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KUHS ENT practical case presentation format 100 marks adenotonsillitis

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KUHS clinical case presentation format ENT practical examination structure marks distribution

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CASE PRESENTATION: ADENOTONSILLITIS

KUHS MBBS ENT Practical Examination | 100 Marks

PATIENT DETAILS


Name	Master Arjun K.
Age	8 years
Sex	Male
Occupation	School student
Address	Ernakulam, Kerala
IP No.	XXXX
Date of Admission	XX/XX/2026

CHIEF COMPLAINTS (5 marks)

Sore throat with pain on swallowing - 4 days
Fever - 4 days
Bilateral ear pain - 2 days
Nasal obstruction and mouth breathing - 3 months (background history)

HISTORY OF PRESENT ILLNESS (10 marks)

The patient was apparently well 4 days prior to admission when he developed sore throat, insidious in onset, gradually progressive, aggravated by swallowing (both liquids and solids), and partially relieved by analgesics. Associated with fever of insidious onset, continuous type, not documented, associated with chills but no rigors. Bilateral ear pain developed 2 days later, dull aching in nature, not associated with ear discharge, hearing loss, or tinnitus.

The patient has a background history of nasal obstruction and mouth breathing for 3 months, associated with snoring at night, rhinorrhoea, and hyponasal voice. Parents also note that the patient has had 5 similar episodes of sore throat in the past 12 months, each requiring antibiotic treatment.

Negative history:

No history of difficulty in breathing / stridor
No trismus or inability to open mouth
No change in voice / "hot potato voice"
No neck swelling or stiffness
No skin rash
No joint pain or swelling
No blood in urine (haematuria)
No snoring / sleep apnoea episodes (new onset)
No previous throat surgery

PAST HISTORY (3 marks)

Similar episodes - 5 times in the past year, each treated with antibiotics
No history of rheumatic fever, nephritis, or cardiac disease
No history of previous tonsillectomy or adenoidectomy
No history of other major illnesses

PERSONAL HISTORY (2 marks)

Diet: Mixed
Appetite: Reduced during episodes
Bowel and bladder habits: Normal
Sleep: Disturbed; snoring noted by parents

FAMILY HISTORY (2 marks)

No similar illness in family members
No history of tuberculosis or malignancy in family

TREATMENT HISTORY (2 marks)

Treated with amoxicillin and analgesics for previous episodes
No known drug allergies

GENERAL PHYSICAL EXAMINATION (8 marks)

Parameter	Finding
Built and Nourishment	Moderately built, mildly malnourished
Consciousness	Conscious and cooperative
Pallor	Absent
Icterus	Absent
Cyanosis	Absent
Clubbing	Absent
Lymphadenopathy	Bilateral level II (jugulodigastric) lymph nodes palpable, tender, 1-2 cm
Oedema	Absent
Temperature	38.6°C
Pulse	104/min, regular, good volume
Blood Pressure	100/70 mmHg
Respiratory Rate	18/min

Adenoid facies: Open-mouth posture, periorbital puffiness, flat midface, narrow alveolar arch - features suggestive of chronic adenoid hypertrophy.

SYSTEMIC EXAMINATION (5 marks)

CVS: S1 S2 heard, no murmurs
RS: Air entry bilaterally equal, no added sounds
P/A: Soft, non-tender, no organomegaly
CNS: No focal neurological deficit

LOCAL EXAMINATION (15 marks)

Oropharynx and Oral Cavity

On inspection:

Mouth breathing noted
Tonsils: Bilateral, Grade III enlargement (Mackenzie's grading) - tonsils meeting at midline
Tonsil surface: Congested, hyperaemic, cryptic with yellowish-white follicles/exudate in tonsillar crypts
Anterior and posterior pillars: Congested and oedematous
Posterior pharyngeal wall: Congested with lymphoid follicles (granular pharyngitis)
Uvula: Midline, not displaced
Soft palate: Mobile bilaterally

Irwin Moore (Squeeze) test: On pressing the anterior pillar against the tonsil, cheesy white debris expressed from tonsillar crypts - positive (indicates chronic tonsillitis with current acute exacerbation)

Nose

External nose: No deformity
Anterior rhinoscopy: Bilateral nasal mucosa congested, turbinates hypertrophied, mucoid discharge present
No septal deviation noted

Nasopharynx (Posterior Rhinoscopy / Mirror examination)

