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Acute tonsillitis

Last updated: November 29, 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
Oral thrush (fungal tonsillitis)
Pharyngeal syphilis
Tonsillitis in infectious mononucleosis
Tonsillitis in diphtheria (diphtheritic croup)
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

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:[3][16]

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

References

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  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. 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.
  5. 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.
  6. Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis.. Am Fam Physician. 2016; 94 (1): p.24-31.
  7. 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.
  8. 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.
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