Acute tonsillitis

Last updated: 29.11.2019

Summary

Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of the pharynx (tonsillopharyngitis). It is particularly common in children and young adults and is primarily caused by viruses and group A streptococci (GAS). Acute tonsillitis is characterized by the sudden onset of fever, sore throat, and painful swallowing. Tender, swollen cervical lymph nodes and tonsillar exudates may occur. The disease is normally self-limiting. However, if GAS infection is confirmed via rapid antigen detection test and/or throat culture, treatment with antibiotics (penicillin) should be started to prevent rheumatic fever. Tonsillectomy is an option in recurrent and chronic tonsillitis, although the procedure is associated with a high risk of postoperative bleeding. Peritonsillar abscess and parapharyngeal abscess are serious suppurative complications of acute bacterial tonsillitis and require immediate treatment.

Epidemiology

  • Peak incidence
    • Viral tonsillitis: children < 5 years and young adults [1]
    • Streptococcal tonsillitis: children aged 5–15 years; rare in children aged < 2 years

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Clinical features

Trismus and changes in voice quality indicate the formation of potentially life-threatening peritonsillar abscess! [4]

Diagnostics

Diagnosis ; of acute tonsillitis is primarily clinical but may be further supported by blood tests and confirmed via microbiological testing.

Modified Centor score [5]

A set of criteria used to estimate the probability that pharyngitis is caused by GAS

  • Criteria
    • No cough (1 point)
    • Tender anterior cervical adenopathy (1 point)
    • Fever (1 point)
    • Tonsillar exudates or swelling (1 point)
    • Age
      • 3–14 years (1 point)
      • 15–44 years (0 points)
      • ≥ 45 years (-1 point)
  • Approach
    • Score ≤ 1: no further diagnostic testing or antibiotic treatment is indicated
    • Score 2 or 3: rapid antigen detection testing (RADT) and/or throat culture is indicated
    • Score ≥ 4: empiric antibiotics

Think of M-CENTOR to remember the Modified Centor score criteria: M = Must be older than 3 years, C = Cough absent, E = Exudate on the tonsils, N = Node enlargement, T = Temperature elevation, OR = young OR old.

Microbiological testing [6]

Differential diagnoses

Disease Etiology Clinical features
Pharyngitis
  • See Etiology section above.
Aphthous stomatitis
  • Unknown
Herpangina
Herpetic pharyngotonsillitis/herpetic gingivostomatitis
Vincent angina
Ludwig angina
  • Submandibular space infection
  • Fever, mouth pain, stiff neck, difficulty swallowing, trismus
  • Airway obstruction may occur! [8]
Oral thrush (fungal tonsillitis)
  • Pseudomembranous stomatitis with white plaques
Pharyngeal syphilis
Tonsillitis in infectious mononucleosis
Tonsillitis in diphtheria (diphtheritic croup)
  • Pseudomembranes
  • Inflammation often exceeds the tonsils; mucosal bleeding
Agranulocytic angina

The differential diagnoses listed here are not exhaustive.

Treatment

Acute tonsillitis is typically self-limiting (symptoms usually resolve within 3–4 days without treatment). However, antibiotics are indicated for bacterial infections. [11]

Conservative

Mistakenly treating an EBV infection (infectious mononucleosis) with ampicillin can lead to maculopapular rash.

Surgery

  • Indications
    • Recurrent and chronic tonsillitis
    • Extreme hypertrophy of the tonsils (“kissing tonsils”)
    • A history of peritonsillar abscess
    • Tonsillitis that does not respond to antibiotic treatment
    • Tonsillitis in children who meet all of the Paradise criteria except those regarding documentation (see table below)
Paradise criteria for tonsillectomy in children [14]
Criterion Description
Minimum frequency of sore throat episodes
  • ≥ 7 episodes in the past year, OR
  • ≥ 5 episodes/year in the past 2 years, OR
  • ≥ 3 episodes/year in the past 3 years
Clinical features
Treatment
Documentation
  • Each episode should be reflected in the medical documentation with the description of the clinical features mentioned above OR
  • There is subsequent observation by the physician of 2 episodes with patterns of frequency and clinical features consistent with the initial history.
  • Procedure
    • Subtotal tonsillectomy: tonsils are partially removed, while the capsule remains [15]
    • Total tonsillectomy: removal of the entire tonsils and capsule

NSAIDs (e.g., acetylsalicylic acid) are contraindicated for postoperative pain relief because of the increased risk of bleeding!

