Tonsillitis

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Tonsillitis
Pos strep.JPG
A culture-positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old
Pronunciation
Specialty Infectious disease
Symptoms Sore throat, fever, enlargement of the tonsils, trouble swallowing, large lymph nodes around the neck [1] [2]
Complications Peritonsillar abscess [1] [3]
Duration~ 1 week [4]
Causes Viral infection, bacterial infection [1] [5] [6]
Diagnostic method Based on symptoms, throat swab, rapid strep test [1] [5]
Medication Paracetamol (acetaminophen), ibuprofen, penicillin [1] [5]
Frequency7.5% (in any given 3 months) [7]

Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. [8] [9] [2] Acute tonsillitis typically has a rapid onset. [10] Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. [1] [2] Complications include peritonsillar abscess (Quinsy). [1] [3]

Contents

Tonsillitis is most commonly caused by a viral infection and about 5% to 40% of cases are caused by a bacterial infection. [1] [5] [6] When caused by the bacterium group A streptococcus, it is classed as streptococcal tonsillitis [11] also referred to as strep throat. [12] Rarely bacteria such as Neisseria gonorrhoeae , Corynebacterium diphtheriae , or Haemophilus influenzae may be the cause. [5] Typically the infection is spread between people through the air. [6] A scoring system, such as the Centor score, may help separate possible causes. [1] [5] Confirmation may be by a throat swab or rapid strep test. [1] [5]

Treatment efforts involve improving symptoms and decreasing complications. [5] Paracetamol (acetaminophen) and ibuprofen may be used to help with pain. [1] [5] If strep throat is present the antibiotic penicillin by mouth is generally recommended. [1] [5] In those who are allergic to penicillin, cephalosporins or macrolides may be used. [1] [5] In children with frequent episodes of tonsillitis, tonsillectomy modestly decreases the risk of future episodes. [13]

About 7.5% of people have a sore throat in any three-month period and 2% of people visit a doctor for tonsillitis each year. [7] It is most common in school-aged children and typically occurs in the colder months of autumn and winter. [5] [6] The majority of people recover with or without medication. [1] [5] In 82% of people, symptoms resolve within one week, regardless if bacteria or viruses were present. [4] Antibiotics probably reduce the number of people experiencing sore throat or headache, but the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. [4]

Signs and symptoms

Illustration comparing normal tonsil anatomy and tonsillitis Blausen 0860 Tonsils&Throat Anatomy.png
Illustration comparing normal tonsil anatomy and tonsillitis

Those with tonsillitis usually experience sore throat, painful swallowing, malaise, and fever. [1] [14] [15] Their tonsils – and often the back of the throat – appear red and swollen, and sometimes give off a white discharge. [1] [15] [16] Some also have tender swelling of the cervical lymph nodes. [1] [15]

Many viral infections that cause tonsillitis will also cause cough, runny nose, hoarse voice, or blistering in the mouth or throat. [17] Infectious mononucleosis can cause the tonsils to swell with red spots or white discharge that may extend to the tongue. [18] This can be accompanied by fever, sore throat, cervical lymph node swelling, and enlargement of the liver and spleen. [18] Bacterial infections that cause tonsillitis can also cause a distinct "scarletiniform" rash, vomiting, and tonsillar spots or discharge. [1] [17]

Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.[ clarification needed ] [19]

Causes

Bacteria or viruses can cause tonsillitis. Tonsillitis cause.jpg
Bacteria or viruses can cause tonsillitis.

Viral infections cause 40 to 60% of cases of tonsillitis. [14] Many viruses can cause inflammation of the tonsils (and the rest of throat) including adenovirus, rhinovirus, coronavirus, influenza virus, parainfluenza virus, coxsackievirus, measles virus, Epstein-Barr virus, cytomegalovirus, respiratory syncytial virus, and herpes simplex virus. [17] Tonsillitis can also be part of the initial reaction to HIV infection. [17] An estimated 1 to 10% of the cases are caused by Epstein-Barr virus. [15]

Tonsillitis can also stem from infection with bacteria, predominantly Group A β-hemolytic streptococci (GABHS), which causes strep throat. [1] [14] Bacterial infection of the tonsils usually follows the initial viral infection. [15] When tonsillitis recurs after antibiotic treatment for streptococcus bacteria, it is usually due to the same bacteria as the first time, which suggests that the antibiotic treatment was not fully effective. [1] [20] Less common bacterial causes include: Streptococcus pneumoniae , Mycoplasma pneumoniae , Chlamydia pneumoniae , Bordetella pertussis , Fusobacterium sp., Corynebacterium diphtheriae , Treponema pallidum , and Neisseria gonorrhoeae . [21] [22] [23] [24]

