Tonsillitis refers to inflammation of the tonsils, which are two lymphoid tissues located at the back of the throat. It is commonly caused by viral or bacterial infections, with group A streptococcus being the most common bacterial etiology.
Diagnosis
The diagnosis of tonsillitis is primarily clinical. Patients typically present with:
- Sore throat
- Painful swallowing
- Fever
- Swollen and red tonsils, often with white or yellow exudates
- Swollen lymph nodes in the neck
- Bad breath
- Voice changes due to swelling
In young children, symptoms may also include abdominal pain, vomiting, and not wanting to eat.
To differentiate between viral and bacterial causes, healthcare providers may use the Centor criteria, which include:
- Tonsillar exudate
- Tender anterior cervical adenopathy
- Fever (by history)
- Absence of cough
The presence of three or four of these criteria suggests a bacterial infection, typically by group A streptococcus.
Differential Diagnosis
Conditions that can present similarly to tonsillitis and need to be considered include:
- Pharyngitis (viral or bacterial other than streptococci)
- Infectious mononucleosis (Epstein-Barr virus)
- Peritonsillar abscess (a complication of tonsillitis)
- Diphtheria (rare in countries with effective vaccination programs)
- Oral thrush (candidiasis)
- Herpangina or hand, foot, and mouth disease (coxsackievirus)
- Gonococcal pharyngitis
Management:
Management depends on the etiology of the tonsillitis:
- Non-Pharmacological: Rest, hydration, salt water gargles, humidification, throat lozenges can all help with symptoms
- Symptomatic: Aspirin gargles, paracetamol and NSAIDs
- Viral Tonsillitis: This is supportive and includes rest, hydration, pain management with analgesics such as ibuprofen or acetaminophen, and sometimes throat lozenges or sprays for symptomatic relief.
- Bacterial Tonsillitis (e.g., Streptococcal): If group A streptococcus is confirmed or highly suspected, appropriate antibiotic therapy is indicated to prevent complications, including rheumatic fever and peritonsillar abscess.
- Phenoxymethyl Penicillin 500mg oral BD for 10 days
- Penicillin allergy – Azithromycin 500mg oral OD for 5/7
- Phenoxymethyl Penicillin 500mg oral BD for 10 days
- Steroids: Steroids may be used in severe cases to reduce inflammation and pain.
- Prednisolone 50mg oral OD for 2/7
- Surgery: Tonsillectomy, the surgical removal of the tonsils, is considered when there is:
- Chronic or recurrent tonsillitis defined as
- 7 episodes in 1 year
- 5 episodes/year for 2 years
- 3 episodes/year for 3 years
- Tonsillar hypertrophy causing obstructive sleep apnea
- Abscess formation not responding to medical treatment
- Suspicion of malignancy
- Chronic or recurrent tonsillitis defined as
- Complications Management: If complications like a peritonsillar abscess (Quinsy) develop, drainage procedures might be necessary in addition to antibiotic therapy.
Patients should be advised to follow up if symptoms worsen or if there is no improvement after several days of treatment. In cases of recurrent infections, referral for tonsillectomy may be warranted. It’s also important to educate patients about the importance of completing the full course of antibiotics if prescribed.