Acute tonsillitis is a common illness that affects patients of all ages but the risk of complication increases with the young. Tonsillitis commonly presents with a sore throat and difficulty swallowing and will often have swelling of the tonsils with exudate on physical examination. Although acute tonsillitis secondary to group A beta-hemolytic Streptococcus should be considered so that antibiotic therapy can be initiated in a timely fashion to prevent complications such as a retropharyngeal abscess or acute rheumatic fever, the most common etiology of tonsillitis is viral. The treatment of viral tonsillitis is supportive with analgesia and hydration.
Key points
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Acute tonsillitis most commonly affects the pediatric population, presenting with sore throat and difficulty swallowing.
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The modified Centor criteria can guide treatment plan for diagnostic testing and/or empiric treatment of group A beta-hemolytic Streptococcus.
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Acute tonsillitis secondary to group A beta-hemolytic Streptococcus should be treated with appropriate antibiotics to prevent complications such as acute rheumatic fever.
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Anti-streptolysin O titers should not be ordered for acute tonsillitis as it is only used in the diagnosis of acute rheumatic fever, not acute tonsillitis.
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Systemic corticosteroids are not recommended routinely for acute tonsillitis.
Introduction
The purpose of this article is to review the currently available material pertaining to tonsillitis. It is a common illness that affects patients of all age ranges but more commonly in the young. Clinical presentation is highly variable and similar symptoms are noted in viral and bacterial tonsillitis. This article focuses on the clinical presentation, diagnosis, and management of this important disease to mitigate the risk of significant morbidity and mortality such as acute rheumatic fever (ARF).
Background
Pharyngitis is a common diagnosis that causes patients to seek care from their primary care physician. It accounts for almost 2% of primary care ambulatory care visits each year. Of these, approximately 5% are due to group A beta-hemolytic streptococci or Streptococcus pyogenes tonsillitis. This review article will focus on tonsillitis.
Tonsillitis is most commonly due to a viral infection and thus self-limiting. Up to 15% of tonsillitis in adults, and 30% in the pediatric population, however, are due to a bacterial etiology. The most common bacterial cause of tonsillitis is infection by group A beta-hemolytic streptococcus, commonly known as strep throat.
Pathophysiology
Tonsils are lymphoid tissues located in the nasopharynx and oral pharynx. This includes the pharyngeal, tubal, lingual, and palatine tonsils. These tissues play an important role in the immune system in exposure to virus or bacteria to the respiratory and gastrointestinal tract. They contain B cells, microfold M cells, T cells, and macrophages that are involved in the presentation, recognition, and response to infectious antigens. ,
Causes
Tonsillitis is caused by viral or bacterial infection of the naso-oro-pharynx. The nasopharynx has hundreds of viruses and bacteria, making it difficult to determine the pathologic etiology of tonsillitis. However, it is suggested that viral infections are implicated in 70% to 95% of all cases. The most common viruses causing acute tonsillitis in the pediatric population are adenovirus, influenza, parainfluenza, Epstein–Barr Virus, human herpes virus 3, and enteroviruses. In adults, almost 50% of cases are due to rhinovirus or coronavirus.
The most common viral and bacterial etiologies are listed in Table 1 . ,
| Viral Etiologies | Bacterial Etiologies |
|---|---|
| Adenovirus Coronavirus Epstein–Barr virus Cytomegalovirus Hepatitis A Herpes simplex virus Human immunodeficiency virus Influenza Respiratory syncytial virus Rhinovirus | Group A beta-hemolytic streptococcus Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenza Corynebacterium diphtheriae Syphilis Chlamydia Gonorrhea Tuberculosis |
Risk factors
Patients who are at risk for development of tonsillitis include those who have high exposure to respiratory and viral infections. These populations include school-aged children from 5 to 15 years old and those who work with or have frequent contact with children. Patients who are immunocompromised are also at higher risk for tonsillitis.
Clinical symptoms and signs
Tonsillitis is a clinical diagnosis that is rooted in a thorough history and physical examination of the nasopharynx and oropharynx. Patients will often present with a constellation of symptoms including fever, tonsillar exudates, cough, anorexia, congestion, and/or tender cervical lymphadenopathy. Less commonly, patients with tonsillitis will present without upper respiratory symptoms. Associated symptoms include palatal petechiae, strawberry tongue, erythematous or edematous uvula, or rash. Headaches, myalgias, nausea and vomiting, and abdominal pain are not common in tonsillitis.