Anaerobic bacteria have been implicated in tonsillitis, and a possible role in the acute inflammatory process is supported by several clinical and scientific observations. [25]

Sometimes tonsillitis is caused by an infection of spirochaeta and treponema, which is called Vincent's angina or Plaut-Vincent angina.[ non-primary source needed ] [26]

Within the tonsils, white blood cells of the immune system destroy the viruses or bacteria by producing inflammatory cytokines like phospholipase A2,[ non-primary source needed ] [27] which also lead to fever. [28] [29] The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx. [1] [30]

Diagnosis

There is no firm distinction between a sore throat that is specifically tonsillitis and a sore throat caused by inflammation in both the tonsils and also nearby tissues. [1] [31] An acute sore throat may be diagnosed as tonsillitis, pharyngitis, or tonsillopharyngitis (also called pharyngotonsillitis), depending upon the clinical findings. [1]

Throat swab Throat Culture.png
Throat swab

In primary care settings, the Centor criteria are used to determine the likelihood of group A beta-hemolytic streptococcus (GABHS) infection in an acute tonsillitis and the need of antibiotics for tonsillitis treatment. [1] [15] However, the Centor criteria have their weaknesses in making precise diagnosis for adults. The Centor criteria are also ineffective in diagnosis for tonsillitis in children and in secondary care settings (hospitals). [15] A modified version of the Centor criteria, which modified the original Centor criteria in 1998, is often used to aid in diagnosis. The original Centor criteria had four major criteria but the modified Centor criteria have five. The five major criteria of the modified Centor score are:

  1. Presence of tonsillar exudate
  2. Painful neck lymph nodes
  3. History of fever
  4. Age between five and fifteen years
  5. Absence of cough

The possibility of GABHS infection increases with increasing score. The probability for getting GABHS is 2 to 23% for the score of 1, and 25 to 85% for the score of 4. [15] The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing the throat and plating them on blood agar medium. This small percentage of false-negative results are part of the characteristics of the tests used but are also possible if the person has received antibiotics prior to testing. Identification requires 24 to 48 hours by culture but rapid screening tests (10–60 minutes), which have a sensitivity of 85–90%, are available. In 40% of the people without any symptoms, the throat culture can be positive. Therefore, throat culture is not routinely used in clinical practice for the detection of GABHS. [15]

Bacterial culture may need to be performed in cases of a negative rapid streptococcal test. [32] An increase in antistreptolysin O (ASO) streptococcal antibody titer following the acute infection can provide retrospective evidence of GABHS infection and is considered definitive proof of GABHS infection, but not necessarily of the tonsils. [33] Epstein Barr virus serology can be tested for those who may have infectious mononucleosis with a typical lymphocyte count in full blood count result. [15] Blood investigations are only required for those with hospital admission requiring intravenous antibiotics. [15]

Nasoendoscopy can be used for those with severe neck pain and inability to swallow any fluids to rule out masked epiglotitis and supraglotitis. Routine nasoendscopy is not recommended for children. [15]

Treatment

Treatments to reduce the discomfort from tonsillitis include: [1] [22] [23] [24] [30]

There are no antiviral medical treatments for virally caused tonsillitis. [34]

Antibiotics

If the tonsillitis is caused by group A streptococcus, then antibiotics are useful, with penicillin or amoxicillin being primary choices. [1] [15] Cephalosporins and macrolides are considered good alternatives to penicillin in the acute care setting. [1] [35] A macrolide, such as azithromycin or erythromycin, is used for people allergic to penicillin. [1] If penicillin therapy fails, bacterial tonsillitis may respond to treatment effective against beta-lactamase producing bacteria such as clindamycin or amoxicillin-clavulanate. [36] Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins. [37] There is no significant difference in efficacy of various groups of antibiotics for treating tonsillitis. [15] Intravenous antibiotics can be for those who are hospitalized with inability to swallow and presented with complications.[ citation needed ] Oral antibiotics can be resumed immediately if the person is clinically improved and able to swallow orally. [15] Antibiotic treatment is usually taken for seven to ten days. [1] [5]

Pain medication

Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to treat throat pain in children and adults. [1] [15] Codeine is avoided in children under 12 years of age to treat throat pain or following tonsilectomy. [38] [39] NSAIDs (such as ibuprofen) and opioids (such as codeine and tramadol) are equally effective at relieving pain, however, precautions should be taken with these pain medications. NSAIDs can cause peptic ulcer disease and kidney damage.[ citation needed ] Opioids can cause respiratory depression in those who are vulnerable. [15] Anaesthetic mouthwash can also be used for symptomatic relief. [15]

