disease, an infection of the gum
tissue . Thispresents as an acute infection of the gingiva without involvementof the other
tissues of the periodontium. Ifthe infection has progressed deeper into the periodontal tissues ,it is subclassified as "necrotizing ulcerativeperiodontitis" (NUP).
The condition is also commonly referred to as "trench mouth" and"Vincent's angina",
named after French physician Jean HyacintheVincent (1862–1950). Other synonyms include
"acute
membranousgingivitis",
"fusospirillarygingivitis",
"
fusospirillo-
sis","fusospirochetal gingivitis", "necrotizing gingivitis", "phagedenicgingivitis", "ulcerative gingivitis", "Vincent stomatitis", "Vincentgingivitis", and "Vincent infection".
Etiology
Necrotizing periodontal disease is caused by a bacterial infectionthat includes anaerobes such as P. intermedia andFusobacterium as well as spirochetes , such as Borrelia
andTreponema .In the late 1980s-early 1990s, it was originally thought thatnecrotizing
periodontal diseases were strictly a sequela of HIV,and it was even called HIV-associated
periodontitis. It is nowunderstood that its association with HIV/ AIDS was due to theimmunocompromised status of such patients, and it occurs withhigher prevalence in association with other diseases in which theimmune system is compromised.
Signs and symptoms
Clinical features of necrotizing periodontal disease may
include:necrosis and/or punched out ulceration of the interdentalpapillae ("punchedout papillae") or gingivalmargin formation of a pseudomembrane (or "film") on the gingival painful, bright red marginal gingiva that bleed upon gentlemanipulationhalitosisCoincident factors may include heavy smoking and poornutrition , especially for those presenting with necrotizingulcerative periodontitis.
Treatment
Treatment includes irrigation and debridement of necrotic areas(areas of dead and/or
dying gum tissue), oral hygiene instructionand the uses of mouth rinses and pain medication. As thesediseases are often associated with systemic medical issues, propermanagement of the systemic disorders is appropriate.
Monocyte tonsillitis
Infectious Mononucleosis
DefinitionInfectious mononucleosis is a contagious illness caused by theEpstein-Barr
virus that can affect the liver, lymph nodes, and oralcavity. While mononucleosis is not
usually a serious disease, itsprimary symptoms of fatigue and lack of energy can linger
forseveral months.
Description
Infectious mononucleosis, frequently called "mono" or the "kissingdisease," is caused
by the Epstein-Barr virus (EBV) found in salivaand mucus. The virus affects a type of
white blood cell called the Blymphocyte producing characteristic atypical lymphocytes
that maybe useful in the diagnosis of the disease.While anyone, even young children, can
develop mononucleosis, itoccurs most often in young adults between the ages of 15 and 35
andis especially common in teenagers. The mononucleosis infection rateamong college
students who have not previously been exposed to EBVhas been estimated to be about
15%. In younger children, the illnessmay not be recognized.The disease typically runs its
course in four to six weeks in peoplewith normally functioning immune systems. People
with weakened orsuppressed immune systems, such as AIDS patients or those who havehad organ transplants, are particularly vulnerable to the potentiallyserious complications of
infectious mononucleosis.
Causes and symptoms
The EBV that causes mononucleosis is related to a group of herpesviruses, including
those that cause cold sores, chicken pox, andshingles . Most people are exposed to EBV at
some point during theirlives. Mononucleosis is most commonly spread by contact with virus-infected saliva through coughing, sneezing, kissing, or sharingdrinking glasses or eating utensils.In addition to general weakness and fatigue, symptoms ofmononucleosis may
include any or all of the following:
Sore throat and/or swollen tonsils
Fever and chills
Nausea and vomiting, or decreased appetite
Swollen lymph nodes in the neck and armpits
Headaches or joint pain
Enlarged spleen
Jaundice
Skin rash.
Complications that can occur with mononucleosis include a temporarilyenlarged
spleen or inflamed liver. In rare instances, the spleen mayrupture, producing sharp pain on
the left side of the abdomen, asymptom that warrants immediate medical attention. Additionalsymptoms of a ruptured spleen include light headedness, rapidlybeating heart, and
difficulty breathing. Other rare, but potentiallylife-threatening, complications may involve
the heart or brain. Theinfection may also cause significant destruction of the body's redblood cells or platelets.
Symptoms do not usually appear until four to seven weeks afterexposure to EBV. An
infected person can be contagious during thisincubation time period and for as many as
five months after thedisappearance of symptoms. Also, the virus will be excreted in thesaliva intermittently for the rest of their lives, although theindividual will experience no
symptoms. Contrary to popular belief,the EBV is not highly contagious. As a result, individuals living in ahousehold or college dormitory with someone who has mononucleosishave a very small risk of being infected unless they have directcontact with the person's
saliva.
