Acute tonsillitis

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.

• Acute tonsillitis
  • Viral (50–80% of cases): adenovirus, EBV, CMV, HSV, rhinovirus, coronavirus, influenza and parainfluenza viruses, HIV ^[2][3]
  • Bacterial (15–30% of cases)
    • Streptococcus pyogenes (most common)
    • Rarely, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Mycoplasma pneumoniae ^[2][3]
• Recurrent tonsillitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria ^[2]

• Sudden onset of symptoms
• Red and swollen pharynx, tonsillar exudates ^[3]
• Fever, sore throat, dysphagia
• Painful, swollen cervical lymph nodes
• Foul breath
• If viral: headache, earache, nasal congestion, and cough ^[3]

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

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]

• Confirmatory tests: rapid antigen detection test and/or throat culture
  • Rapid GAS antigen detection test
    • Throat swab allows for simple and quick detection of GAS infection (highly specific, sensitivity ∼ 70–90%). ^[5]
    • In children and adolescents, negative test results should be confirmed with throat culture.
  • Throat culture: to identify pathogen and determine antibiotic sensitivity ^[7]
• Blood tests
  • Inflammatory markers (↑ CRP, ↑ ESR, leukocytosis) may be elevated but are not specific.
  • Antistreptolysin O (ASO) titer
    • ↑ ASO titer indicates a previous infection with GAS.
    • Particularly useful for detecting prior infections in patients presenting with complications (e.g., rheumatic fever)
    • Not recommended for diagnosing acute infection ^[7]

Disease	Etiology	Clinical features
Pharyngitis	See Etiology section above.	Sore throat Pharyngeal erythema More common in viral pharyngitis: nasal congestion, coryza, and hoarseness More common in bacterial pharyngitis: fever, tonsillar exudate, and cervical lymphadenopathy
Aphthous stomatitis	Unknown	Ulcers on anterior oral mucosa Usually no systemic symptoms
Herpangina	Coxsackie A virus	Herpes-like oral lesions: multiple 1-mm vesicles located on the posterior oropharynx and tonsils; pharyngeal and tonsillar redness Fibrin-covered ulcerations appear in later stages Sore throat and high fever May occur as a component of hand, foot, and mouth disease
Herpetic pharyngotonsillitis/herpetic gingivostomatitis	HSV-1	Multiple small oral lesions located in the anterior oropharynx and lips Fever, sore throat, pharyngeal redness
Vincent angina	Synergistic mixed infection with Treponema vincentii and Fusobacterium nucleatum	Unilateral ulcers on the pharyngeal tonsils Mild general symptoms Difficulty swallowing Foul breath
Ludwig angina	Mixed infection (Viridans streptococci and anaerobes) [8] Usually arising from an infected mandibular molar, an infection of the upper airways, or acute lingual tonsillitis Predisposing factors: diabetes mellitus, alcohol use disorder, and other immunocompromising conditions [9]	Submandibular space infection Fever, mouth pain, stiff neck, difficulty swallowing, trismus Airway obstruction may occur! [8]
Oral thrush (fungal tonsillitis)	Candida albicans	Pseudomembranous stomatitis with white plaques
Pharyngeal syphilis	Treponema pallidum	Primary syphilis chancre in the posterior pharynx Early stages are often asymptomatic; sore throat may occur. [10]
Tonsillitis in infectious mononucleosis	Epstein-Barr virus (EBV)	Fever, pharyngitis, and enlarged erythematous tonsils with white and gray deposits Generalized lymphadenitis Possible involvement of liver, spleen, and skin
Tonsillitis in diphtheria (diphtheritic croup)	Corynebacterium diphtheriae	Pseudomembranes Inflammation often exceeds the tonsils; mucosal bleeding
Agranulocytic angina	Appears in the context of agranulocytosis	Triad of aphthous stomatitis, sore throat, and fever Dirty necrosis of pharyngeal tonsils

The differential diagnoses listed here are not exhaustive.

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

Conservative

• Symptom relief: rest, sufficient fluid intake, analgesics, salt-water gargles ^[3]
• Avoid aspirin in children. ^[12]
• Antibiotics if infection with GAS has been confirmed ^[12]
  • Although streptococcal tonsillopharyngitis is usually self-limiting, antibiotics are required to reduce the risk of rheumatic fever. ^[12]
  • Penicillin V (or aminopenicillin) ^[13]
  • Most antibiotics are taken for at least 10 days.
  • In patients with penicillin allergies: macrolides; (e.g., clarithromycin, azithromycin, erythromycin) ^[13]

Agent	Route	Dosage	Treatment duration
For patients with no penicillin allergy
Penicillin V	Oral	Pediatric: 250 mg 2 or 3 times daily Adolescent and adult: 250 mg 4 times daily or 500 mg twice daily (1000 mg daily total)	10 days
Amoxicillin	Oral	50 mg/kg once daily OR 25 mg/kg twice daily (total 50 mg/kg daily)	10 days
Benzathine penicillin G	Intramuscular	For patients < 27 kg: 600,000 U For patients ≥ 27 kg: 1,200,000 U	Single dose
For patients with penicillin allergy
Cephalexin	Oral	20 mg/kg twice daily	10 days
Cephadroxil	Oral	30 mg/kg once daily	10 days
Azithromycin	Oral	12 mg/kg (maximal 500 mg) once daily	5 days
Clarithromycin	Oral	7.5 mg/kg (maximal 250 mg) 2 times daily	10 days
Clindamycin	Oral	7 mg/kg (maximal 300 mg) 3 times daily	10 days

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 in the past 2 years, OR ≥ 3 episodes in the past 3 years
Clinical features	Episodes are counted if sore throat + ≥ 1 of the following are present: Temperature ≥ 100.9°F (38.3°C) Cervical lymphadenopathy (lymph nodes are tender or > 2 cm in size) Tonsillar exudate Culture positive for group A beta-hemolytic streptococci
Treatment	Antibiotics were administered in the conventional regimen for each of the proved/suspected streptococcal episodes.
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]
    • Advantage: There is a low rate of postoperative bleeding.
    • Disadvantage: Relapse is possible. ^[15]
  • Total tonsillectomy: removal of the entire tonsils and capsule
    • Postoperative hemorrhage is a serious complication (occurs in ∼ 5% of cases)
      • Primary hemorrhage: within 24 hours after surgery (once the vasoconstrictive effect of the anesthetic drugs subsides)
      • Secondary hemorrhage: 5–10 days after surgery (typically the period when the fibrin eschar separates from the wound)

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

• Suppurative complications
  • Peritonsillar abscess
  • Parapharyngeal abscess
  • Otitis media
  • Sinusitis
  • Cervical lymphadenitis
  • Mastoiditis
  • Infectious thrombophlebitis of the internal jugular vein (Lemierre syndrome): A severe, potentially fatal condition usually resulting from oropharyngeal infections
    • Characterized by infection of the carotid sheath vessels and bacteremia.
    • Etiology: Most commonly caused by oropharyngeal flora (e.g., Fusobacterium necrophorum).
    • Clinical features: fever, respiratory distress, neck pain, throat pain
• Nonsuppurative complications
  • Rheumatic fever
  • Scarlet fever
  • Poststreptococcal glomerulonephritis

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.