Corticosteroids

Corticosteroids reduce tonsillitis pain and improve symptoms in 24 to 48 hours. Oral corticosteroids are recommended unless the person is unable to swallow medications. [15]

Surgery

When tonsillitis recurs frequently, often arbitrarily defined as at least five episodes of tonsillitis in a year, [40] or when the palatine tonsils become so swollen that swallowing is difficult as well as painful, a tonsillectomy can be performed to surgically remove the tonsils. A randomised controlled trial of tonsillectomy versus medical treatment (antibiotics and pain killers) in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat. [41] [42]

Children have had only a modest benefit from tonsillectomy for repeated cases of tonsillitis. [43]

Prognosis

Since the advent of penicillin in the 1940s, a major preoccupation in the treatment of streptococcal tonsillitis has been the prevention of rheumatic fever, and its major effects on the nervous system and heart.

Complications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and pharyngitis due to the spread of infection. [22] [23] [24] [30]

An abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis.[ citation needed ] This is termed a peritonsillar abscess (or quinsy).

Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading infectious thrombophlebitis (Lemierre's syndrome).[ citation needed ]

In strep throat, diseases like post-streptococcal glomerulonephritis [ non-primary source needed ] [44] can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations. [45] [46]

Epidemiology

Tonsillitis occurs throughout the world, without racial or ethnic differences. [47] Most children have tonsillitis at least once during their childhood, [48] although it rarely occurs before the age of two. [47] It most typically occurs between the ages of four and five; bacterial infections most typically occur at a later age. [47]

Society and culture

Tonsillitis is described in the ancient Greek Hippocratic Corpus. [49]

Recurrent tonsillitis can interfere with vocal function and the ability to perform among people who use their voices professionally. [50] [51]

Related Research Articles

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enter the bloodstream an infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<span class="mw-page-title-main">Scarlet fever</span> Infectious disease caused by Streptococcus pyogenes

Scarlet fever, also known as scarlatina, is an infectious disease caused by Streptococcus pyogenes, a Group A streptococcus (GAS). It most commonly affects children between five and 15 years of age. The signs and symptoms include a sore throat, fever, headache, swollen lymph nodes, and a characteristic rash. The face is flushed and the rash is red and blanching. It typically feels like sandpaper and the tongue may be red and bumpy. The rash occurs as a result of capillary damage by exotoxins produced by S.pyogenes. On darker-pigmented skin the rash may be hard to discern.

<span class="mw-page-title-main">Streptococcal pharyngitis</span> Medical condition

Streptococcal pharyngitis, also known as streptococcal sore throat, is pharyngitis caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.

<span class="mw-page-title-main">Lemierre's syndrome</span> Medical condition

Lemierre's syndrome is infectious thrombophlebitis of the internal jugular vein. It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.

<span class="mw-page-title-main">Pharyngitis</span> Inflammation of the back of the throat

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

<span class="mw-page-title-main">Sore throat</span> Medical condition

Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include:

<span class="mw-page-title-main">Palatine tonsil</span> Lymphoid organs at the back of the throat on both sides

Palatine tonsils, commonly called the tonsils and occasionally called the faucial tonsils, are tonsils located on the left and right sides at the back of the throat, which can often be seen as flesh-colored, pinkish lumps. Tonsils only present as "white lumps" if they are inflamed or infected with symptoms of exudates and severe swelling.

<span class="mw-page-title-main">Rheumatic fever</span> Post-streptococcal inflammatory disease

Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum. The heart is involved in about half of the cases. Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. The damaged valves may result in heart failure, atrial fibrillation and infection of the valves.

<span class="mw-page-title-main">Upper respiratory tract infection</span> Medical condition

An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx or trachea. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold. Most infections are viral in nature, and in other instances, the cause is bacterial. URTIs can also be fungal or helminthic in origin, but these are less common.

<span class="mw-page-title-main">Peritonsillar abscess</span> Pus behind the tonsil due to an infection

Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Complications may include blockage of the airway or aspiration pneumonitis.

<span class="mw-page-title-main">Tonsil stones</span> Mineralized debris within the crevices of the tonsils

Tonsil stones, also known as tonsilloliths, are mineralizations of debris within the crevices of the tonsils. When not mineralized, the presence of debris is known as chronic caseous tonsillitis (CCT). Symptoms may include bad breath, foreign body sensation, sore throat, pain or discomfort with swallowing, and cough. Generally there is no pain, though there may be the feeling of something present. The presence of tonsil stones may be otherwise undetectable, however some people have reported seeing white material in the rear of their throat.

Fusobacterium necrophorum is a species of bacteria responsible for Lemierre's syndrome. It has also been known to cause sinusitis, mastoiditis, and odontogenic infections.

