- Clinical science
Acute tonsillitis
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
-
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]
Clinical features
- 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]
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]
-
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]
-
Rapid GAS antigen detection test
-
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]
Differential diagnoses
Disease | Etiology | Clinical features |
---|---|---|
Pharyngitis |
|
|
Aphthous stomatitis |
|
|
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
- 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]
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 |
|
Clinical features |
|
Treatment |
|
Documentation |
|
-
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)
-
Subtotal tonsillectomy: tonsils are partially removed, while the capsule remains [15]
NSAIDs (e.g., acetylsalicylic acid) are contraindicated for postoperative pain relief because of the increased risk of bleeding!
Complications
-
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
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.