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Tonsillitis

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Tonsillitis, Acute Tonsillitis, Exudative Pharyngitis, Acute Exudative Tonsillitis, Acute Catarrhal Tonsillitis

  • See Also
  1. Pharyngitis
  2. Pharyngitis Causes
  3. Dysphagia
  4. Group A Streptococcal Pharyngitis
  5. Peritonsillar Abscess
  6. Retropharyngeal Abscess
  7. Lemierre Syndrome
  8. Diphtheria
  9. Chronic Pharyngeal Carriage of Streptococcus pyogenes
  10. Tonsillectomy Indications
  • Definitions
  1. Tonsillitis
    1. Tonsillar Inflammation
  • Epidemiology
  1. Incidence: 0.4% of outpatient clinic visits in U.S.
  • Pathophysiology
  1. Droplet transmission is primary route of infectious causes
  • Symptoms
  1. Pharyngitis
  2. Difficulty taking oral intake
  3. Difficulty Swallowing secretions
  4. Otalgia (common innervation of ear and throat)
  • Signs
  1. Fever
  2. Appears ill
  3. Mucus membranes dry
  4. Tonsils enlarged, beefy red, and with exudate
  5. Tender cervical adenopathy
  6. Splenomegaly in Epstein-Barr Virus
  7. Palatal Petechiae in Group A Streptococcal Pharyngitis
  • Differential Diagnosis
  • Select Causes
  1. See Pharyngitis Causes for complete Pharyngitis differential
  2. Viral (70 to 95% of cases)
    1. Common viruses (e.g. Rhinovirus, Respiratory Syncytial Virus, Adenovirus, Coronavirus)
    2. Mononucleosis or Mononucleosis-Like Syndrome (Epstein Barr Virus, Cytomegalovirus)
    3. Acute HIV Infection
    4. Herpes Simplex Virus
    5. Coxsackie Virus A (Hand Foot and Mouth Disease)
  3. Bacterial
    1. Group A Streptococcal Pharyngitis (5 to 15% of cases in adults, 15 to 30% of cases in children age 5 to 15 years)
      1. See Strep Score (Walsh Pharyngitis Criteria, McIsaac Decision Rule, Modified Centor Criteria)
      2. Still responsible for Acute Rheumatic Fever worldwide (but significantly reduced in U.S. with treatment)
      3. Other species of Streptococcus (Group C, G) can also cause Tonsillitis, but do not require treatment
    2. Staphylococcus aureus
    3. Hemophilus Influenzae (rare in U.S. given Immunizations)
    4. Gonorrhea
    5. Peritonsillar Abscess
    6. Retropharyngeal Abscess
    7. Lemierre Syndrome or Fusobacterium Necrophorum (Incidence as high as 21% in young adults)
    8. Diphtheria (rare in U.S. due to Immunizations)
    9. Ludwig Angina
    10. Epiglottitis
  4. Fungal
    1. Oral Candidiasis (Thrush)
  5. Other
    1. Kawasaki Disease
  • Labs
  1. Streptococcal Rapid Antigen Test (with follow-up Throat Culture) or Point-Of-Care GAS Nucleic Acid Amplification Test
    1. See Group A Streptococcal Pharyngitis for protocols
  2. Consider Gonorrhea PCR
  3. Consider Epstein Barr Virus Infection
    1. Heterophil Agglutination (Monospot Test)
    2. Peripheral Blood Smear with Atypical lymphocytes
    3. Liver Function Test Elevation
  • Imaging
  1. Indications: Evaluate for complications (e.g. abscess, Epiglottitis, Lemierre Syndrome, Ludwig Angina)
    1. Hemodynamic instability
    2. Toxic appearance
    3. Inability to swallow oral fluids or control secretions
    4. Trismus
    5. Asymmetric oropharyngeal swelling
  2. Modalities
    1. CT soft tissue neck with contrast
  • Management
  • General
  1. See Pharyngitis for symptomatic management
  2. See Group A Streptococcal Pharyngitis for specific Antibiotics for Streptococcal Pharyngitis
  3. Consider Dexamethasone single dose orally: 10 mg in adults and 0.6 mg/kg (up to 10 mg) in children
  4. Unresponsive to medications for Pharyngitis
    1. Consider Pharyngitis Causes
    2. Consider Point-Of-Care GAS Nucleic Acid Amplification Test
    3. Consider Monospot
    4. Consider STD Causes (Gonorrhea, Acute HIV Infection, HSV)
    5. Consider empiric Antibiotics for Lemierre Syndrome (Fusobacterium Necrophorum)
    6. Consider Clindamycin 300 mg orally four times daily (with or without Dexamethasone 10 mg orally once)
    7. Assess for Peritonsillar Abscess and Retropharyngeal Abscess
    8. Assess for Laryngeal pathology (e.g. Epiglottitis, Bacterial Tracheitis)
    9. Consider ENT referral
  1. See Tonsillectomy Indications
  2. Prognosis following Tonsillectomy
    1. Reduces Pharyngitis frequency (esp. Streptococcus)
    2. Effect lasts 2-3 years after surgery
  • Complications
  1. Peritonsillar Abscess
  2. Retropharyngeal Abscess
  3. Lemierre Syndrome
  4. Group A Streptococcal Pharyngitis Complications
    1. Poststreptococcal Glomerulonephritis
    2. Rheumatic Fever
    3. Scarlet Fever
  • Resources
  1. Tonsillitis (Stat Pearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK544342/
  • References
  1. Bartlett (2015) J R Nav Med Serv 101(1):69-73 [PubMed]
  2. Georgalas (2014) BMJ Clin Evid +PMID: 25051184 [PubMed]
  3. Smith (2023) Am Fam Physician 107(1): 35-41 [PubMed]