Diagnosis
If symptoms associated with a cold persist longer than two weeks,mononucleosis is a
possibility; however, a variety of other conditionscan produce similar symptoms. If mononucleosis is suspected, aphysician will typically conduct a physical examination , including a"Monospot" antibody blood test that can indicate the presence ofproteins or antibodies produced in response to infection with the EBV.These antibodies may not be detectable, however, until the second orthird weeks of the illness. Occasionally, when this test is
inconclusive,other blood tests may be conducted.
Treatment
The most effective treatment for infectious mononucleosis is restand a gradual return
to regular activities. Individuals with mild casesmay not require bed rest but should limit
their activities. Anystrenuous activity, athletic endeavors, or heavy lifting should beavoided until the symptoms completely subside, since excessiveactivity may cause the spleen to
rupture.The sore throat and dehydration that usually accompanymononucleosis may be relieved by drinking water and fruit juices.Gargling salt water or taking throat lozenges may
also relievediscomfort. In addition, taking over-the-counter medications, such asacetaminophen or ibuprofen, may relieve symptoms, but aspirin shouldbe avoided because
mononucleosis has been associated with Reye'ssyndrome, a serious illness aggravated by
aspirin.While antibiotics do not affect EBV, the sore throat accompanyingmononucleosis
can be complicated by a streptococcal infection, whichcan be treated with antibiotics. Cor-
tisone anti-inflammatorymedications are also occasionally prescribed for the treatment ofseverely swollen tonsils or throat tissues.
Acute pharingitis
Your throat starts at the back of your mouth and noseand connects to your oesophagus (the pipe that goesfrom your mouth to your stomach), windpipe (trachea)and voice
box (larynx).Pharyngitis can be an acute or chronic inflammation ofyour throat. When describing an illness, the terms'acute' and 'chronic' refer to how long a person hashad it, not
to how serious the condition is.Acute pharyngitis is typically over quite quickly.It usually
lasts about a week and is a commoncondition, particularly in children and youngadults.
Chronic pharyngitis (or a persistent sorethroat) lasts for longer - sometimes for severalweeks or months.Pharyngitis is inflammation of your throat, usually caused by an infection. The infection can sometimescause inflammation of your tonsils as well.Pharyngitis is
a common condition, particularly inchildren and young adults.There are two types of
pharyngitis - chronic andacute.
Acute pharyngitis is common and is usually caused bya viral infection. It's often
caused by the same viralinfection that causes the common cold. The symptomsof acute
pharyngitis usually last for a week or less.
Chronic pharyngitis is a persistent sore throat. Thesymptoms of chronic pharyngitis
last for longer thanthose of acute pharyngitis.The symptoms of pharyngitis vary, depending on howinflamed your throat is. Symptoms can include:a sore throat - pain at the back
of your mouth,which may be mild or severedifficulty and pain when swallowingearachea
fever - a temperature higher than 37.5Cfeeling generally unwell
muscle aches
cough
enlarged and tender glands in your neck
enlarged and tender tonsils (tonsillitis)
You don't always need to see a doctor for thesesymptoms if they are not very severe
and you canmanage them at home. However, if your symptomsdon't improve or get worse,
or you have a constanthigh temperature that isn't helped by painkillers suchas paracetamol,
see your GP.
Most people with pharyngitis won't have anycomplications. However, if you have
had pharyngitiscaused by a bacterial infection, there is a smallchance that you may develop:an ear infection (otitis media)a sinus infection (sinusitis)a throat abscess (retropharyngeal abscess) -this is most common in young childrenan abscess behind your tonsils (peritonsillarabscess or quinsy)an inflammation of the flap of tissue thatcovers your windpipe
(epiglottis), which canmake it difficult to breathe - this is very rarenowadaysIf you have an
abscess, you may have severe pain,drool, and find it very hard to swallow. You should
seeyour GP if you have these symptoms, or seek urgentmedical attention if you are finding
it hard tobreathe.
You are more likely to develop complications if youhave a weakened immune system, for instance if youhave HIV/AIDS, or if you are taking medicines thatsuppress the
immune system.Pharyngitis is usually caused by an infection with avirus or bacterium.
