Tonsilitis Flashcards
Define tonsilitis
Acute infection of the parenchyma of the palatine tonsils
What are the causes of tonsilitis
Viral: rhinovirus, coronavirus, adenovirus
Infectious mononucleosis (EBV)
Bacterial (10-30%): Group A beta-haemolytic streptococci (s. pyogenes), mycoplasma pneumoniae, neisseria gonorrhoea, other steptococci
What are the risk factors for tonsilitis
5-15
Contact with infected people in enclosed spaces e.g. child care centre, schools, prison
Sexually active adolescents, particularly engaging in oral sex (N. gonorrhoea)
Winter/Spring
What causes children to get obstructive sleep apnoea
Tonsils and adenoids increase in size until 8 years old, then gradually regress.
In young children, the adenoids grow proportionately faster than their airway, which can lead to narrowing of the airway from 2-8yo.
Airway narrowing can lead to obstructive sleep apnoea (OSA),
What are the symptoms of tonsilitis
Sore throat
Pain on swallowing (odynophagia)
Sudden onset
Fever >38
Headache
Abdominal pain
Nausea and vomiting
Cough or runny nose
± symptoms of dehydration
What are the differentials for tonsilitis
Infectious mononucleosis
Scarlet fever
Epiglottitis
Peri-tonsilar abscess (quinsy)
retropharyngeal abscess
Gonococcal pharyngitis
Diphtheria
What are the signs of tonsilitis on exam
General
? dehydration: reduced skin turgor, prolonged CRT, dry mucous membranes, sunken eyes
ENT
Tonsillar exudate, erythema and enlargement
Lymph node
Enlarged, painful anterior cervical lymph nodes
What investigations should be done for tonsilitis
Not required but can be done for those who need diagnosis e.g. rheumatic fever, very young, immunosuppression, severe symptoms
Throat swab for culture
Rapid streptococcal antigen test: positive for GAS
FBC: raised neutrophils (bacterial), lymphocytes (Infectious mono)
Cervical x-ray: assess for retropharyngeal and oropharyngeal enlargement
Describe the FeverPAIN score for tonsilitis
score 1 point for each (maximum score of 5)
* Fever over 38°C.
* Purulence (pharyngeal/tonsillar exudate).
* Attend rapidly (3 days or less)
* Severely Inflamed tonsils
* No cough or coryza
A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus.
A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus.
A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus.
Describe the centor criteria for tonsilitis
Score 1 point for each:
* Tonsillar exudate
* Tender anterior cervical lymphadenopathy or lymphadenitis
* History of fever (over 38°C)
* Absence of cough
A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus.
A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.
What is the management for tonsilitis (non-severe)
Supportive:
Ensure adequate fluid intake
Ibuprofen and paracetamol for symptomatic relief
Salt water gargling
Lozenges
Avoid hot water drinks
School exclusion until after fever has resolved and no longer unwell OR Abx for 24h
GAS confirmed OR high risk (FeverPAIN/Centor) → Antibiotics: phenoxymethylpenicillin oral course 10 days (PenAll: clarithromycin), unable to swallow → single IM
Swelling or upper airway limitation: corticosteroids
Recurrent: tonsillectomy
What features of tonsilitis would suggest need for hospital admission
Breathing difficulty.
Clinical dehydration.
Peri-tonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre syndrome (as there is a risk of airway compromise or rupture of the abscess).
Signs of marked systemic illness or sepsis.
A suspected rare cause such as Kawasaki disease, diphtheria, or yersinial pharyngitis.
When is a tonsillectomy indicated
Recurrent tonsilitis (7 or more episodes in 12 months, 5 or more in each of the 2 previous years, 3 or more in each of the previous 3 years)
Complications develop e.g. quinsy
Sleep disordered breathing e.g. OSA
Post-op delayed bleed - same-day ENT assessment
Post-op <24 hours bleed - immediate return to theatre
What safety netting should be done for tonsilitis
Seek advice if:
Symptoms do not improve after 3-4 days of Abx therapy
Pain does no improve and/or fever >38
Difficult to swallow saliva or liquids
Difficulty in breathing
One-sided throat swelling
What are the complications of tonsilitis
Scarlet fever
Acute sinusitis
Acute otitis media
Peri-tonsillar or neck abscess (quinsy)
Acute rheumatic fever
Acute post-strep glomerulonephritis
Streptococcal toxic shock syndrome
Obstructive sleep apnoea
PANDAS syndrome
