- Clinical science
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 . Tonsillectomy is an option in recurrent and chronic tonsillitis, although the procedure is associated with a high risk of postoperative bleeding. and are serious suppurative complications of acute bacterial tonsillitis and require immediate treatment.
- Peak incidence
- Viral tonsillitis: children < 5 years and young adults 
- Streptococcal tonsillitis: children aged 5–15 years; rare in children aged < 2 years
Epidemiological data refers to the US, unless otherwise specified.
- Acute tonsillitis
- Recurrent tonsillitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria 
- Sudden onset of symptoms
- Red and swollen pharynx, tonsillar exudates 
- Fever, sore throat, dysphagia
- Painful, swollen cervical lymph nodes
- Foul breath
- If viral: headache, earache, nasal congestion, and cough 
Diagnosis ; of acute tonsillitis is primarily clinical but may be further supported by blood tests and confirmed via microbiological testing.
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 
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%). 
- In children and adolescents, negative test results should be confirmed with throat culture.
- Throat culture: to identify pathogen and determine antibiotic sensitivity 
- Rapid GAS antigen detection test
- Inflammatory markers (↑ CRP, ↑ ESR, leukocytosis) may be elevated but are not specific.
- Antistreptolysin O (ASO) titer
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|Vincent angina|| || |
|(fungal tonsillitis)|| || |
|Pharyngeal syphilis|| |
|Tonsillitis in (diphtheritic croup)|| || |
|Agranulocytic angina|| |
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. 
- Symptom relief: rest, sufficient fluid intake, analgesics, salt-water gargles 
- Avoid aspirin in children. 
Antibiotics if infection with GAS has been confirmed 
- Although streptococcal tonsillopharyngitis is usually self-limiting, antibiotics are required to reduce the risk of rheumatic fever. 
- Penicillin V (or aminopenicillin) 
- Most antibiotics are taken for at least 10 days.
- In patients with penicillin allergies: macrolides; (e.g., clarithromycin, azithromycin, erythromycin) 
|For patients with no penicillin allergy|
|Penicillin V||Oral|| ||10 days|
|Amoxicillin||Oral|| ||10 days|
|Benzathine penicillin G||Intramuscular|| ||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|
|Paradise criteria for tonsillectomy in children |
|Minimum frequency of sore throat episodes|| |
Subtotal tonsillectomy: tonsils are partially removed, while the capsule remains 
- Advantage: There is a low rate of postoperative bleeding.
- Disadvantage: Relapse is possible. 
Total tonsillectomy: removal of the entire tonsils and capsule
- Postoperative hemorrhage is a serious complication (occurs in ∼ 5% of cases)
- Subtotal tonsillectomy: tonsils are partially removed, while the capsule remains 
- Cervical lymphadenitis
- Infectious thrombophlebitis of the internal jugular vein (Lemierre syndrome): A severe, potentially fatal condition usually resulting from oropharyngeal infections
Streptococcus "ph"yogenes is the most common cause of bacterial pharyngitis, which can result in rheumatic "phever" and poststreptococcal glomerulonephritis.
We list the most important complications. The selection is not exhaustive.