Most people with acute pharyngitishave a viral infection such as the common cold. Themost common type of bacterial infection isStreptococcus (known as strep throat). Strep
throatoccurs most often in children. There is no evidencethat sore throats caused by a bacterial infection aremore severe than those caused by a virus, or thatthey last any longer.Irritants and allergens can also inflame the linings ofyour throat and cause a persistent
sore throat(chronic pharyngitis). Some examples of irritantsinclude:airborne allergens such
as grass and tree pollensmoke and air pollutionsprays containing chemicals (eg householddetergents)alcoholYou may be more likely to have a persistent sorethroat if you
smoke or have a medical conditionaffecting your mouth, nose or upper respiratorysystem
(such as hay fever, sinusitis or a chroniccough).
Medicines
You can take over-the-counter painkillers such asibuprofen or paracetamol to relieve
pain and bringyour temperature down if you have a fever. Alwaysread the patient information that comes with yourmedicine and if you have any questions, ask yourpharmacist
for advice.If you have pharyngitis and an allergy then you mayfind that controlling your
allergy helps to reduce thesymptoms of your pharyngitis. Antihistamine tabletssuch as loratadine (egClarityn) may help to do this.
Your GP won't usually prescribe antibiotics, even ifyour sore throat is thought to be
caused by abacterial infection, as antibiotics won't usually help torelieve your symptoms
or help you to recover anysooner. Your GP may prescribe you antibiotics if youhave a severe infection or if he or she thinks you'reat risk of complications. You may also be givenantibiotics if you're admitted to hospital because of acomplication, such as an abscess
(quinsy).If you're prescribed antibiotics, make sure that youtake the full course. Always
ask your GP for adviceand read the patient information leaflet that comeswith your medicine.
Faucial diphtheria
Faucial diphtheria: is caused by corynebacterium diphtheria.This is a very rare condition these days considering theeffectiveness of the universally administeredvaccinations
under the immunization schedule. The disease is characterized bymembranous exudate at
the site of infection. This is followed by distant toxiceffects. Age of occurrence: Occurs in
the age group between 2 and10 years. Below 2 years the passive immunity provided bythe
mother is still persistent. After the age of 10 the childgains immunity from exposure to
community infections orimmunization.
Pathogenesis: Organisms multiply in the throat, producing toxins. The necrosisof
mucosa along with collection of polymorphs and fibrin leadsto false membrane formation.
This is a pseudomembranebecause it contains layers of necrotic mucosa, while a truemembrane will be found superimposed on intact mucosa.
Incubation period: ranges from 2 - 10 days
Clinical features:
1. The child is abnormally quietand refuses to eat
2. Malaise and headache
3. Toxemia could be present
4. Pulse rate increased out ofproportion to fever
5. Presence of massive cervicallymphadenopathy (Bull's neck)
6. Toxic myocarditis is common
Investigations:1. Throat swab reveals the
Organisms2.Schick test - positive
Treatment:
1. Antibiotics - Penicillin group
2. Antidiphtheretic serum toneutralize the toxin. This isadministered as follows:
Mildcase 20,000 units, moderate tosevere cases 40,000 to 80,000units. Half of this dose
isadministered intravenously andthe other half intramuscularly.Of course test dose should
beadministered.
3. If airway is compromisedtracheostomy should be done
3. Complete isolation - 2 weeks
Appendix №3
Get acquainted with "the rules for the cluster."
 2.3. cluster
Cluster (sheaf, bunch).
• Stimulates the actualization of
knowledge helps freely and openly
engage in new associative thinking
process representation by theme.
Applies at all stages of of lesson
In the center of the chalkboard or a large sheet of paper
written keyword / name of the theme of 1-2 words
By association with the keyword attribute the side of it in
the circles smaller "satellite", connecting them with lines
of "chief." These "satellite" can be "small satellites", etc.
Write down the words or sentences that are related to
the topic.
They exchange clusters for discussion
Cluster
Diagnos
is
Treat
ment
Angina
com
plain
h
i
g
v
o
m
it
i
n
g
f
a
ti
g
u
e
,
,
h
Diagnosis
Treat
ment
Angina
com
plain
h
i
g
h
t
e
m
p
e
v
o
m
it
i
n
g
,
,
h
e
a
d
a
c
h
f
a
ti
g
u
e
Scheme "fishbone"
Acquainting with the rules of
building schemes, individually / in pairs recorded on the
upper "bone" sub-problem,
and the bottom is evidence
that these sub-problems
exist
Allows one to describe the whole
range of problems
and try to solve it.
Develops and activates the system,
creative, analytical
thinking.
Combined into small
groups, compare and
complete their
scheme. Reduce the
general scheme
Presentation of results: presentation of filled
schemes allows to demonstrate interrelation of
sub-problems, their complex character
Scheme “Angina. Etiology ”
In acute infectious diseases
Etiological classification of angina
Nonspecific
Flora (main)
Infectious granulomatous and specific pathogens
In blood diseases and
hemorrhagic
diathesis