1. Peritonsillitis
(1) Common types
of infection
1. Bacterial infection
-The most common pathogen of peritonsillar inflammation is beta hemolytic streptococcus, which can produce a variety of toxins and enzymes to destroy the defense barrier of the tissue around the tonsil and cause inflammation. It can cause congestion and edema of local tissues, resulting in severe sore throat. In addition, Staphylococcus, Streptococcus pneumoniae and anaerobic bacteria can also participate in the infection, especially in the case of mixed infection, the condition is often more complex. For example, when anaerobic bacteria are mixed with aerobic bacteria, it will aggravate the process of tissue necrosis and suppuration.
Haem
ophilus influenzae is also one of the potential pathogens of tonsillitis, especially in children. It can invade the tissues around the tonsils and cause inflammation when the body’s resistance decreases, such as after a cold.
2. Bacterial infection
secondary to viral infection
-Some patients with peritonsillar inflammation may initially be caused by viral infections, such as rhinovirus, adenovirus, etc. These viral infections can destroy the integrity of the mucosa around the tonsil and reduce local resistance, thus creating conditions for secondary bacterial infections. When bacterial secondary infection occurs, inflammation aggravates rapidly, from mild inflammation caused by simple viral infection to peritonsillar inflammation, with typical symptoms such as fever and dysphagia.
(2) Principles
of clinical treatment of drugs
1. Empiric medication
-Penicillins, such as penicillin G, are generally the first choice when the pathogen is not clear, in view of the fact that beta hemolytic streptococcus is the main pathogen. Penicillin G has high antibacterial activity against hemolytic streptococcus, which can effectively inhibit the synthesis of bacterial cell wall, thus achieving bactericidal effect. The dosage should be determined according to the patient’s age, weight and severity of the disease. For adults, the usual daily dose is 2.4 to 9.6 million units in 3 to 4 intravenous drips. The dosage for children is calculated according to body weight, generally 25000-50000 units/kg per day, divided into 2-4 times.
-If the patient is allergic to penicillin, a macrolide, such as azithromycin, may be an option. Azithromycin has a good antibacterial effect on Gram-positive bacteria, and has the advantages of high tissue concentration and long half-life. For adults, the first dose is 500 mg, followed by 250 mg daily for 4-5 days; for children, the dose is 10 mg/kg once daily for 3-5 days.
2. Adjust the medication
according to the results of drug sensitivity.
-When bacterial culture and drug sensitivity test are available, antibiotics should be adjusted according to the results. Second-generation cephalosporins, such as cefuroxime, can be used if susceptibility results show sensitivity to cephalosporins. Cefuroxime has antibacterial activity against Gram-positive bacteria and some Gram-negative bacteria, and can effectively cover the common pathogenic bacteria of tonsillitis. It is administered intravenously 0.75-1.5g every 8 hours for adults and 50-100mg/kg/day in 3-4 divided doses for children.
-If anaerobes are cultured, metronidazole may be used in combination. Metronidazole has potent antibacterial activity against anaerobic bacteria and is administered intravenously at a dose of 0.5g every 8-12 hours for adults and 20-30 mg/kg daily in 2-3 divided doses for children.
3. Use
of glucocorticoids
-In the treatment of peritonsillar inflammation, glucocorticoids reduce the inflammatory response and edema. Commonly used drugs such as dexamethasone, the general adult dose is 5-10 mg, intravenous drip, 1-2 times a day; children’s dose is 0.2-0.3 mg/kg, 1-2 times a day. When using glucocorticoids, attention should be paid to their adverse reactions, such as elevated blood sugar, blood pressure fluctuations, digestive tract ulcers, etc., especially for patients with diabetes, hypertension and other underlying disease, the relevant indicators should be closely monitored.
4. Topical medication
-Compound borax solution and compound chlorhexidine gargle can be used for gargling. These drugs can clean mouth and around the tonsils, reduce bacterial growth and relieve local inflammation. Compound borax solution is usually diluted with warm water and gargled several times a day; compound chlorhexidine gargle can be gargled directly for 1-2 minutes each time, 3-4 times a day.