Adenoid tissue visible in nasopharynx, filling more than 50% of the choanal aperture
Mucus pooling in nasopharynx

Ear Examination

	Right	Left
Pinna	Normal	Normal
Tragus pressure	Non-tender	Non-tender
Mastoid	Non-tender	Non-tender
Ear canal	Clear	Clear
TM	Dull, retracted (type B tympanogram), no perforation	Similar

SUMMARY / CASE SUMMARY (5 marks)

Master Arjun, an 8-year-old male, presents with a 4-day history of sore throat, odynophagia, and bilateral otalgia with fever, on a background of 3 months of nasal obstruction, mouth breathing, and snoring. He has had 5 similar acute episodes in the past 12 months. Examination reveals fever (38.6°C), bilateral tender jugulodigastric lymphadenopathy, adenoid facies, Grade III bilateral tonsil enlargement with exudates, and bilateral dull retracted tympanic membranes suggesting Eustachian tube dysfunction secondary to adenoid hypertrophy.

PROVISIONAL DIAGNOSIS (5 marks)

Acute exacerbation of recurrent chronic adenotonsillitis with adenoid hypertrophy and secondary Eustachian tube dysfunction / bilateral otitis media with effusion

RELATED ANATOMY (10 marks)

Waldeyer's Ring

Waldeyer's lymphoid ring is a circular arrangement of lymphoid tissue guarding the entrances to the digestive and respiratory tracts. It consists of:

Pharyngeal tonsil (adenoids) - on the roof and posterior wall of nasopharynx
Tubal tonsils - around the opening of the Eustachian tubes (Gerlach's tonsil)
Palatine tonsils (faucial tonsils) - in the tonsillar fossa between anterior and posterior pillars
Lingual tonsil - on the posterior one-third of the tongue base
Small collections of lymphoid tissue on the posterior pharyngeal wall (lateral bands)

Palatine Tonsil

Located in the tonsillar fossa (sinus tonsillaris) between the diverging palatoglossal (anterior pillar) and palatopharyngeal (posterior pillar) arches
Medial surface projects into oropharynx with 10-15 crypts extending through its full thickness - these crypts trap debris and organisms, making the tonsil susceptible to recurrent infection
Lateral surface covered by the fibrous hemicapsule, separated from the superior pharyngeal constrictor muscle by loose areolar tissue (surgical plane of tonsillectomy)
External palatine (paratonsillar) vein descends lateral to the hemicapsule - important cause of haemorrhage during tonsillectomy
Blood supply: Main arterial supply is the tonsillar branch of the facial artery (the most important); also supplied by the dorsal lingual artery (lingual), ascending palatine (facial), ascending pharyngeal, and lesser palatine arteries
Nerve supply: Glossopharyngeal nerve (IX) and lesser palatine nerve - explains referred otalgia to the ear via Jacobson's nerve (tympanic branch of IX, also known as the Arnold-Jacobson reflex)
Size: Maximum at 6-7 years, involutes at puberty

Adenoids (Pharyngeal Tonsil)

Located on the roof and posterior wall of the nasopharynx (subepithelial lymphoid tissue)
Covered by ciliated pseudostratified columnar (respiratory) epithelium
No crypts (unlike palatine tonsil); surface has longitudinal folds / ridges
Forms the superior and posterior arc of Waldeyer's ring
Important anatomical relations:
- Eustachian tube openings - laterally; hypertrophied adenoids obstruct tube, causing otitis media with effusion
- Choanae - anteriorly; obstruct nasal airflow when hypertrophied
- Rosenmuller's fossa (pharyngeal recess) - posterolateral
Blood supply: Ascending pharyngeal, ascending palatine, and pharyngeal branch of internal maxillary artery
Maximal size at 3-7 years, involutes at puberty

(Source: Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Scott-Brown's Vol. 2)

INVESTIGATIONS (10 marks)

Routine / Haematological

Investigation	Purpose
Complete Blood Count (CBC)	Leucocytosis with neutrophilia in bacterial infection; lymphocytosis in viral/EBV
ESR	Elevated in active infection/inflammation
CRP	Acute phase reactant, elevated in bacterial infection
Blood culture and sensitivity	If septicaemia suspected
Peripheral smear	Atypical lymphocytes in EBV/infectious mononucleosis

