Acute Tonsillitis and Pharyngitis

Acute tonsillitis is an inflammation of the tonsils that frequently occurs with pharyngitis, inflammation of the pharynx

Aetiology

Viral causes

  • Account for the majority of cases
  • rhinovirus, influenza, parainfluenza, enterovirus, adenovirus, EBV

Bacterial causes

  • 5-30% bacterial, most commonly Strep. pyogenes (Group A strep)
  • Others include H. influenza, S. aureus and streptococcus pneumonia
  • ~40% are beta-lactamase-producing

Non-infectious pharyngitis

  • Non-infectious causes of pharyngitis are uncommon and can include physical irritation e.g. from GORD, chronic irritation from cigarette smoke

Clinical presentation

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Viral tonsilitis

  • Malaise
  • Sore throat, mild analgesia requirement
  • Temperature
  • Able to undertake near normal activity
  • Possible lymphadenopathy
  • Lasts 3-4 days

Bacterial tonsilitis

  • Systemic upset
  • Fever
  • Odynophagia
  • Halitosis
  • Unable to work/school
  • Lymphadenopathy
  • Lasts ~1 week, requires antibiotics to settle

Investigations

  • History and clinical examination - throat swabs not routinely carried out in primary care management
    • Throat swabs are unhelpful as core species do not always correlate with surface bacteria
  • Scoring systems used to identify those who would benefit from antibiotics (Strep. pyrogenes)
    • Centor - 1 point for each of: tonsillar exudate, tender anterior cervical lymph nodes, history of fever, absence of cough
      • 3-4 = 32-56% risk
    • FeverPAIN - 1 point for each of: Purulence, Attend rapidly (within 3 days), very Inflamed tonsils, No cough

Management

  • Self-limiting regardless of viral or bacterial aetiology
  • Symptoms resolve in 3 days in 40% of people and within 1 week in 85% of people
  • If sore throat and lethargy persist into the second week, especially if the person is 15-25 years of age, consider infectious mononucleosis/glandular fever (caused by Ebstein Barr Virus) should be suspected

Self-care advice

  • Eat and drink, rest
  • Regular analgesia (paracetamol/ibuprofen)
  • Medicated lozenges

Use of antibiotics

  • Prescribe antibiotics only where appropriate - penicillin (clarithromycin if allergic)
    • Acute follicular tonsilitis indicates Strep. pyrogenes
    • Use of scoring systems
Prescribing antibiotics with FeverPAIN
  • 0 or 1 points - low association of isolating streptococcus
  • 2-3 points - moderate association with streptotoccus, consider delated presentation for antibiotics
  • 4 or 5 points - highest association (62-65% likelihood of streptococcus), treat with antibiotic

When to admit/refer

  • Refer immediately if patient presents with stridor, breathing difficulty, clinical dehydration or is systemically unwell
  • Persistent sore throat, especially if there is a neck mass, requires investigation for a throat cancer
  • Refer patients with a sore/painful throat which lasts for 3 to 4 weeks, with pain swallowing or dysphagia for 3+ weeks
  • Refer if there are red, or red and white patches, or ulceration or swelling or the oral/pharyngeal mucosa which persists for 3+ weeks

Management of tonsilitis in hospital

  • IV fluids, antibiotics and steroids
Infection control for acute Strep. pyrogenes infection
  • Isolation for the first 48 hours of treatment
  • Standard infection control precautions
  • Contact precautions
  • Risk assess need for droplet precautions

Surgical management

  • 'Watchful waiting' more appropriate than tonsillectomy for children with mild sore throats
  • Recommended for recurrent severe sore throat due to acute tonsillitis in adults

Complications

  • Otitis media (most common)
  • Peritonsillar abscess (quincy)
  • Parapharyngeal abscess
  • Lemierre symdrome (suppurative thrombophlebitis of jugular vein)

Late complications for Strep. pyrogenes infection

  • Rheumatic fever - fever, arthritis and pancarditis 3 weeks post sore throat
  • Glomerulonepthritis - haematuria, albuminuria and oedema 1-3 weeks post sore throat