Acute Tonsilitis

Aetiology

• Viral - EBV, HSV, Adenovirus
• Bacterial - Beta haemolytic streptococci, Mycoplasma, Corynebacterim diptheria

Clinical

• May need a torch to get a good look at the tonsils:tonsillar exudate and enlargement and erythema of the tonsils. There may be anterior cervical lymphadenopathy.
• Severe Sore throat, Fever, Headache, Mild dysphagia
• Cervical Lymphadenopathy, Splenomegaly (EBV)
• Tonsils often enlarged and covered in white (pus suggests bacterial)
• Nasal features suggest a viral aetiology such as the common cold

An episode of tonsillitis defined by Paradise criteria

• A sore throat plus the presence of one or more of the following
  • Temperature >38.3°C
  • Swollen tender anterior cervical lymph nodes >2cm
  • Tonsilliar exudates
  • Positive culture for group A Beta-Haemolytic Streptococcus

Tonsillitis in children

• Attacks are common
• Frequency may reduce with age
• Can impact significantly on education as loss of time at school is usually 3-5 days per attack

Tonsillitis in Adults

• Less common than in children
• Attacks can be as frequent and more severe than in children
• Can cause significant loss of work due to illness
• A severe complication which occurs mainly in adults is peritonsillar abscess or quinsy
• often requires admission for treatment and pain control

Red Flags

• If a patient presents with breathing difficulty, or has suspected epiglottitis, or other serious upper airway disease do not attempt to examine the throat
• Immediately send to acute hospital via ambulance
• Suspect acute epiglottitis when the patient
  • Respiratory distress or stridor
  • Is drooling
  • Is systemically very unwell
  • Has dysphagia
  • Has a muffled voice

Investigations

• FBC, U&E and CRP if unwell.
• Take throat swabs
• FBC, ? ASO titre, Monospot/Paul Bunnell for EBV

Complications

• Dysphagia and Dehydration and weight loss
• Otitis media, Peritonsillar abscess
• Retropharyngeal abscess, Sinusitis
• ß-haem Strep: Scarlet fever, rheumatic fever
• Glomerulonephritis, Infectious mono due to CMV

Complications

• Peritonsillar abscess (quinsy) [See topic] fever, neck pain, trismus, a muffled voice, a displaced uvula, and an enlarged, displaced tonsil, with swelling of the peri-tonsillar region. It is most common in children 2 to 4 years of age.
• Retropharyngeal abscess suggested by severe sore throat that does not resolve after a few days. There may be trismus or visible neck swelling.
• Lemierre syndrome — thrombophlebitis of the jugular vein. Typically seen in people with SIRS or sepsis.

Who to admit

• A sore throat with any of the following: stridor|respiratory distress| progressive difficulty swallowing or drooling|increasing pain|severe systemic symptoms|any features suggestive of epiglottitis|suspected severe suppurative complications which carry a risk of airway compromise or rupture of the abscess and may require parenteral antibiotics
• Suspected peritonsillar cellulitis or abscess (quinsy)
• Suspected parapharyngeal abscess - not common
• Suspected retropharyngeal abscess
• Lemierre's syndrome
• Suspected Kawasaki disease
• Dehydration or reluctance to take any fluids
• Signs of being markedly systemically unwell
• At the risk of immunosuppression
• Suspected diphtheria - characteristic tonsillar or pharyngeal membrane
• Signs of being profoundly unwell and the cause is unknown or a rare cause is suspected, such as Stevens-Johnson syndrome|Yersinial pharyngitis
• Embedded foreign body as object might be sharp
• Seek specialist advice or consider referral to a specialist if the patient is immunosuppressed patient has severe oral mucositis

Management

• Analgesia: Admit if difficulty swallowing and signs of dehydration. Ibuprofen is recommended for the relief of fever, headache, and throat pain in adults with a sore throat. Paracetamol may be used as an alternative to ibuprofen in cases of intolerance. Paracetamol is used in children.
• Hydration: Consider oral fluids and if unable to swallow then IV fluids and IV analgesia
• Antibiotics. Antibiotics should only be used in severe cases where the practitioner is concerned about the clinical condition of the patient or if the patient is systemically unwell or has associated conditions or immunosuppressive illness. Avoid Amoxicillin and Co-amoxiclav as it causes a rash with EBV. The usual choice is phenoxymethylpenicillin (penicillin V) for 5-10 days is recommended first-line. Alternatives include a 5-10 day course of clarithromycin. If the patient is immunosuppressed, seek urgent specialist advice and consider referral.
• Tonsillectomy considered if multiple episodes over several years or episode of quinsy and may be reasonable to refer to ENT.

References

• Tonsilitis guidelines