Tonsillitis

Question 1

ESSENCE

Answer 1

Inflammation of the tonsils

Question 2

AETIOLOGY

Most common cause and other causes

Answer 2

• Most common cause is a viral infection
• Most common bacterial cause is group A streptococcus (streptococcus pyogenes)
  
  • Second most common cause is streptococcus pneumoniae

Question 3

ANATOMY

Waldeyer’s ring composed of

Answer 3

• Ring of lymphoid tissue
  
  • Adenoids
  • Tubal tonsils
  • Palatine tonsils (ones typically infected in tonsillitis)
  • Lingual tonsils

Question 4

EPIDEMIOLOGY

Age

Answer 4

Most common in children aged 5-15 years

Question 5

CLINICAL FEATURES

Presentation

Answer 5

• Sore throat
• Fever
• Pain on swallowing

Question 6

CLINICAL FEATURES

Signs

Answer 6

• Red, inflammed and enlarged tonsils with or without exudates
• Anterior cervical lymphadenopathy

Question 7

What criteria can be used to estimate the liklihood the tonsillitis is due to bacterial infection?

Answer 7

• Centor criteria
• FeverPAIN score

Question 8

Describe centor criteria

Answer 8

• Score of 3 or more gives 40-60% probability of bacterial tonsillitis
  
  • Fever over 38
  • Tonsillar exudates
  • Absence of cough
  • Tender anterior cervical lymph nodes (lymphadenopathy)

Question 9

Describe FeverPAIN score

Answer 9

• Score of 2-3 gives 34-40% probability, score of 4-5 gives 62-65% probability is bacterial
  
  • Fever during previous 24 hours
  • P - purulence (pus on tonsils)
  • A - attended within 3 days of onset of symptoms
  • I - inflamed tonsils
  • N - no cough or coryza

Question 10

INVESTIGATIONS

First line

Answer 10

• Usually none required
  
  • Sometimes throat culture or rapid streptococcal antigen test

Question 11

MANAGEMENT

General

Answer 11

• Admission if patient immunocompromised, systemically unwell, respiratory distress or abscess
• Calculate Centor criteria or FeverPAIN score
  
  • If likely viral educate and give safety net
  • If likely bacteria consider antibiotics
• Consider delayed prescriptions

Question 12

MANAGEMENT

Antibiotic first choice and second

Answer 12

• Phenoxymethylpenicillin for 10 days course - first
• Clarithromycin in penicillin allergy

Question 13

COMPLICATIONS

Answer 13

• Peritonsillar abscess
• Otitis media
• Scarlet fever
• Rheumatic fever
• Post-streptococcal glomerulonephritis
• Post-streptococcal reactive arthritis

Question 14

MANAGEMENT

Recurrent

Answer 14

Consider tonsillectomy with antibiotic therapy