Tonsillitis is inflammation due to infection of the tonsils. Pharyngitis is inflammation of the oropharynx but not the tonsils. The tonsils tend to atrophy in early adulthood. In laryngitis there are few visible signs of infection but with soreness lower down the throat often associated with a hoarse voice.
- It is a very common condition, most frequent in children aged 5 to 10 years and young adults between 15 and 25 years.
- In one study, rates of asymptomatic carriage of Group A streptococcus were:
- 10.9% aged 14 or less
- 2.3% aged 15 to 44
- 0.6% aged 45 and over
- A GP with a list of 2,000 can expect to see around 120 cases of sore throat a year with considerable seasonal variation - see separate article Sore Throat. General practices taking part in the fourth National Survey of Morbidity reported a consultation rate of 0.1 per capita annually. The Scottish Intercollegiate Guidelines Network (SIGN) suggests that only 1 patient in 18 with a sore throat will consult.
These include immune deficiency and a family history of tonsillitis or atopy.
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- Pain in the throat is sometimes severe and may last more than 48 hours, along with pain on swallowing.
- Pain may be referred to the ears.
- Small children may complain of abdominal pain.
- Loss of voice or changes in the voice.
- The throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them.
- Possibly a high temperature.
- Swollen regional lymph glands.
- Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and dysphagia.
- Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior cervical glands.
- Only about 20-30% of patients present with classical disease.
Tonsillitis tends to be misdiagnosed leading to inappropriate treatment with antibiotics.
- If the sore throat is due to a viral infection the symptoms are usually milder and often related to the common cold.
- If due to infection with the Coxsackie virus, small blisters develop on the tonsils and the roof of the mouth. The blisters erupt in a few days and are followed by a scab, which may be very painful.
- Infectious mononucleosis (glandular fever) affects teenagers most often. They may be quite unwell with very large and purulent tonsils and a long-lasting lethargy. An enlarged spleen is classically described and infrequently found.
- In streptococcal infection the tonsils often swell and become coated and the throat is sore. The patient has a temperature, foul-smelling breath and may feel quite ill. The differences are variable and it is impossible to tell on inspection if the infection is viral or bacterial.
- Check that the patient is not taking a drug that may cause agranulocytosis.
- Epiglottitis requires immediate admission.
- Unusual bacteria may be involved including gonococcal infection.
- Unilateral enlargement of the tonsils, especially in the elderly, may indicate malignancy.
- Diphtheria has appeared at times in Russia in the last decade but very few British doctors have ever seen the disease because of a longstanding and very effective programme of immunisation.
- It is not uncommon for HIV infection to present with ENT symptoms, especially in children. The most common presentations are cervical lymphadenopathy, oro-oesophageal candidiasis and otitis media.
- It is usually recommended that throat swabs and rapid antigen tests should not be performed routinely but swabs may be helpful in higher-risk groups as a guide to choice of treatment or with treatment failure.
- There is some validity to the argument that swabs do not differentiate between infection and carriage.
- Antistreptolysin O (ASO) titre shows recent infection and can help in patients who do not improve or in those who develop complications. However, some authors state that investigations are cost-effective in terms of reducing unnecessary antibiotics.
- SIGN states that rapid antigen tests detect the presence of Group A streptococcal antigen on a throat swab within a few minutes but they have poor sensitivity and make little impact on prescribing decisions.
- An adolescent or young adult with a nasty sore throat may well have glandular fever. A Paul Bunnell or equivalent blood test may be indicated.
Culture of Group A beta-haemolytic streptococcus (GABS) is inefficient as a diagnostic criterion as it is too slow and it fails to differentiate between infection and carriage. There are 4 Centor Criteria that may be used:
- History of fever.
- Tonsillar exudates.
- No cough.
- Tender anterior cervical lymphadenopathy.
Patients with 1 or none of these criteria are most unlikely to have GABS. Patients with 2 criteria may merit testing, including rapid antigen tests. Antibiotic prescription should be limited to patients with 3 or 4 criteria.
- Upper respiratory tract infections are quite infectious and so sufferers should avoid social contact and stay away from work, especially if feeling unwell.
