Tonsillitis

Inflammation due to infection of the tonsils

Aetiology

  • Majority of cases are viral - EBV, rhinovirus, influenza, parainfluenza, enterovirus, adenovirus
  • 5-30% bacterial, most commonly Strep. pyrogenes (Group A strep)
    • Others include H. influenza, S. aureus and streptococcus pneumonia
    • 'Strep throat' - inflamed tonsils and surrounding part of throat caused by Streptococcus
    • ~40% are beta-lactamase-producing

Clinical presentation

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Viral tonsillitis

  • Malaise
  • Sore throat, mild analgesia requirement
  • Temperature
  • Able to undertake near normal activity
  • Possible lymphadenopathy
  • Lasts 3-4 days

Bacterial tonsillitis

  • Dysphagia, odynophagia, dysphonia
  • Systemic upset
  • Fever
  • Halitosis
  • Unable to work/school
  • Lymphadenopathy
  • Lasts ~1 week, requires antibiotics to settle
  • Soft palate and tonsils may be inflamed and tender

Investigations

  • Clincial diagnosis - throat swabs not routinely carried out in primary care management
    • Throat swabs are unhelpful as core species do not always correlate with surface bacteria
  • Scoring systems used to identify those who would benefit from antibiotics (Strep. pyrogenes) - FeverePAIN, Centor
    • Centor - 1 point for each of: tonsillar exudate, tender anterior cervical lymph nodes, history of fever, absence of cough
    • FeverPAIN - 1 point for each of: Purulence, Attend rapidly (within 3 days), very Inflamed tonsils, No cough

Management

  • Antibiotics NOT generally recommended
  • Self-limiting regardless of viral or bacterial aetiology
  • Symptoms resolve in 3 days in 40% of people and within 1 week in 85% of people

Self-care advice

  • Eat and drink, rest
  • Regular analgesia (paracetamol/ibuprofen)
  • Medicated lozenges

Use of antibiotics

  • Prescribe antibiotics only where appropriate - penicillin (clarithromycin if allergic)
    • Acute follicular tonsilitis indicates Strep. pyrogenes
    • Use of scoring systems

Management in secondary care

  • Severely unwell patients should be admitted to hospital e.g. stridor, breathing difficulty, dehydration, systemically unwell
  • Treatment involves IV fluids, antibiotics and steroids
  • Ensure infection control for acute Strep. pyrogenes infection - solation for the first 48 hours of treatment, contact precautions, standard infection control precautions, consider droplet precautions

Surgical management

  • 'Watchful waiting' more appropriate than tonsillectomy for children with mild sore throats
  • Recommended for recurrent severe sore throat due to acute tonsillitis in adults

Complications

  • Otitis media (most common)
  • Peritonsillar abscess (quincy)
  • Parapharyngeal abscess
  • Epiglottitis
  • Lemierre symdrome - suppurative thrombophlebitis of jugular vein
  • Rheumatic fever is a late complication of Strep. pyrogenes infection - fever, arthritis and pancarditis 3 weeks post sore throat
  • Quinsy
  • Epiglottitis