Tonsillitis (Acute and Chronic)

Tonsillitis is inflammation due to infection of the tonsils. Pharyngitis is inflammation of the oro-pharynx but not 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:¹
  • 10.9% aged 14 or less
  • 2.3% aged 15 to 44
  • 0.6% aged 45 and over
• A GP with a list of 2000 can expect to see around 120 cases of sore throat a year with considerable seasonal variation - see sore throat record. General practices taking part in the Fourth National Morbidity Survey reported a consultation rate of 0.1 per capita annually.² SIGN suggest that only 1 patient in 18 with a sore throat will consult.³

Symptoms

• 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
• Headache
• Loss of voice or changes in the voice

Signs

• 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 to 30% of patients present with classical disease

It is diagnosed too frequently leading to unnecessary 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 Coxsackie virus infection, small blisters develop on the tonsils and 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 due to a virus or a 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 commonest presentations are cervical lymphadenopathy, oro-oesophageal candidiasis and otitis media.⁷

• 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.⁸
• Antistreptolysin O (ASO titre) shows recent infection and can help in patients who do not improve or develop complications. However, some authors state that investigations are cost effective in terms of reducing unnecessary antibiotics.⁹
• 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.³
• 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 Streptococci (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.¹⁰

Non-drug

• Upper respiratory tract infections are quite infectious and so sufferers should avoid social contact and stay away from work, especially if feeling unwell.
• Explanation and 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.

Drugs

• 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.
  NICE suggests that indications for antibiotics include:¹²
  • 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)

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.²

A Cochrane Review found that there was a trend for protection against acute glomerulonephritis by antibiotics, but insufficient cases were recorded to be sure of this effect.¹³ Several studies found benefit from antibiotics for acute rheumatic fever, which reduced this complication but 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. An updated review in 2006 reached the same conclusions.¹⁴

Choice of antibiotic

Referral for specialist opinion¹⁷

NICE suggest referring children up to the age of 15 for specialist advice in the following circumstances:

• The patient has, or is suspected of having, a quinsy.
• The swelling is causing acute upper airways obstruction.
• The swelling is interfering with swallowing, causing dehydration and marked systemic upset
• There is a history of sleep apnoea, daytime somnolence and failure to thrive.
• The child has had five or more episodes of acute sore throat documented in the preceding 12 months, and these episodes have been severe enough to disrupt their normal behaviour or day-to-day activity.
• The patient has guttate psoriasis which is exacerbated by recurrent tonsillitis.
• There is suspicion of a serious underlying disorder such as leukaemia.

Surgical

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. Tonsils should not be seen as a useless focus of infection but important lymph tissue that protects the upper airways.

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:⁸

• Sore throats are due to tonsillitis.
• The person has five 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.

Surgical methods used¹²

• 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 (current passes between the two tips of the forceps) or monopolar (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 lowest rates for cold steel and ligature haemostasis.

• Complications of tonsillitis and sore throat include otitis media, usually confined to those under 5, and sinusitis. Streptococcus spp. is not as fearsome as it was 80 to 100 years ago. This may be less due to the advent of antibiotics than the reduced virulence of the organism. Lancefield GABS can cause rheumatic fever, Sydenham's chorea, glomerulonephritis and scarlet fever. The last is often called scarletina these days to emphasis 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.¹⁸
• Enlarged and chronically infected tonsils interfere with children's sleep.¹⁹ Tonsillitis does not seem to cause growth retardation in children but after operation there is higher than expected weight gain.²⁰
• Complications of tonsillectomy include otitis media and haemorrhage that can be very difficult, especially where there is an undiagnosed bleeding tendency such as haemophilia. In the 1950s the operation became less popular because of an outbreak of poliomyelitis. Patients who have had tonsillectomy are more susceptible to bulbar polio.

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.¹⁴

The children of parents who smoke are more likely to have tonsillitis and to require tonsillectomy.²¹