- Explanation with reassurance that this is a self-limiting condition is sufficient management advice for some patients.
- Gargles are anecdotally helpful but there is no evidence base to support their use.
- 'Watchful waiting' is appropriate for children with mild recurrent sore throats.
- Antipyretic analgesics such as paracetamol and ibuprofen are of value.
- For most patients, antibiotics have little effect on the duration of the condition or the severity of symptoms. The National Institute for Health and Clinical Excellence (NICE) suggests that indications for antibiotics include:
- Features of marked systemic upset secondary to the acute sore throat.
- Unilateral peritonsillitis.
- A history of rheumatic fever.
- An increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency).
- Corticosteroids may be helpful for tonsillitis due to infectious mononucleosis, especially if severe.
Use of antibiotics
Reviews of the literature concur that antibiotics confer no benefit in the majority of patients with sore throat, that the 'numbers needed to treat' warrant a conservative approach in developed countries and that they should be reserved for specific clinical scenarios.
A British study divided children with tonsillitis into 3 groups. One group was given 10 days of antibiotic, the 2nd group was given none and the 3rd group was given a prescription and told to use it only if symptoms did not settle by the 3rd day. There was no difference in outcome between the 3 groups and, in the 3rd group, only 69% used the prescription.
A Cochrane review in 2006 found that there was a trend for protection against acute glomerulonephritis by antibiotics but insufficient cases were recorded to be sure of this effect. Several studies found benefit from antibiotics for acute rheumatic fever, which reduced this complication; however, rheumatic fever is rare in Western societies in the 21st century. Antibiotics reduced the incidence of acute otitis media to about 25% compared with placebo and reduced the incidence of acute sinusitis to about 50% of that in the placebo group. The incidence of quinsy was also reduced.
Symptoms of headache, sore throat and fever were reduced by antibiotics to about 50% but the greatest time for this to be evident was around 3 days when the symptoms of about 50% of untreated patients had settled. About 90% of treated and untreated patients were symptom-free by one week. They concluded that antibiotics confer relative benefits in the treatment of sore throat but the absolute benefits are modest and at the cost of treating many with antibiotics who will derive no benefit. Antibiotics shorten the duration of symptoms but by a mean of only 1 day about half way through the illness (the time of maximal effect) and by about 16 hours overall.
The SIGN guidelines suggest that antibiotics with beta-lactamase activity may be used in patients with group A beta-haemolytic streptococcus as an alternative to surgery, where surgery is contraindicated, or in those who do not want to have the operation.
Choice of antibiotic
- Where antibiotic is thought to be necessary, Penicillin V is the drug of choice (10-day course), as in bacterial infections the organism of concern is the Lancefield's Group A beta-haemolytic streptococcus (GABS) which is still 100% susceptible to penicillin.
- A recent meta-analysis confirmed that a 10-day course was superior to shorter courses in terms of bacterial eradication.
- Macrolides including erythromycin and azithromycin can be used where there is allergy, and a course need be only 5 days.
- They can also be used for treatment failures, which do occur with penicillin. Between 5% and 35% of patients do not have bacteriological eradication. This may be due to commensal infection with bacteria that produce beta lactamase.
- Ampicillin or amoxicillin should not be used because, if the diagnosis is really glandular fever, it will produce a rash.
Referral criteriaNICE has produced guidance on the referral of children with recurrent episodes of acute sore throat, up to the age of 15 years.
- Refer same day for suspected quinsy, or if swelling is causing any airway obstruction, marked swallowing difficulty with dehydration and/or systemic upset.
- Refer urgently (eg within 2 weeks) if there is history of sleep apnoea (daytime sleepiness, failure to thrive), or suspicion of an underlying disorder such as leukaemia.
- Routine referral is appropriate if patients have 5 or more episodes of sore throat in the previous year - significant to affect day-to day activities, or if they have guttate psoriasis exacerbated by acute tonsillitis.
