Tonsillitis

• Overview:

  • Refers to the acute inflammation of the palatine tonsils secondary to infection
  • Tonsillitis is most commonly caused by a viral infection and associated with an URTI
• Bacterial tonsillitis is most commonly caused by group A beta-haemolytic streptococcus (GABHS) infection - mainly streptococcus pyogenes
• Features of bacterial infection:

  • Fever over 38
  • Tonsillar exudates - pus on tonsils
  • Severely inflamed tonsils
  • Absence of cough
  • Tender anterior cervical lymph nodes - lymphadenopathy
• Penicillin V (phenoxymethylpenicillin) for a 10 day course is first line treatment
• Complications:

  • Peritonsillar abscess - quinsy
  • Otitis media - infection spreads to the inner ear
  • Post-streptococcal glomerulonephritis
  • Post-streptococcal reactive arthritis
• EBV can also result in exudative tonsillitis

  EBV can be distinguished by  lymphadenopathy which should be limited to the anterior chain in a simple bacterial tonsillitis, whilst is more generalised with infectious mononucleosis.
• The Centor criteria evaluate the patient for the following:

  • Tonsillar exudate
  • Tender anterior cervical lymphadenopathy or lymphadenitis
  • History of fever (over 38°C)
  • Absence of cough
• The FeverPAIN criteria are used as an alternative to the Centor criteria.

  • Fever (during previous 24 hours)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • Severely Inflamed tonsils
  • No cough or coryza (inflammation of mucus membranes in the nose)
• Most patients can be managed with antipyretic analgesia (e.g. paracetamol, ibuprofen).

  • Unlikely to benefit from antibiotics: those with a Centor score of 0-2 or a FeverPAIN score of 0-1. They should not routinely be offered antibiotics.
  • May benefit from antibiotics: those with a FeverPAIN score of 2-3. Many offer a ‘back-up’ prescription that can be used if symptoms persist for longer than 3-5 days.
  • Most likely to benefit from antibiotics: those with a Centor score of 3-4 or a FeverPAIN score of 4-5. They will generally be offered antibiotics though the evidence shows minimal overall benefit.
• In patients presenting with any of a severe sore throat, drooling, stridor or trismus – epiglottitis – a rare but potentially life-threatening condition should be considered.
• Severe tonsillitis

  • Symptoms may be severe with dysphagia and high fevers
  • May benefit from hospital admission for IV fluid, IV antibiotics and a dose of IV steroids
• The NHS will normally fund tonsillectomy where:

  • Malignancy is suspected
  • More than one episode of quinsy or airway obstruction
  • Recurrent sore throat with disabling episodes preventing normal function, due to tonsillitis (seven or more eligible episodes in the last year or five or more in each of the last two years or three or more in each of the preceding three years)
  • Obstructive sleep apnoea