Acute tonsillitis

Acute tonsillitis is an inflammation of the pharyngeal tonsils that frequently arises 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 a sudden onset of fever, sore throat, and painful swallowing. Tender, swollen cervical lymph nodes and tonsillar exudates may occur. Normally, the disease is self-limiting. However, if group A streptococcal infection is confirmed with rapid antigen detection test and/or throat culture, treatment with antibiotics (penicillin) should be initiated to prevent rheumatic fever and poststreptococcal glomerulonephritis. 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 virus, HIV ^[2][3]
  • Bacterial (15–30% of cases)
    • Streptococcus pyogenes (most common)
    • Rarely, Staphylococcus aureus, Streptococcus pneumoniae, 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]

Acute tonsillitis is primarily a clinical diagnosis that may be supported by blood tests and confirmed via microbiological testing.

• Modified Centor score^[5]: a set of criteria that is used to estimate the probability that pharyngitis is caused by group A Streptococcus (GAS).
  • Criteria
    • No cough (1 point)
    • Anterior cervical adenopathy (1 point)
    • Fever (1 point)
    • Tonsillar exudates or swelling (1 point)
    • Age:
      • 3–14 years (1 point)
      • 15–44 years (0 point)
      • ≥ 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
    • Score ≥ 4: empiric antibiotics
• Microbiologic testing ^[6]
  • Confirmatory tests: rapid antigen detection test and/or throat culture
    • Rapid GAS antigen detection test
      • Throat swab allows simple and quick detection of group A streptococcal infection (highly specific, sensitivity ∼70–90%)^[5]
      • A negative test should be confirmed by throat culture in children and adolescents.
    • Throat culture: to identify pathogen and determine antibiotic sensitivity ^[7]
• Blood tests
  • Inflammatory markers (↑ CRP, ↑ ESR, leukocytosis)
  • Potential elevation of the antistreptolysin O titer ^[7]

Pharyngitis	Viral (more common) or bacterial (Group A Streptococcus, or GAS) , Neisseria gonorrhoeae, M. pneumoniae, Corynebacterium diphtheriae)	Sore throat Pharyngeal erythema Fever (more common in bacterial pharyngitis) Nasal congestion, coryza, and hoarseness (more common in viral pharyngitis)
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 the 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's 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, alcoholism, and other immunocompromising conditions	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 [9]
Tonsillitis in infectious mononucleosis	Epstein-Barr virus (EBV)	Fever, pharyngitis, and enlarged erythematous tonsils with white and grey deposits Generalized lymphadenitis Possible involvement of liver, spleen, and skin
Tonsillitis in diphtheria (diphtheric 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 usually self-limiting (symptoms usually resolve within 3–4 days without treatment). However, antibiotic therapy is indicated for bacterial infections.^[10]

Conservative

• Symptom relief: rest, sufficient fluid intake, analgesics, salt-water gargles^[3]
• Antibiotic treatment if infection with group A Streptococcus has been confirmed
  • Penicillin V (or aminopenicillin)^[11]
  • In patients with penicillin allergies: macrolides; (e.g., clarithromycin, azithromycin, erythromycin)^[11]

A maculopapular rash may result from mistakenly treating an EBV infection (infectious mononucleosis) with ampicillin!

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
• Procedure
  • Subtotal tonsillectomy: tonsils are partially removed, while the capsule remains^[12]
    • Advantage: Low rate of postoperative bleeding
    • Disadvantage: relapse is possible ^[12]
  • Total tonsillectomy: removal of the entire tonsils and capsule
    • Postoperative hemorrhage is a serious complication (occurs in ∼ 5%)
      • 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 due to the increased risk of bleeding!

• Suppurative complications
  • Peritonsillar abscess
  • Parapharyngeal abscess
  • Otitis media
  • Sinusitis
• Nonsuppurative complications
  • Rheumatic fever
  • Scarlet fever
  • Poststreptococcal glomerulonephritis

Refernces^[13]

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