Microbiological

Investigation	Purpose
Throat swab for culture and sensitivity	Identify causative organism; most commonly GABHS (Group A Beta-Haemolytic Streptococcus)
Rapid Antigen Detection Test (RADT) for GABHS	Quick bedside test (sensitivity ~70-90%)
Monospot test (Paul-Bunnell / Heterophile antibody test)	To rule out infectious mononucleosis (sensitivity 50% in children, 70-90% in adults)
ASO titre (Anti-Streptolysin O)	Evidence of previous GABHS infection; relevant for rheumatic fever screening

Audiological (given Eustachian tube dysfunction)

Investigation	Purpose
Pure Tone Audiometry (PTA)	Assess degree of hearing loss (conductive type expected)
Tympanometry	Type B flat curve = OME (Otitis Media with Effusion); Type C = Eustachian tube dysfunction

Radiological

Investigation	Purpose
X-ray lateral neck (soft tissue)	Assess adenoid size; adenoid to nasopharyngeal (A/N) ratio >0.7 indicates significant hypertrophy
X-ray PNS (Waters' view)	If sinusitis suspected
CT neck with contrast	If peritonsillar or parapharyngeal abscess suspected; defines extent of deep space infection

Special

Investigation	Purpose
Nasal endoscopy / nasopharyngoscopy	Gold standard for adenoid assessment; direct visualization
ECG and Echo	Before surgery; if rheumatic fever or cardiac disease suspected
Urine routine and microscopy	Haematuria/proteinuria to rule out post-streptococcal glomerulonephritis
LFT	If EBV/infectious mononucleosis (hepatitis can occur)

Scoring tools used clinically:

Centor Score (adults ≥15 yrs): Fever >38°C, tonsillar exudate, tender anterior cervical LN, no cough - each 1 point (score ≥3 suggests GABHS)
McIsaac Score (children 3-14 yrs): Modified Centor with age adjustment

DIFFERENTIAL DIAGNOSIS (5 marks)

Condition	Distinguishing Features
Infectious mononucleosis (EBV)	Grey/white membrane on tonsil (not easily peeled), axillary and inguinal LN enlarged, splenomegaly, atypical lymphocytosis; AVOID ampicillin/amoxicillin (causes rash in 90% of cases)
Peritonsillar abscess (Quinsy)	Unilateral sore throat, asymmetric tonsil, uvular deviation, trismus, "hot potato voice", bulging soft palate
Diphtheria	Greyish-white adherent membrane extending beyond tonsil - bleeds on removal, bull-neck appearance; Corynebacterium diphtheriae - in unvaccinated children
Ludwig's angina	Floor of mouth cellulitis, brawny oedema of submandibular space, potentially fatal airway compromise
Retropharyngeal abscess	Mainly <5 years, dysphagia, neck stiffness, bulge on posterior pharyngeal wall
Viral pharyngitis	Rhinovirus, RSV, Adenovirus; no exudate, less toxaemia, self-limiting
Agranulocytosis / leukaemia	Recurrent oral infections with necrotic ulcers; FBC shows abnormal cells

MANAGEMENT (15 marks)

A. Immediate / Medical Management (Acute Exacerbation)

1. Supportive Care:

Bed rest, adequate hydration (oral / IV if unable to swallow)
Soft diet / cool liquids
Steam inhalation with nasal decongestants (for nasal congestion)
Saline nasal irrigations

2. Antipyretics / Analgesics:

Tab. Paracetamol 15 mg/kg/dose TDS (children) - for fever and pain
Ibuprofen (anti-inflammatory)

3. Antibiotics: First-line: Benzylpenicillin (Penicillin G) - drug of choice for GABHS tonsillitis

Oral: Phenoxymethylpenicillin (Penicillin V) 250-500 mg BD for 10 days OR
Parenteral: Benzylpenicillin if severe

Alternatives:

Amoxicillin-clavulanic acid (Co-amoxiclav) - if anaerobes suspected
Erythromycin / Azithromycin - if penicillin allergy
Cephalosporins (Cephalexin) - second option

Note: Ampicillin/amoxicillin must be avoided if infectious mononucleosis is suspected.