Tonsillectomy dates back to antiquity. Before the NHS, GPs used to perform tonsillectomies on the kitchen table on a Saturday morning. It has received much adverse comment in recent decades but remains a very common ENT operation. Two-thirds of tonsillectomies in the UK are performed on children. Tonsils should not be seen as a useless focus of infection but important lymph tissue that protects the upper airways. Recurrent infection however does alter this situation and chronic tonsillitis can turn tonsillar tissue into a nidus for anaerobic bacteria. Tonsillectomy may help to change the oropharyngeal bacterial profile to a more normal pattern.
Surgery is not a treatment for the acute condition but aimed at reducing the incidence of recurrent infections.
Consistent with the referral advice from NICE, tonsillectomy should be considered if all of the following criteria are met:
- Sore throats are due to tonsillitis.
- The person has 5 or more episodes of sore throat per year.
- Symptoms have been occurring for at least a year.
- The episodes of sore throat are disabling and prevent normal functioning.
SIGN has produced its own criteria for tonsillectomy for children and adults, viz:
- Sore throats are due to acute tonsillitis.
- The episodes of sore throat are disabling and prevent normal functioning.
- Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year; or
- Five or more such episodes in each of the preceding two years; or
- Three or more such episodes in each of the preceding three years.
A six-month period of watchful waiting is appropriate in patients for whom the indications for surgery are not clear-cut.
Surgical methods used
- Cold steel - this is the traditional method which involves removal of the tonsils by blunt dissection followed by haemostasis using ligatures.
- Diathermy - this uses radiofrequency energy applied directly to the tissue. It can be bipolar (the current passes between the two tips of the forceps) or monopolar (the current passes between the forceps' skin and a plate attached to the patient's skin).The heat generated may be used to dissect the tonsils away from the pharyngeal wall and also to promote haemostasis. Diathermy is sometimes used as an adjunct to cold steel surgery to achieve haemostasis.
- Coblation - this involves passing a radiofrequency bipolar electric current through normal saline. The resulting plasma field of sodium ions can be used to dissect tissue by disrupting intercellular bonds and causing tissue vaporisation. This method generates less heat than diathermy.
The conclusions reached by a systematic review of the published evidence was that:
- The mean operating time was shortest for diathermy and longest for coblation.
- The majority of studies looking at time taken to return to a normal diet favoured cold steel over diathermy. Evidence comparing diathermy with coblation was conflicting.
- Data from studies looking at rates of primary haemorrhage (within 24 hours of surgery) were conflicting. One study suggested that this was highest with cold steel and ligature haemostasis. However, a much larger study found the highest rates with monopolar diathermy and coblation.
- Data from studies looking at rates of secondary haemorrhage found the highest rates with diathermy and coblation and the lowest rates for cold steel and ligature haemostasis.
- Complications of tonsillitis and sore throat include otitis media, usually confined to those aged under 5, and sinusitis. Streptococcus spp. is not as fearsome as it was 80-100 years ago. This may be due less to the advent of antibiotics than to the reduced virulence of the organism. Lancefield's Group A beta-haemolytic streptococcus (GABS) can cause rheumatic fever, Sydenham's chorea, glomerulonephritis and scarlet fever. The last is often called scarletina these days to emphasise the much more benign character of the modern disease.
- The association between streptococcal infection and flare-up of guttate psoriasis is well known but it may also have an adverse effect on other forms of psoriasis.
- Enlarged and chronically infected tonsils interfere with children's sleep. Tonsillitis does not seem to cause growth retardation in children but after operation there is higher than expected weight gain.
- Complications of tonsillectomy include otitis media and haemorrhage which can be very difficult, especially where there is an undiagnosed bleeding tendency such as haemophilia. Altered taste sensation has been reported. In the 1950s the operation became less popular because of an outbreak of poliomyelitis. Patients who have had tonsillectomy are more susceptible to bulbar poliomyelitis.
The vast majority of patients will have a full recovery with or without medication. Symptoms resolve within 3 days in 40% of people and within 1 week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection. In otherwise healthy patients with no other pathology, antibiotics provide limited benefit with a high number needed to treat for the benefit of more rapid recovery and reduced incidence of complications. One study found that if tonsillectomy does have to be performed in children it produces a positive and durable increase in 'Health-related Quality of Life' measures.
The children of parents who smoke are more likely to have tonsillitis and to require tonsillectomy.
