II. Definitions
- Tonsillitis
- Tonsillar Inflammation
III. Epidemiology
- Incidence: 0.4% of outpatient clinic visits in U.S.
IV. Pathophysiology
- Droplet transmission is primary route of infectious causes
V. Symptoms
- