Summary
Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of the pharynx (tonsillopharyngitis). The terms tonsillitis and pharyngitis are often used interchangeably, but they refer to distinct sites of inflammation. Acute tonsillitis and pharyngitis are particularly common in children and young adults and are primarily caused by viruses or group A streptococci (GAS). They are characterized by the sudden onset of fever, sore throat, and painful swallowing. Patients may also have tender, swollen cervical lymph nodes and tonsillar exudates. The disease is normally self-limited. However, if GAS infection is confirmed via rapid antigen detection test and/or throat culture, treatment with antibiotics (most often penicillin) should be initiated to prevent rheumatic fever. Tonsillectomy is a treatment option for recurrent and chronic tonsillitis, especially in patients with tonsillar hypertrophy that causes obstructive sleep-disordered breathing. Peritonsillar abscess and parapharyngeal abscess are serious suppurative complications of acute bacterial tonsillitis and require immediate treatment.
Epidemiology
-
Peak incidence [1]
- Acute viral tonsillopharyngitis: children < 5 years and young adults
- Acute GAS tonsillopharyngitis: children aged 5–15 years; rare in children aged < 2 years
- Peak season: Acute GAS tonsillopharyngitis most commonly occurs in winter and spring. [1]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
-
Acute tonsillopharyngitis
- Viral (50–80% of cases): adenovirus, EBV, CMV, HSV, rhinovirus, coronavirus, influenza and parainfluenza viruses, HIV [2][3]
-
Bacterial (15–30% of cases)
- Most common: Streptococcus pyogenes (also known as group A streptococcus or GAS) [2]
- Rare: Neisseria gonorrhoeae, Corynebacterium diphtheriae, Mycoplasma pneumoniae [2][3]
- Recurrent tonsillopharyngitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria
Clinical features
-
Acute bacterial tonsillopharyngitis (including acute GAS tonsillopharyngitis) [2]
- Sudden onset of symptoms; : fever, sore throat, dysphagia
- Significantly inflamed pharynx
- Pharyngeal and/or tonsillar erythema and edema
- Pharyngeal and/or tonsillar exudates (rare in children < 3 years)
- Palatal petechiae
- Excoriation of skin around the nostrils (more common in children < 3 years)
- Scarlatiniform rash
- Cervical lymphadenitis
- Absence of cough
-
Acute viral tonsillopharyngitis [2][3]
- Cough
- Coryza
- Rhinorrhea
- Oral ulcers, anterior stomatitis
- Conjunctivitis
- Diarrhea
- Absence of fever
Trismus and change in voice quality indicate the formation of potentially life-threatening peritonsillar abscess!
Diagnostics
Approach [2]
The diagnosis of acute tonsillitis or acute pharyngitis is primarily clinical.
-
Suspected acute bacterial tonsillopharyngitis: Evaluate for acute GAS tonsillopharyngitis. [2][4][5]
- Consider a clinical scoring system (e.g., modified Centor score) to determine the need for diagnostic workup.
- Initial test: rapid GAS antigen detection test (RADT)
- Additional evaluation: depends on the RADT report and the age of the patient
- RADT positive: diagnosis confirmed; initiate antibiotic therapy for GAS tonsillopharyngitis
-
RADT negative
- Children ≥ 3 years: Obtain a throat culture to reliably rule out GAS infection.
- Adults: Further diagnostic tests are not routinely required.
-
Suspected acute viral tonsillopharyngitis: Diagnostic evaluation is not routinely recommended.
- Suspected infectious mononucleosis: heterophile antibody test (see “Diagnostics” in “Infectious mononucleosis”) [6]
- Suspected COVID-19: See “COVID-19: Testing” for details.
Infectious mononucleosis (IM) can manifest with clinical features similar to acute bacterial tonsillopharyngitis. Consider a heterophile antibody test if clinical suspicion for IM is high.
The diagnostic workup of suspected acute bacterial tonsillopharyngitis is described below.
Clinical scoring systems
- Clinical scoring systems (e.g., the modified Centor score; ) can be used to estimate the likelihood of acute GAS tonsillopharyngitis based on clinical features.
- The goal is to identify patients who are unlikely to have a GAS infection. [2][4]
- The Modified Centor score is less accurate in children ≤ 4 years of age. [7]
Modified Centor score [8][9] | ||
---|---|---|
Criteria | Points | |
Age | 3–14 years | +1 |
15–44 years | 0 | |
> 44 years | -1 | |
Exudate or swelling on tonsils | Yes | +1 |
No | 0 | |
Tender or swollen anterior cervical lymph nodes | Yes | +1 |
No | 0 | |
Temperature > 100.4°F (38°C) | Yes | +1 |
No | 0 | |
Cough | Absent | +1 |
Present | 0 | |
Interpretation
|
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.
Empiric antibiotic therapy for patients with a modified Centor score ≥ 4 is not routinely recommended. [2]
Rapid antigen detection test (RADT) [2]
-
Indications: first-line test in suspected acute bacterial tonsillopharyngitis
- All symptomatic children ≥ 3 years and adults (unless symptoms are suggestive of acute viral tonsillopharyngitis)
- Consider in symptomatic children < 3 years if there is household contact with proven GAS infection.
- Modified Centor score ≥ 2 (if scoring has been used)
- Procedure: Swab the patient's tonsils and the back of the throat.
