Tonsillitis

Introduction

Acute tonsillitis is an acute inflammatory condition of the faucial tonsils, involving the mucosa, crypts, follicles, and/or tonsillar parenchyma.

Mainly affecting children, acute tonsillitis is also commonly observed in adults. However, it is rare in infants and individuals aged 50 and above.

Failure to resolve acute tonsillitis adequately or experiencing repeated attacks can result in chronic tonsillitis.

Causative Agents

Viral: Influenza, Para-influenza, Adenovirus, Rhinovirus.

Bacterial: Streptococcus Hemolyticus, Hemophilus Influenzae, Pneumococcus, Moraxella Catarrhalis, Staphylococci.

Predisposing Factors

Poor orodental hygiene

Poor nutrition

Congested environment

Pathogenesis

Viral infection of the upper respiratory tract, including the mucosa of the tonsils (catarrhal tonsillitis).

Secondary bacterial infection becomes entrapped within the crypts with associated inflammatory exudates (cryptic tonsillitis).

Spread from the crypts to the surrounding tonsillar follicles (acute follicular tonsillitis).

Pathogenesis Continued:

Exudates in the crypts coalesce to form a coating, giving the appearance of a false membrane (acute membranous tonsillitis).

Spread into the parenchyma of the tonsils (acute parenchymal tonsillitis).

Recurrent acute infection spreads from the tonsils to the peritonsillar space, leading to peritonsillar abscess.

Clinical Symptoms

• Sore throat
• Difficulty in swallowing
• Odynophagia
• High-grade Fever: Varies from 38 to 40°C and may be associated with chills and rigors
• Dry cough
• Earache: in the form of referred otalgia or the result of acute otitis media, which may occur as a complication
• Constitutional symptoms: headache, general body aches, malaise, anorexia, and constipation

Clinical Signs

• Mouth breath is fetid, and tongue is coated.
• Hyperemia of pillars, soft palate, and uvula.
• Tonsils are red, swollen/enlarged, and congested.
• Crypts are filled with yellowish spots of purulent material.
• There may be a whitish membrane on the medial surface of the tonsil, which can be easily wiped away with a swab.
• Oedema of the uvula and soft palate may be present.
• The jugulodigastric lymph nodes are enlarged and tender.
• Other signs include features of generalized upper respiratory tract infection, including adenoiditis in children.

Differential Diagnosis

• Scarlet fever
• Diphtheria
• Vincent’s fever
• Agranulocytosis
• Infective mononucleosis

Investigation

• Throat swab for culture and sensitivity
• Peripheral smear - to rule out hematopoietic disorders like leukemia, agranulocytosis, etc.
• Paul-Bunnel test may be required if a membrane is seen to rule out infectious mononucleosis
• X-ray of the paranasal sinuses to rule out sinonasal septic focus
• X-ray postnasal space for adenoid enlargement
• Computed tomographic scan of the sinuses and neck for sinus infection focus or suspected complications

Medical Treatment

• Adequate bed rest
• Encourage to take plenty of fluids
• Analgesics: given according to the age of the patient to relieve local pain and bring down the fever
• Antimicrobial therapy:
• Penicillin is the drug of choice
• Patients allergic to penicillin can be treated with erythromycin
• Antibiotics are better prescribed according to the culture sensitivity report
• Should be continued for 7-10 days
• Antiseptic/warm saline gargles
• Throat lozenges

Introduction

It follows as a complication of acute tonsillitis.

May be a subclinical infection of the tonsils without an acute attack.

Mostly affects children and young adults.

Predisposing factor may be chronic infection in sinuses or teeth.

Clinicopathological Types

Chronic Follicular Tonsillitis: Tonsillar crypts are full of infected cheesy materials that show on the surface as yellowish spots.

Chronic Parenchymatous Tonsillitis: Hyperplasia of the lymphoid follicles of the tonsillar parenchyma leading to obstruction to food and air passages.

Chronic Fibrotic Tonsillitis: Small tonsils due to atrophy with recurrent infection.

Clinical Features - Symptoms

• Sore throat: recurrent attacks 3-4 times a year
• Cough
• Chronic irritation in the throat
• Halitosis
• Dysphagia
• Sleep apneic episodes

Clinical Features - Signs

• Persistent congestion of the anterior pillars
• Enlarged tonsils
• Purulent yellowish discharge from the crypts
• Enlarged jugulodigastric lymph nodes

Investigations

• Full blood count + differential count, ESR, platelet count, and peripheral smear.
• Throat swab for culture and sensitivity
• Prothrombin time and partial thromboplastin time with kaolin (PTTK)
• X-ray post nasal space or diagnostic nasal endoscopy to rule out coexisting adenoid hypertrophy
• X-ray chest PA view
• ECG for childhood or elderly patients

Treatment

Conservative:

• General health care
• Adequate and balanced diet
• Treatment of co-existent infection of teeth, nose, and sinuses.

Surgical:

Total removal of the tonsils - Tonsillectomy

Indications for Tonsillectomy

• Recurrent attacks of acute tonsillitis:
• 6 or more episodes in a year
• 4 or more episodes per year in 2 consecutive years
• 2 or more episodes per year in 3 consecutive years
• 2 weeks or more of lost normal daily activities (school, work, etc.)
• Recurrent peritonsillar abscess
• Obstructive sleep apnea
• Unilateral enlargement - suspected malignancy
• Integral part of the uvulopalatopharyngoplasty

Complications

• Peritonsillar abscess
• Parapharyngeal abscess
• Intratonsillar abscess
• Tonsillolith (calculus of the tonsil)
• Tonsillar cyst
• Cervical abscess due to suppuration of jugulodigastric lymph nodes
• Acute otitis media. Recurrent attacks of acute otitis media may coincide with recurrent tonsillitis.
• Rheumatic fever. Often seen in association with tonsillitis due to Group A beta-haemolytic streptococci.
• Acute glomerulonephritis - rare
• Subacute bacterial endocarditis in a patient with valvular heart disease. It is usually due to Streptococcus viridans infection.