ENT: Tonsillitis Flashcards
What are the 3 most common viral causes of a sore throat?
1) Rhinovirus (most common)
2) Coronavirus
3) Parainfluenza virus
Is tonsillitis usually viral or bacterial?
Viral
What is the most common cause of bacterial tonsillitis?
Group A Strep (Strep. pyogenes)
What is the most common organsim causing otitis media and rhinosinusitis?
Streptococcus pneumoniae.
What is the most common alternative bacterial cause of tonsillitis (i.e. not GAS)?
Streptococcus pneumoniae.
What Abx can bacterial tonsillitis caused by GAS (S. pyogenes) be treated by?
penicillin V (phenoxymethylpenicillin)
What is the ring of lymphoid tissue found in the throat called?
Waldeyer’s Tonsillar Ring –> made up of the tonsils, adenoids, and other lymphoid tissue.
Acute tonsillitis is the inflammatory infection of which tonsils?
Palatine tonsils
Typical features of acute tonsilitis?
- Sore throat
- Fever
- Dysphagia
- Nasal congestion, headache, earache, cough (if viral)
May present with non-specific features in childre –> fever, poor oral intake, headache, vomiting or even abdominal pain.
Does the presence of a cough indicate a viral or bacterial cause of tonsillitis?
Viral (if no cough is present, this is more likely bacterial cause).
What may you see on examination of the pharynx in acute tonsillitis?
- Severely inflamed tonsils
- Painfully enlarged anterior cervical lymph nodes
- Purulent tonsils (suggestive of bacterial cause)
When should you NOT do an examination of the pharynx in tonsillitis?
If epiglottitis suspected.
Give some additional features that may be suggestive of epiglottitis
- A young child
- A muffled voice
- Excessive drooling and pooling of saliva.
What should you do if epiglottitis is suspected?
Call for an anaesthetist and an ENT surgeon!
What 3 things should your exam consist of in tonsillitis?
1) Exam of pharynx (if epiglottitis is not suspected)
2) Otoscopy: to visualise tympanic membranes
3) Palpate for any cervical lymphadenopathy
What is the Centor criteria for?
The Centor criteria can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.
What Centor score indicates that it is appropriate to offer Abx?
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis –> it is appropriate to offer antibiotics.
What makes up the Centor criteria?
A point is given if each of the following features are present:
1) Fever over 38ºC
2) Tonsillar exudates
3) Absence of cough
4) Tender anterior cervical lymph nodes (lymphadenopathy)
What is an alternative to the Centor criteria?
The FeverPAIN score
Acute tonsillitis is usually a clinical diagnosis.
When may investigations be required?
In patients on immunosuppression, very old or young, with severe symptoms.
What is the 1st line investigation in acute tonsillitis in those who require it?
A rapid antigen test for GAS, followed by a throat culture.
What does management of most cases of tonsillitis involve?
Reassure – symptoms can last for around 1 week, but most people get better within this time without treatment.
Paracetamol or ibuprofen – for pain or fever.
Fluids – adequate intake maintained.
Are Abx routinely indicated in tonsillitis?
No
if antibiotics are indicated in tonsillitis, what is 1st line?
phenoxymethylpenicillin (or erythromycin if penicillin allergic) for 7-10 days
Give some indications for Abx in tonsillitis
- features of marked systemic upset secondary to the acute sore throat
- unilateral peritonsillitis
- a history of rheumatic fever
- an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
What does the feverPAIN criteria consist of?
1 point for each (maximum score of 5)
1) Fever over 38°C.
2) Purulence (pharyngeal/tonsillar exudate).
3) Attend rapidly (3 days or less)
4) Severely Inflamed tonsils
5) No cough or coryza
What does a feverPAIN score of 4-5 indicate?
62-65% likelihood of isolating Streptococci (i.e. bacterial) - consider Abx
What are some potential complications of acute tonsillitis?
1) Acute otitis media
2) Peritonsillar abscess (quinsy) or neck abscess
3) Acute sinusitis
Rare –> scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis:
How does post-streptococcal glomerulonephritis present?
Haematuria, oedema, vomiting and anorexia.
The indications for tonsillectomy are controversial.
When should surgery be considered (according to NICE)?
If the person meets all of the following criteria:
1) sore throats are due to tonsillitis (i.e. not recurrent URTI)
2) the person has 5 or more episodes of sore throat per year
3) symptoms have been occurring for at least a year
4) the episodes of sore throat are disabling and prevent normal functioning
Other indications:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing or snoring
Complications of a tonsillectomy can be 1ary or 2ary.
What is the difference?
1ary: <24 hpurs
2ary: 24 hours to 10 days
How may pain change after a tonsillectomy?
The pain may increase for up to 6 days following a tonsillectomy.
What is a feared complication following tonsillectomy?
Haemorrhage
When does 1ary (or reactionary) haemorrhage most commonly occur following a tonsillectomy?
First 6-8 hours after surgery
Management of a 1ary haemorrhage following a tonsillectomy?
Immediate return to theatre.
What is 1ary haemorrhage following a tonsillectomy most commonly associated with?
Inadequate homeostasis
What is 2ary haemorrhage following a tonsillectomy most often associated with?
Wound infection