4. Corticosteroids:

Oral prednisolone or single dose IM dexamethasone - provides symptomatic pain relief and reduces tonsillar oedema; used in severe cases as adjunct to antibiotics (Scott-Brown's Otorhinolaryngology, Vol. 2)

5. For Adenoid Hypertrophy (initial/mild):

Intranasal corticosteroids (e.g., Mometasone, Fluticasone) - first-line medical treatment for adenoid hypertrophy
Montelukast (leukotriene receptor antagonist) - add-on for mild cases (KJ Lee's Essential Otolaryngology)

B. Surgical Management

Indications for Tonsillectomy (Paradise Criteria - Modified)

Surgery is indicated when the child has:

≥7 sore throats in 1 year, OR
≥5 sore throats per year for 2 consecutive years, OR
≥3 sore throats per year for 3 consecutive years

Each episode must be documented with: temperature >38.3°C, cervical lymphadenopathy, tonsillar exudate, or positive culture for GABHS.

Additional absolute indications:

Peritonsillar abscess (Quinsy) - especially recurrent or bilateral
Suspected tonsil malignancy (asymmetric tonsil, rapid growth)
OSA with adenotonsillar hypertrophy
Failure to thrive in children due to recurrent tonsillitis
Tonsillitis causing febrile convulsions
Diphtheria carrier state

In this case: 5 episodes/year with Centor criteria met - meets surgical threshold (borderline; interval tonsillectomy planned after acute resolution)

Tonsillectomy Technique

Performed under general anaesthesia
Position: Supine, Boyle-Davis mouth gag with Draffin bipods
Classical: Dissection-ligation method (cold steel)
Modern alternatives: Coblation, diathermy, laser, bipolar scissors
The tonsil is dissected in the peritonsillar space (between hemicapsule and superior constrictor)

Indications for Adenoidectomy

(Bailey and Love's Short Practice of Surgery 28th Ed.):

Obstructive sleep apnoea from postnasal obstruction
Recurrent acute otitis media (≥3 episodes/6 months or ≥4/year)
Prolonged serous otitis media (>3 months) / OME (glue ear) - often combined with grommet insertion
Recurrent rhinosinusitis / chronic postnasal discharge
Adenoid facies

Technique: St. Clair Thomson adenoid curette; alternatively suction monopolar diathermy or coblation under direct vision.

In this case: Adenoidectomy with bilateral grommet insertion indicated for bilateral OME.

COMPLICATIONS (10 marks)

A. Local Complications of Adenotonsillitis

Complication	Features
Peritonsillar abscess (Quinsy)	Most common. Pus between tonsillar capsule and superior constrictor. Trismus, uvular deviation, "hot potato voice". Treat: needle aspiration + IV antibiotics
Retropharyngeal abscess	Rare; mainly children <5 yrs. Dysphagia, neck stiffness, airway compromise. CT diagnosis. Treat: IV antibiotics ± incision and drainage
Parapharyngeal abscess	Trismus + airway compromise. Deep neck space infection. May spread to mediastinum. Treat: IV antibiotics + surgical drainage
Lemierre's syndrome	Rare, potentially fatal. Septic thrombophlebitis of the internal jugular vein caused by Fusobacterium necrophorum. Presents with severe neck pain, septicaemia, septic emboli. Treat: 6 weeks antibiotics (penicillin + metronidazole or Co-amoxiclav); anticoagulation if spreading thrombophlebitis
Otitis media with effusion (Glue ear)	From Eustachian tube obstruction by adenoids; conductive hearing loss
Sinusitis	Chronic adenoid hypertrophy causes mucus stasis and recurrent sinusitis

B. Systemic / Immune-Mediated Complications (Post-GABHS)

Complication	Mechanism
Acute Rheumatic Fever (ARF)	Immune complex-mediated; molecular mimicry between GABHS M protein and cardiac/joint tissue. Leads to carditis, arthritis, Sydenham's chorea, erythema marginatum, subcutaneous nodules (Jones criteria). Can cause rheumatic heart disease (mitral regurgitation most common)
Acute Post-Streptococcal Glomerulonephritis (APSGN)	Immune complex deposition in glomeruli. Presents 1-3 weeks post-pharyngitis with haematuria, proteinuria, hypertension, oedema

C. Complications of Surgery (Tonsillectomy)

Complication	Detail
Primary haemorrhage	During surgery (within 24 hrs); due to inadequate haemostasis or slipped ligature
Reactionary (Immediate secondary) haemorrhage	6-24 hours post-op; from rise in BP as patient recovers from anaesthesia
Secondary haemorrhage	5-10 days post-op; most common; from infection and sloughing of scab
Velopharyngeal insufficiency (VPI)	Hypernasality after adenoidectomy, especially if submucous cleft palate undetected
Grisel's syndrome	Atlantoaxial subluxation / torticollis after adenoidectomy; increased risk in Down syndrome
Nasopharyngeal stenosis	Scarring post adenoidectomy / tonsillectomy
Dental / lip injury	From Boyle-Davis gag
Aspiration pneumonia	Rare; during or after surgery
Eustachian tube injury	From aggressive adenoidectomy