Complications

Streptococcus "ph"yogenes is the most common cause of bacterial pharyngitis, which can result in rheumatic "phever" and poststreptococcal glomerulonephritis.

References:[16][3]

We list the most important complications. The selection is not exhaustive.

References

  1. Shah UK. Tonsillitis and Peritonsillar Abscess. In: Meyers AD, Tonsillitis and Peritonsillar Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-overview#a6. Updated: October 6, 2016. Accessed: November 6, 2016.
  2. Shah UK. Tonsillitis and Peritonsillar Abscess. In: Meyers AD, Tonsillitis and Peritonsillar Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-overview#showall. Updated: October 6, 2016. Accessed: November 6, 2016.
  3. Le T, Bhushan V, Bagga H. First Aid for the USMLE Step 2 CK. McGraw-Hill ; 2009 : p. 221-222
  4. Shah UK. Tonsillitis and Peritonsillar Abscess. In: Meyers AD, Tonsillitis and Peritonsillar Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-overview#showall. Updated: October 6, 2016. Accessed: November 6, 2016.
  5. Wald ER. Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/group-a-streptococcal-tonsillopharyngitis-in-children-and-adolescents-clinical-features-and-diagnosis?source=search_result&search=acute%20tonsillitis&selectedTitle=3∼150#H162978199. Last updated: September 29, 2016. Accessed: November 6, 2016.
  6. Shah UK. Tonsillitis and Peritonsillar Abscess Workup. In: Meyers AD, Tonsillitis and Peritonsillar Abscess Workup. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-workup#showall. Updated: October 6, 2016. Accessed: November 6, 2016.
  7. Chow AW. Submandibular space infections (Ludwig's angina). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/submandibular-space-infections-ludwigs-angina?source=search_result&search=ludwig%20angina&selectedTitle=1~9. Last updated: July 31, 2015. Accessed: November 6, 2016.
  8. Hicks CB, Clement M. Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/syphilis-epidemiology-pathophysiology-and-clinical-manifestations-in-hiv-uninfected-patients?source=see_link§ionName=CLINICAL%20MANIFESTATIONS&anchor=H8#H8. Last updated: August 1, 2016. Accessed: November 6, 2016.
  9. Shah UK. Tonsillitis and Peritonsillar Abscess Clinical Presentation. In: Meyers AD, Tonsillitis and Peritonsillar Abscess Clinical Presentation. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-clinical#showall. Updated: October 6, 2016. Accessed: November 6, 2016.
  10. Shah UK. Tonsillitis and Pharyngitis Empiric Therapy . In: Bronze MS, Tonsillitis and Pharyngitis Empiric Therapy . New York, NY: WebMD. http://emedicine.medscape.com/article/2011856-overview. Updated: November 23, 2015. Accessed: November 6, 2016.
  11. Gibber MJ. Tonsillectomy in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/tonsillectomy-in-adults?source=search_result&search=tonsillectomy&selectedTitle=2~57. Last updated: June 8, 2016. Accessed: November 6, 2016.
  12. Pichichero ME. Complications of streptococcal tonsillopharyngitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/complications-of-streptococcal-tonsillopharyngitis. Last updated: February 4, 2016. Accessed: November 6, 2016.
  13. Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis.. Am Fam Physician. 2016; 94 (1): p.24-31.
  14. Shulman et al.. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2012; 55 (10): p.e86–e102. doi: 10.1093/cid/cis629 .
  15. Mitchell et al.. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery. 2019; 160 (1): p.S1-S42. doi: 10.1177/0194599818801757 .
  16. Spinks et al.. Antibiotics for sore throat. Cochrane Database of Systematic Reviews. 2013 . doi: 10.1002/14651858.CD000023.pub4 .
  17. Simon. Pediatric Pharyngitis. In: Steele, Pediatric Pharyngitis. New York, NY: WebMD. https://emedicine.medscape.com/article/967384-overview#a4. Updated: December 11, 2018. Accessed: May 6, 2019.
  18. Winters. Evidence-Based Diagnosis and Management of ENT Emergencies. https://www.medscape.com/viewarticle/551650_4. Updated: February 15, 2007. Accessed: May 6, 2019.
  19. Coelho MotaVera et al.. CHAPTER 54A - Rheumatic Fever. Churchille Livingstone : p. 1091-1113
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