Signs and symptoms associated with more severe cases of tonsillitis include dysphagia and/or odynophagia due to tonsillar swelling. Enlargement of the tonsils may also cause narrowing of the posterior oropharynx, leading to hoarseness, and affect the patient’s ability to maintain and protect the airway. Uvula deviation may be indicative of a tonsillar abscess. Other symptoms that warrant more urgent evaluation in the emergency department are trismus, muffled voice, uvula deviation, drooling, or unilateral facial swelling.
Table 2 reviews the common associated signs and symptoms of viral versus bacterial tonsillitis.
| Viral Tonsillitis | Bacterial Tonsillitis |
|---|---|
| Cough Rhinorrhea Conjunctivitis | Sudden onset of fever Sore throat Dysphagia Tonsillar erythema and exudate Cervical lymphadenopathy Absence of cough Strawberry tongue |
Diagnosis
Tonsillitis is a clinical diagnosis. Determining viral versus bacterial etiology is of utmost importance for antibiotic stewardship.
Clinical Diagnosis
Obtaining a thorough history and physical is essential in the diagnosis of tonsillitis. History should focus on the presence of fever and absence of cough. And, the physical examination should assess for tonsillar enlargement, tonsillar exudate, and tender cervical lymphadenopathy. It is these history and physical components and patient age that comprise the modified Centor (McIsaac) score; one point is assigned to each of these components. The Centor score risk stratifies patients with possible group A beta-hemolytic streptococcus (GAS) tonsillitis. Scores of 1 or less are low risk for GAS tonsillitis and do not require any further testing. If there is high clinical suspicion for GAS tonsillitis and a Centor score of 2 or 3, further testing can with point-of-care testing or throat culture should be considered. Scores of 4 or more should be treated with empiric antibiotics regardless of point-of-care testing and a throat culture obtained. The modified Centor score was created to estimate the probability of tonsillitis to be secondary to streptococcus; it was meant to provide support for immediate treatment of bacterial tonsillitis while being judicious in the use of antibiotics. , ,
Laboratory Testing
Testing for GAS tonsillitis is not recommended for patients aged less than 3 years or those suspected to have viral tonsillitis.
Please note that neither of these tonsil swabs can differentiate between acute infection and chronic colonization of GAS. Despite adequate treatment, persistent GAS, without active infection or inflammatory response, has been noted for over 1 year. Chronic GAS has little to no risk in developing immune-mediated post-streptococcal complications.
Tonsil swabs
Non-culture-based tests for GAS
A systematic review shows an estimated sensitivity and specificity of 93% and 99% in children versus 95% and 97% in adults for molecular tests. This is compared to immunoassays that show an estimated sensitivity and specificity of 80% and 92% in children versus 91% and 93% in adults. The sensitivity of these tests is dependent on bacterial load and quality of the tonsil swab/throat culture. Serial testing may reduce false negative rates. Due to the almost immediate results, less than 10 minutes, of the non-culture-based tests and its availability at the point of care, these tests aid in timely diagnosis and treatment.
Throat culture
The bacterial culture is the gold standard in the diagnosis of GAS tonsillitis. Although time intensive, often requiring 24 to 72 hours for a result, the sensitivity of the bacterial throat culture is 90% to 95%. These statistics are questionable as they have not been reproduced in clinical practice, only in research laboratories. ,
Other tests to consider
C-reactive protein
Elevated C-reactive protein (CRP) values are most commonly noted in bacterial infections but do not differentiate between upper and lower respiratory tract infections. Elevated CRP 7 days after the onset of symptoms may be more consistent with bacterial infection.
Antistreptolysin O titers
The antistreptolysin O (ASLO) titers are not useful in the diagnosis of acute tonsillitis. It is useful in the diagnosis of ARF, one of the major complications of GAS tonsillitis. Titers should not be ordered to diagnose acute tonsillitis.
Diagnostic imaging
Imaging is rarely indicated for acute, uncomplicated tonsillitis. However, if there are signs of complicated or invasive infection such as unstable vital signs, deviated uvula, drooling, trismus, unilateral facial swelling, or airway compromise, the patient should be redirected to the emergency department for advanced imaging and possible airway management and protection.
Treatment
Tonsillitis is usually self-limiting, often caused by viruses rather than bacteria. The mainstay of treatment is supportive care, using acetaminophen and nonsteroidal anti-inflammatory drugs for analgesia. Adequate hydration is also recommended. Patients may return to work or school 24 hours if treatment is indicated.
Acute Tonsillitis
Tonsillitis secondary to bacterial infection will require antibiotic therapy. Group A beta-hemolytic Streptococcus, specifically, requires appropriate and timely treatment to prevent complications. First-line antibiotic choice for GAS tonsillitis is penicillin as noted in Table 3 . Cephalosporins and macrolides are also effective therapies but only recommended for patients with a true penicillin allergy.
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