Tonsillitis

Question 1

Definition

Answer 1

Inflammation of the parenchyma of the palatine tonsils and is most commonly due to viral infection

Question 2

Epidemiology

Answer 2

Young age
Infected contacts

Question 3

Aetiology

Answer 3

• Viral (MC) :
  = rhinovirus (MC)
  = Coronavirus
  = Adenovirus
• Bacterial (10-30%)
  = Group A beta-haemolytic streptococci strep. pyogenes = MC bacterial cause
• Recurrent tonsillitis : staph. aureus common cause = antimicrobial resistance and persistence in the internal tissues of the tonsils
• Non-infectious tonsillitis: (rare)
  = GORD,
  = chronic cigarette smoke,
  = hayfever

Question 4

Pathophysiology

Answer 4

Pathogens penetrate the tonsillar epithelium, causing local inflammation that results in oropharyngeal swelling, erythema, oedema and pain.

Question 5

AKA

Answer 5

Pharyngitis
- both sore throat

Question 6

Ddx

Answer 6

Infectious mononucleosis (glandular fever; due to EBV) = can closely mimic tonsillitis but has a slightly different pathophysiology

Question 7

Signs

Answer 7

• Pyrexia : >38°C
• Tonsillar exudate with enlargement and erythema of the tonsils
• Anterior cervical lymphadenopathy
• Evidence of dehydration if reduced oral intake : e.g. reduced skin turgor, dry mucous membranes

Question 8

Symptoms

Answer 8

Sore throat: sudden onset
Pain on swallowing
Fever
Non-specific symptoms:
- headache
- nausea
- voming

Question 9

Diagnosis

Answer 9

• Clinical diagnosis
  Consider:
• GOLD STANDARD =
  Throat culture
• Rapid group A strep antigen test: offers immediate results:
  = only performed if the diagnosis of GAS must be confirmed with certainty e.g. high risk of rheumatic fever, vulnerable
  = A negative result with suspected GAS requires a throat culture

Question 10

Centor criteria

Answer 10

The probability that tonsilitis is due to bacterial cause:
- Presence of tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough

0-2 = 3-17%
3-4 = 32-56%

Question 11

FeverPAIN criteria

Answer 11

Probability of bacterial cause:
- Fever over 38°C
- Purulence (pharyngeal or tonsillar exudate)
- Attend rapidly (3 days or less)
- Severely inflamed tonsils
- No cough or coryza

0 - 1 = 13 - 18%
2 - 3 = 34 - 40%
4 - 5 = 62 - 65%

Question 12

Treatment

Answer 12

Low centor score:
- Simple analgesia
- Fluids
- Delayed Abx if Sx does not improve
Centor 3-4 or FeverPAIN 4-5
- FIRST LINE ABX: PHENOXYMETHYLPENICILLIN for 5-10 days
- Clarithromycin or erythromycin for 5 days if FL CI (5-10 days in children)

Question 13

Admission

Answer 13

• Inability to swallow,
• Breathing difficulty,
• Clinical dehydration,
• Peri-tonsillar abscess,
• Retropharyngeal abscess
• Sepsis

Tx: Corticosteroids : oral prednisolone or IV/IM dexamethasone = severe clinical features, e.g. significant oropharyngeal swelling, upper airway limitation, or inability to tolerate any oral intake

Question 14

Complications

Answer 14

• Acute otitis media
• Peri-tonsillar abscess (quinsy)
• Paryngeal abscess
• Acute rheumatic fever
• Acute post-strep glomerulonephritis