Acute tonsillitis

Last updated: 29.11.2019

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

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] Acute tonsillopharyngitis Acute tonsillitis

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]
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	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

Acute pharyngitis Acute tonsillopharyngitis Acute tonsillitis Aphthous stomatitis Herpangina Herpetic pharyngotonsillitis Oral candidiasis Infectious mononucleosis Tonsillar and pharyngeal diphtheria

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	≥ 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	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)

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

Tonsillectomy Tonsil specimen

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.

References

Shah UK. Tonsillitis and Peritonsillar Abscess. In: Meyers AD, Tonsillitis and Peritonsillar Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-overview#a6. Updated: October 6, 2016. Accessed: November 6, 2016.
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.
Le T, Bhushan V, Bagga H. First Aid for the USMLE Step 2 CK. McGraw-Hill ; 2009 : p. 221-222
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.
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.
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.
Chow AW. Submandibular space infections (Ludwig's angina). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/submandibular-space-infections-ludwigs-angina?source=search_result&search=ludwig%20angina&selectedTitle=1~9. Last updated: July 31, 2015. Accessed: November 6, 2016.
Hicks CB, Clement M. Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/syphilis-epidemiology-pathophysiology-and-clinical-manifestations-in-hiv-uninfected-patients?source=see_link§ionName=CLINICAL%20MANIFESTATIONS&anchor=H8#H8. Last updated: August 1, 2016. Accessed: November 6, 2016.
Shah UK. Tonsillitis and Peritonsillar Abscess Clinical Presentation. In: Meyers AD, Tonsillitis and Peritonsillar Abscess Clinical Presentation. New York, NY: WebMD. http://emedicine.medscape.com/article/871977-clinical#showall. Updated: October 6, 2016. Accessed: November 6, 2016.
Shah UK. Tonsillitis and Pharyngitis Empiric Therapy . In: Bronze MS, Tonsillitis and Pharyngitis Empiric Therapy . New York, NY: WebMD. http://emedicine.medscape.com/article/2011856-overview. Updated: November 23, 2015. Accessed: November 6, 2016.
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.
Pichichero ME. Complications of streptococcal tonsillopharyngitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/complications-of-streptococcal-tonsillopharyngitis. Last updated: February 4, 2016. Accessed: November 6, 2016.
Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis.. Am Fam Physician. 2016; 94 (1): p.24-31.
Shulman et al.. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2012; 55 (10): p.e86–e102. doi: 10.1093/cid/cis629 .
Mitchell et al.. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery. 2019; 160 (1): p.S1-S42. doi: 10.1177/0194599818801757 .
Spinks et al.. Antibiotics for sore throat. Cochrane Database of Systematic Reviews. 2013 . doi: 10.1002/14651858.CD000023.pub4 .
Simon. Pediatric Pharyngitis. In: Steele, Pediatric Pharyngitis. New York, NY: WebMD. https://emedicine.medscape.com/article/967384-overview#a4. Updated: December 11, 2018. Accessed: May 6, 2019.
Winters. Evidence-Based Diagnosis and Management of ENT Emergencies. https://www.medscape.com/viewarticle/551650_4. Updated: February 15, 2007. Accessed: May 6, 2019.
Coelho MotaVera et al.. CHAPTER 54A - Rheumatic Fever. Churchille Livingstone : p. 1091-1113