Further reading & references
- Hoffmann S; The throat carrier rate of group A and other beta hemolytic streptococci among patients in general practice. Acta Pathol Microbiol Immunol Scand. 1985 Oct;93(5):347-51.
- Little P, Williamson I, Warner G, et al; Open randomised trial of prescribing strategies in managing sore throat. BMJ. 1997 Mar 8;314(7082):722-7.
- Management of sore throat and indications for tonsillectomy, Scottish Intercollegiate Guidelines Network - SIGN (April 2010)
- Shah U; Tonsillitis and Peritonsillar Abscess, eMedicine, Apr 2009
- Johnson BC, Alvi A; Cost-effective workup for tonsillitis. Testing, treatment, and potential complications. Postgrad Med. 2003 Mar;113(3):115-8, 121.
- Wright S, Deskin R; Tonsillitis, Tonsillectomy, and Adenoidectomy Grand Rounds Presentation, University of Texas Medical Branch, Dept. of Otolaryngology 2003
- Pichichero ME; Group A beta-hemolytic streptococcal infections. Pediatr Rev. 1998 Sep;19(9):291-302.
- Sore throat - acute; Prodigy (April 2008)
- Hadfield PJ, Birchall MA, Novelli V, et al; The ENT manifestations of HIV infection in children. Clin Otolaryngol Allied Sci. 1996 Feb;21(1):30-6.
- Cooper RJ, Hoffman JR, Bartlett JG, et al; Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001 Mar 20;134(6):509-17.
- Respiratory tract infections, NICE Clinical Guideline (July 2008)
- Del Mar CB, Glasziou PP, Spinks AB; Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000023.
- Falagas ME, Vouloumanou EK, Matthaiou DK, et al; Effectiveness and safety of short-course vs long-course antibiotic therapy for Mayo Clin Proc. 2008 Aug;83(8):880-9.
- Dykhuizen RS, Golder D, Reid TM, et al; Phenoxymethyl penicillin versus co-amoxiclav in the treatment of acute streptococcal pharyngitis, and the role of beta-lactamase activity in saliva. J Antimicrob Chemother. 1996 Jan;37(1):133-8.
- Referral Advice. A guide to appropriate referral from general to specialist services; NICE Clinical Guideline (2001)
- Munir N, Clarke R; Indications for tonsillectomy: the evidence base and current UK practice. Br J Hosp Med (Lond). 2009 Jun;70(6):344-7.
- Karaman E, Enver O, Alimoglu Y, et al; Oropharyngeal flora changes after tonsillectomy. Otolaryngol Head Neck Surg. 2009 Nov;141(5):609-13. Epub 2009 Oct 1.
- Electrosurgery (diathermy and coblation) for tonsillectomy - guidance; IPG150 NICE 2005
- Wardrop P, Weller R, Marais J, et al; Tonsillitis and chronic psoriasis. Clin Otolaryngol Allied Sci. 1998 Feb;23(1):67-8.
- Capper R, Canter RJ; A comparison of sleep quality in normal children and children awaiting (adeno)tonsillectomy for recurrent tonsillitis. Clin Otolaryngol Allied Sci. 2001 Feb;26(1):43-6.
- Camilleri AE, MacKenzie K, Gatehouse S; The effect of recurrent tonsillitis and tonsillectomy on growth in childhood. Clin Otolaryngol Allied Sci. 1995 Apr;20(2):153-7.
- Smithard A, Cullen C, Thirlwall AS, et al; Tonsillectomy may cause altered tongue sensation in adult patients. J Laryngol Otol. 2009 May;123(5):545-9. Epub 2008 Jul 30.
- Schwentner I, Schmutzhard J, Schwentner C, et al; The impact of adenotonsillectomy on children's quality of life. Clin Otolaryngol. 2008 Feb;33(1):56-9.
- Hinton AE, Herdman RC, Martin-Hirsch D, et al; Parental cigarette smoking and tonsillectomy in children. Clin Otolaryngol Allied Sci. 1993 Jun;18(3):178-80.
|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott|
|Last Checked: 26/10/2010||Document ID: 2876 Version: 23||© EMIS|
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