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Tonsillitis
Tonsillitis

Tonsillitis

Pathophysiology

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We have 6 tonsils in total that create a ring in the oral cavity known as Waldeyer’s ring. This ring serves as a lymphoid gateway and allows immune surveillance for anything passing through our nasal and oral cavity from the external environment.

The 6 tonsils can be broken down as such:

  • Pharyngeal/adenoid tonsil x 1
  • Tubal tonsils x 2
  • Palatine tonsils x 2
  • Lingual tonsil x 1

When these tonsils get inflamed we get tonsillitis which can of course present with an acutely sore throat. It may occur in isolation or can occur with pharyngitis generally.

🦠 Causative agents

🏆 It is mainly due to viral infection in 60-70% of cases. Some common viral agents are:

  • Adenovirus
  • Rhinovirus
  • Influenza
  • Parainfluenza

Approximately 1/3rd of cases are bacterial, with the common agents being:

  • 🥇 Strep. pyogenes i.e. strep throat.
  • 🥈 Strep. pneumoniae is another common agent.
  • S. aureus, h. influenzae, moraxella catharralis are some other causative bacterial agents.
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😷 Presentation

  • ⭐️ Dysphagia
  • ⭐️ Fever
  • ⭐️ General malaise such as headache, body pains, nausea.
  • ⭐️ Halitosis

On examination we may see:

  • Enlarged tonsils that are erythematous and may have white patches of exudate (if bacterial).
  • Lymphadenopathy in the anterior cervical area may be noted.

🔍 Investigations

It is important to differentiate between viral and bacterial tonsillitis and we can use 2 criteria for this:

  1. FeverPAIN criteria
  2. Centor criteria

FeverPAIN criteria

🔥
It is scored out of 5:
  • 0 - 1 should not be offered antibiotics.
  • 2 – 3 gives a 34 – 40% probability of bacterial tonsillitis. A backup antibiotic should be considered.
  • 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis. Consider an immediate antibiotic prescription.
Fever
>38ºC
P
Purulence (exudate)
A
Attended within 3 days of onset
I
Inflamed tonsils
N
No cough or coryza (cold symptoms)

Centor criteria

🐂
Scored out of 4. Bacterial cause is suspected if 2 or more of the criteria are met:
  1. Fever >38ºC
  2. Exudate on the tonsils
  3. Absent cough
  4. Cervical lymphadenopathy

A score of 0 - 2 should not be offered an antibiotic.

A score of 3 - 4 should be considered for immediate antibiotic prescription.

🧰 Management

💊
Medical management:
  • If considering viral aetiology then analgesia and safety netting is all that is needed.
  • If considering bacterial aetiology then we need to give antibiotics:
    • 🥇 Penicillin V (phenoxymethylpenicillin) for 10 days, or
    • 🥇 Clarithromycin/erythromycin for 5 days if allergic to penicillin.
    • ⚠️ Amoxicillin is to be avoided as this can cause a maculopapular rash if EBV is the causative agent
🔪
Surgical management:

Tonsillectomy may be considered if the patient meets ALL of the 3 criteria:

  1. Sore throats are due to tonsillitis
  2. These episodes prevent normal function
  3. 7 or more well documented, clinically significant, adequately treated sore throats in the preceding 1 year OR
  4. 5 or more such episodes in each of the preceding 2 years OR
  5. 3 or more such episodes in each of the preceding 3 years

🚨 Complications

Tonsillitis may lead to:

  • Otitis media
  • Quinsy - a peritonsillar abscess. It presents with severe sore throat that is worse on one side and also severe odynophagia. There will be erythema, soft palate swelling and a deviated uvula, and trismus (inability to open the mouth) is a specific sign to quinsy. Management involves IV antibiotics, steroids and drainage.
  • Rheumatic fever and glomerulonephritis
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