<i>Arcanobacterium haemolyticum</i> Species of bacterium

Arcanobacterium haemolyticum is a species of bacteria classified as a gram-positive bacillus. It is catalase-negative, facultative anaerobic, beta-hemolytic, and not motile. It has been known to cause head and neck infections, pharyngitis, and sinusitis.

<span class="mw-page-title-main">Rapid strep test</span> Test for strep throat

The rapid strep test (RST) is a rapid antigen detection test (RADT) that is widely used in clinics to assist in the diagnosis of bacterial pharyngitis caused by group A streptococci (GAS), sometimes termed strep throat. There are currently several types of rapid strep test in use, each employing a distinct technology. However, they all work by detecting the presence of GAS in the throat of a person by responding to GAS-specific antigens on a throat swab.

<span class="mw-page-title-main">Centor criteria</span> Tool for medical diagnosis of the throat

The Centor criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in patients complaining of a sore throat. They were developed as a method to quickly diagnose the presence of Group A streptococcal infection or diagnosis of streptococcal pharyngitis in "adult patients who presented to an urban emergency room complaining of a sore throat." The Centor criteria are named after Robert M. Centor, an internist at the University of Alabama at Birmingham School of Medicine.

<span class="mw-page-title-main">Throat culture</span>

A throat culture is a laboratory diagnostic test that evaluates for the presence of a bacterial or fungal infection in the throat. A sample from the throat is collected by swabbing the throat and placing the sample into a special cup (culture) that allows infections to grow. If an organism grows, the culture is positive and the presence of an infection is confirmed. The type of infection is found using a microscope, chemical tests, or both. If no infection grows, the culture is negative. Common infectious organisms tested for by a throat culture include Candida albicans known for causing thrush and Group A streptococcus known for causing strep throat, scarlet fever, and rheumatic fever. Throat cultures are more sensitive than the rapid strep test (70%) for diagnosing strep throat, but are nearly equal in terms of specificity.

<span class="mw-page-title-main">Streptococcal intertrigo</span> Medical condition

Streptococcal intertrigo is a skin condition that is secondary to a streptococcal bacterial infection. It is often seen in infants and young children and can be characterized by a fiery-red color of the skin, foul odor with an absence of satellite lesions, and skin softening in the neck, armpits or folds of the groin. Newborn children and infants commonly develop intertrigo because of physical features such as deep skin folds, short neck, and flexed posture. Prompt diagnosis by a medical professional and treatment with topical and/or oral antibiotics can effectively relieve symptoms.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Throat irritation can refer to a dry cough, a scratchy feeling at the back of the throat, a sensation of a lumpy feeling, something stuck at the back of the throat, or possibly a feeling of dust in the throat. The symptoms are unpleasant and usually temporary, but occasionally signifies a more serious health issue, such as laryngitis.

Bacteriophage T12 is a bacteriophage that infects Streptococcus pyogenes bacteria. It is a proposed species of the family Siphoviridae in the order Caudovirales also known as tailed viruses. It converts a harmless strain of bacteria into a virulent strain. It carries the speA gene which codes for erythrogenic toxin A. speA is also known as streptococcal pyogenic exotoxin A, scarlet fever toxin A, or even scarlatinal toxin. Note that the name of the gene "speA" is italicized; the name of the toxin "speA" is not italicized. Erythrogenic toxin A converts a harmless, non-virulent strain of Streptococcus pyogenes to a virulent strain through lysogeny, a life cycle which is characterized by the ability of the genome to become a part of the host cell and be stably maintained there for generations. Phages with a lysogenic life cycle are also called temperate phages. Bacteriophage T12, proposed member of family Siphoviridae including related speA-carrying bacteriophages, is also a prototypic phage for all the speA-carrying phages of Streptococcus pyogenes, meaning that its genome is the prototype for the genomes of all such phages of S. pyogenes. It is the main suspect as the cause of scarlet fever, an infectious disease that affects small children.

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  42. ↑ "Removing tonsils is effective and cost-effective for adults with frequent tonsillitis". NIHR Evidence. 5 September 2023. doi:10.3310/nihrevidence_59646. S2CID   261565310.
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  44. ↑ [ non-primary source needed ]Zoch-Zwierz W, Wasilewska A, Biernacka A, et al. (2001). "[The course of post-streptococcal glomerulonephritis depending on methods of treatment for the preceding respiratory tract infection]". Wiad. Lek. (in Polish). 54 (1–2): 56–63. PMID   11344703.
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  49. ↑ Dean-Jones 2013
  50. ↑ Sataloff & Hawkshaw 2019.
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