- Findings: Identifies the presence of GAS (positive RADT). [2][4]
Testing for GAS infection is not recommended in patients with clinical features that strongly suggest acute viral tonsillopharyngitis. [2]
Throat culture
-
Indications
- Confirmatory test to definitively rule out GAS infection in symptomatic children ≥ 3 years and adolescents with negative RADT
- Patients who fail to improve after 3–4 days despite antibiotic treatment [11]
- Recurrent or chronic tonsillitis [2][12]
- Consider in adults with risk factors for invasive GAS infection. [13]
- Findings: causative bacteria and their antibiotic susceptibility (see “Etiology” for details)
Additional laboratory tests
Not routinely indicated; can be obtained as supportive diagnostic evidence
An elevated antistreptolysin O (ASO) titer indicates a previous GAS infection. ASO titer assay is not indicated in an acute setting but rather in the workup of nonsuppurative complications of GAS tonsillopharyngitis (e.g., acute rheumatic fever, poststreptococcal glomerulonephritis). [2]
Imaging [11]
- Not routinely indicated
- Consider CT of head and neck if there is clinical suspicion of suppurative complications
Differential diagnoses
Differential diagnoses of acute tonsillopharyngitis | ||
---|---|---|
Disease | Etiology | Clinical features |
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
Approach [2]
-
GAS pharyngitis and/or tonsillitis: self-limited; antibiotic therapy for acute GAS pharyngitis recommended to prevent rheumatic fever. [2][17]
- RADT or throat culture positive: Initiate antibiotic therapy for acute GAS pharyngitis.
- Delay antibiotics if RADT is negative until receiving a positive throat culture result. [9]
- Acute viral tonsillopharyngitis: self-limited; symptomatic care
-
Disposition: Outpatient treatment is possible for most patients.
- Improvement can be expected within 3–4 days. [11]
- If symptoms persist or worsen, patients should return for reassessment.
General measures [2]
- Minimize the spread of GAS infection: Advise patients to stay home until afebrile and/or completion of ≥ 24 hours of appropriate antibiotic therapy. [5]
-
Symptomatic care
- Ensure adequate hydration.
- Consider household remedies such as salt-water gargles.
-
Analgesics and antipyretics [2]
- Acetaminophen
- NSAIDs: e.g., ibuprofen
Avoid aspirin in children due to the risk of Reye syndrome.
Antibiotic therapy [2]
- Indication: patients with laboratory confirmation of GAS infection [2][10]
- Important consideration: The antibiotic regimens described here are valid for children ≥ 2 years of age and for adults.
Recommended antibiotic regimens for acute GAS pharyngitis [2] | ||
---|---|---|
Drug | Duration | |
No penicillin allergy | Penicillin V : treatment of choice | 10 days |
Amoxicillin | 10 days | |
Benzathine penicillin G : | Single-dose | |
Penicillin allergy | Cephalexin | 10 days |
Cefadroxil | 10 days | |
History of anaphylaxis to penicillin: clindamycin or macrolides | Clindamycin | 10 days |
Azithromycin | 5 days | |
Clarithromycin | 10 days |
Mistakenly treating an EBV infection (infectious mononucleosis) with amoxicillin can lead to a maculopapular rash.
Tonsillectomy [1][2]
Indications [1][2][18]
- Extreme hypertrophy of the tonsils (“kissing tonsils”) causing obstructive sleep-disordered breathing. [19]
-
Documented recurrent throat infections [20]
- In patients who fulfill all of the following criteria: [1][2][18]
- Frequency of throat infections
- ≥ 7 episodes in the past year
- OR ≥ 5 episodes/year in the past 2 years
- OR ≥ 3 episodes/year in the past 3 years
- Each episode has ≥ 1 of the following features:
- Temperature > 101°F (38.3°C)
- Cervical adenopathy
- Tonsillar exudate
- Positive test for GAS
- Each episode has been documented in a medical record.
- Frequency of throat infections
- If the above criteria are not met, consider tonsillectomy in patients with any of the following:
- History of peritonsillar abscess
- Allergy or intolerance to multiple antibiotics
- PFAPA syndrome
- In patients who fulfill all of the following criteria: [1][2][18]
- Suspected tonsillar neoplasm
- Chronic tonsillitis
Procedure [1][21][22]
-
Total tonsillectomy
- Tonsils are removed with their surrounding capsule.
- Dissection is lateral to the tonsil in the plane between the tonsillar capsule and pharyngeal muscles.
- Subtotal tonsillectomy
Do not use acetylsalicylic acid for postoperative pain relief after tonsillectomy because of the increased risk of bleeding. Recommended analgesics after tonsillectomy are ibuprofen and acetaminophen. [1][23]
Complications [1]
Acute management checklist
- Suspected acute viral tonsillopharyngitis
- Diagnostic tests not routinely required
- Consider testing for COVID-19 or infectious mononucleosis as needed.
- Supportive care
- Suspected acute bacterial tonsillopharyngitis
- Clinical diagnosis unclear: Consider a clinical scoring system (e.g., modified Centor score) to identify patients at low risk of GAS infection.
- Suspected acute GAS tonsillopharyngitis: Perform RADT.
- RADT negative: Obtain a throat culture in patients aged 3–18 years to reliably rule out GAS infection.
- RADT and/or throat culture positive: Initiate antibiotic therapy for GAS tonsillopharyngitis.
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: [3][24]
We list the most important complications. The selection is not exhaustive.