2. Acute epiglottitis
(1) Common types
of infection
1. Bacterial infection
-The main pathogen of acute epiglottitis is Haemophilus influenzae type B, especially in children, which causes acute inflammation of the epiglottis, resulting in rapid swelling of the epiglottis. In addition, Staphylococcus, Streptococcus and Streptococcus pneumoniae can also cause infection. In adult patients, these bacterial infections are more common, causing inflammation of the epiglottic mucosa and submucosal tissue, and in severe cases involving the aryepiglottic fold and arytenoid cartilage.
-When the patient’s resistance is low, such as long-term fatigue and chronic diseases, anaerobic infections may also be involved, aggravating the damage and inflammation of epiglottic tissue.
2. Viral infection
-Viral infection can also cause acute epiglottitis, such as influenza virus. During the influenza epidemic season, some patients may have symptoms of epiglottitis after infection with influenza virus. Viral infection can cause congestion and edema of epiglottic mucosa, which may be followed by secondary bacterial infection and aggravate the condition.
(2) Principles
of clinical treatment of drugs
1. Selection
of Antibiotics
-Since Haemophilus influenzae type B is the predominant pathogen, amoxicillin-clavulanic acid may be administered orally in patients with mild illness. This combination of drugs can enhance antibacterial activity and be effective against bacteria such as Haemophilus influenzae, which produces beta-lactamases. The adult dose is generally 375-750 mg once every 8-12 hours; the pediatric dose is generally 20-40 mg/kg daily in 2-3 divided doses based on age and body weight.
-For patients with severe illness, drugs with rapid onset and broad antibacterial spectrum should be selected, such as third-generation cephalosporins, such as ceftriaxone. Ceftriaxone has strong antibacterial activity against Gram-negative bacteria such as Haemophilus influenzae and can penetrate the blood-epiglottis barrier. Adults generally receive 1-2g intravenously daily; children receive 50-100mg/kg daily in 1-2 divided doses.
-If anaerobic infection is considered, metronidazole or tinidazole may be added. Tinidazole has a strong anti-anaerobic effect, and the dose for adults is 0.8g once a day by intravenous infusion; the dose for children is 20 mg/kg once a day in 1-2 divided doses.
2. Use
of glucocorticoids
-Glucocorticoids are essential in the treatment of acute epiglottitis. Early and adequate use can reduce epiglottis edema and relieve expiratory dyspnoea and other symptoms. Methylprednisolone is commonly used, with a dose of 40-80mg/d for adults and 1-2mg/kg for children. Generally, it can be effective within a few hours after medication, and can be gradually reduced according to the patient’s condition. Dexamethasone can also be used at a dose of 10-20 mg/d by intravenous infusion, but the duration of action of dexamethasone is relatively long, and more caution is needed when adjusting the dose.
3. Drugs and measures
to keep the respiratory tract unobstructed
-If the patient has a expiratory dyspnoea, an aerosolized drug, such as budesonide suspension for inhalation, may be used. It can relieve local inflammation and epiglottic edema, usually 1-2 mg each time, 2-3 times a day. At the same time, for patients with severe expiratory dyspnoea, tracheotomy or tracheal intubation should be prepared to ensure airway patency and prevent asphyxia.
4. Supportive drugs
-Patients may have insufficient nutritional intake due to dysphagia during the illness, and may be supplemented with nutrients such as glucose, amino acids, fat emulsion, etc. Intravenously. For patients with fever, antipyretic drugs, such as acetaminophen, can be used appropriately according to body temperature, but aspirin and other drugs that may aggravate bleeding tendency should be avoided, because epiglottic inflammation may lead to local mucosal fragility and increase the risk of bleeding.
In a word, the choice of drugs for the treatment of tonsillitis and acute epiglottitis should take into account the type of infection, the severity of the disease and the individual condition of the patient, rationally use antibiotics and glucocorticoids, and pay attention to supportive treatment and keeping the respiratory tract unobstructed, so as to improve the therapeutic effect and reduce the occurrence of complications.
