Tonsillitis (ENT)

Question 1

Define tonsillitis.

Answer 1

Inflammation of the tonsils; specifically infection of the parenchyma of the palatine tonsils

Question 2

Describe the clinical distinction between tonsillitis and pharyngitis?

Answer 2

Unclear in the literature - the condition is often referred to as ‘acute sore throat’

Question 3

What are the two types of causes of tonsillitis?

Answer 3

• viral tonsillitis (more common)
• bacterial tonsillitis

Question 4

What can viral tonsillitis be caused by?

Answer 4

• rhinovirus
• coronavirus
• adenovirus
• mono (EBV)
• (influenza, parainfluenza, enterovirus, herpes)

Question 5

What is bacterial tonsillitis caused by?

Answer 5

Streptococcus pyogenes

(Common: Group A beta-haemolytic streptococci, Mycoplasma pneumoniae, Neisseria gonorrhoeae)

Question 6

What condition is viral tonsillitis associated with?

Answer 6

Infectious mononucleosis (EBV)

Question 7

How is tonsillitis spread?

Answer 7

Infectious condition and can be spread by exposure to an infected person (hence predominantly a disease of school children)

Question 8

What are the clinical features of tonsillitis? (10)

Answer 8

• pain on swallowing
• fever >38C (100.5F)
• tonsillar exudate (yellow/white pustules may be present - also prominent in infectious mononucleosis)
• sudden onset of sore throat
• headache
• abdominal pain
• nausea & vomiting
• cough/runny nose
• tonsillar erythema and enlargement
• enlarged anterior cervical lymph nodes

Question 9

Which age group is acute tonsillitis most common in?

Answer 9

Children 5 to 15 years old

Question 10

What are some risk factors for tonsillitis? (3)

Answer 10

• age between 5 and 15
• contact with infected people in enclosed spaces e.g. school, prison
• oro-genital sexual activity

Question 11

What are the first-line investigations for tonsillitis?

Answer 11

• throat culture - definitive diagnosis of bacterial tonsillitis, but results >48h
• rapid streptococcal antigen test - sensitivity lower than culture but immediate results; ordered if suspicious of Group A beta-haemolytic Streptococcus pyogenes (GABHS) using Centor Criteria

Question 12

When is rapid streptococcal antigen test done for tonsillitis?

Answer 12

1st line if suspicion of Group A beta haemolytic Streptococcus pyogenes (GABHS) via Centor Criteria (3+ = Strep pyogenes):

• presence of tonsillar exudate
• tender anterior cervical lymphadenopathy or lymphadenitis
• fever 38C
• absence of cough

Question 13

What other investigations can be considered for tonsillitis? (Split into microbiology and bloods)

Answer 13

Microbiology:

• serological testing for streptococci - suspected rheumatic fever
• vaginal and cervical / penile and rectal cultures - if suspecting gonococcal pharyngitis due to oro-genital involvement
• HIV viral load assay

Bloods:

• WBC count and differential - useful in suspected infectious mononucleosis (raised WBC+neutrophilia=bacterial, raised WBC+lymphocytosis=infectious mononucleosis)
• heterophile antibodies

Question 14

What are some differential diagnoses for tonsillitis? (7)

Answer 14

• infectious mononucleosis - adolescents (older), does not resolve over 1 week, heterophile antibody testing
• epiglottitis - rare in countries with routine Hib vaccination, muffled voice, drooling, stridor, difficulty breathing, prompt referral to A&E
• peri-tonsillar abscess - trismus/lockjaw, muffled voice, displaced uvula, enlarged tonsil + swelling of peritonsillar region
• retropharyngeal abscess - trismus (lockjaw) / visible neck swelling
• gonococcal pharyngitis
• diphtheria - grey-green membrane, serosanguineous nasal discharge
• HIV - constitutional symptoms (malaise, fatigue, weight loss etc)

Question 15

What are the Centor criteria?

Answer 15

The Centor criteria give an indication of the likelihood of a sore throat being due to a bacterial infection:

• tonsillar exudate
• tender anterior cervical adenopathy
• fever >38C/100.5F
• absence of cough

3/4 = positive predictive value 40-60% (and rapid streptococcal antigen test can be done)

Question 16

What is the 1st line treatment for acute tonsillitis NOT due to group A beta-haemolytic streptococcal infection?

Answer 16

Analgesics (paracetamol or ibuprofen/aspirin/naproxen)

Question 17

What is the 1st line treatment for acute tonsillitis DUE to confirmed group A beta-haemolytic streptococcal infection?

Answer 17

• analgesics
• PLUS Abx e.g. phenoxymethylpenicillin 500mg PO 2-3 times (children<27kg=250mg)
• (or amoxicillin/clarithromycin)
• CONSIDER corticosteroids (dexamethasone sodium phosphate)

Question 18

What do you give to patients with acute tonsillitis DUE to group A beta-haemolytic streptococcal infection, that are allergic to penicillin?

Answer 18

Macrolide e.g. clarithromycin, (erythromycin, azithromycin)

Question 19

What is the 1st line treatment for a patient with recurrent tonsillitis (7 episodes in 1 year)?

Answer 19

Tonsillectomy
Consider Abx therapy

Question 20

What is the 1st line treatment if quinsy (peritonsillar abscess) is present?

Answer 20

Antibiotics and aspiration

Question 21

What is the most common complication following a tonsillectomy and what do we do?

Answer 21

• haemorrhage
• if within 24h - immediate return to theatre due to risk of further bleeding
• if after 5-10 days - give Abx (indicative of infection) + refer to ENT for assessment

Question 22

What are some complications of tonsillitis? (3)

Answer 22

• scarlet fever
• acute sinusitis
• acute otitis media

Question 23

What is the prognosis of tonsillitis?

Answer 23

Acute tonsillitis is an acute, self-limiting infective condition that normally resolves completely within 1 week with no sequelae.
Some patients may develop recurrent tonsillitis –> consider tonsillectomy