DISCUSSION / THEORETICAL BACKGROUND (5 marks)

Definition: Adenotonsillitis refers to acute, recurrent, or chronic inflammation of the palatine tonsils (tonsillitis) and pharyngeal tonsil/adenoid (adenoiditis), often occurring simultaneously - hence adenotonsillitis.

Aetiology:

Acute: Most commonly Group A Beta-Haemolytic Streptococcus (GABHS) - Streptococcus pyogenes; also Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae
Viral (acute catarrhal): Rhinovirus, RSV, Adenovirus, Coronavirus, EBV, CMV
Recurrent/Chronic: Polymicrobial, including anaerobes

Types of acute tonsillitis:

Acute catarrhal/superficial - viral, part of generalized pharyngitis
Acute follicular - purulent material in tonsillar crypts appearing as yellow spots
Acute membranous - exudate coalesces into a membrane
Acute parenchymatous - entire tonsil uniformly red and enlarged

Immunity: The tonsils are part of Waldeyer's ring and function as the first line of immune defence in the upper aerodigestive tract, producing immunoglobulins (predominantly IgA). There is no evidence that tonsillectomy impairs systemic immunity as an extensive backup immune system exists. (Scott-Brown's Otorhinolaryngology, Vol. 2)

PROGNOSIS (2 marks)

Individual acute episodes: Good prognosis with appropriate antibiotic therapy; resolve in 3-4 days (may last up to 2 weeks)
Following tonsillectomy: Significant reduction in frequency and severity of throat infections; improvement in quality of life
Adenoid hypertrophy: Resolution expected post adenoidectomy; OME generally resolves with grommet insertion
Rare complications (Lemierre's, ARF, APSGN): Require vigilant follow-up

FINAL DIAGNOSIS

Acute exacerbation of recurrent chronic adenotonsillitis (GABHS) with adenoid hypertrophy, bilateral otitis media with effusion

Planned management: Acute medical management followed by elective adenotonsillectomy + bilateral grommet insertion once acute inflammation resolves (6-8 weeks interval)

SOURCES

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 2 - Inflammatory Disorders of the Tonsil, pp. 479-482
Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Palatine Tonsil (Anatomy), p. 679
KJ Lee's Essential Otolaryngology - Adenoid Hypertrophy, p. 1013
Bailey and Love's Short Practice of Surgery, 28th Ed. - Adenoidectomy, p. 804
Textbook of Family Medicine, 9e - Adenoid Hypertrophy

MARKS DISTRIBUTION GUIDE

Section	Marks
Chief Complaints	5
History of Presenting Illness	10
Past / Personal / Family / Treatment History	9
General Physical Examination	8
Systemic Examination	5
Local Examination (ENT)	15
Summary + Provisional Diagnosis	10
Related Anatomy	10
Investigations	10
Differential Diagnosis	5
Management	15
Complications	10
Discussion + Prognosis	7
Total	100

---This is a complete KUHS-format case presentation structured for 100 marks. Here are some key points to remember when presenting this in your practical:

High-yield viva points examiners love:

Waldeyer's ring components - name all 5 in order
Mackenzie's grading of tonsils (Grade I-IV) - mention Grade III tonsils meeting the midline is "kissing tonsils"
Paradise criteria for tonsillectomy - the numbers matter (7/5/3 rule)
Drug to AVOID in EBV: Ampicillin/Amoxicillin causes rash in 90% of patients
Lemierre's syndrome - rare but examiners love testing it
Type B tympanogram = flat = OME (glue ear)
Irwin Moore's/Squeeze test for chronic tonsillitis
External palatine (paratonsillar) vein - important surgical anatomy

Key nerve for referred otalgia: Glossopharyngeal nerve (CN IX) via its tympanic branch (Jacobson's nerve) - stimulation of CN IX in the throat refers pain to the ear. This is why patients with tonsillitis complain of ear pain.

Antibiotic of choice: Benzylpenicillin / Phenoxymethylpenicillin (Penicillin G/V) - GABHS remains universally penicillin-sensitive.

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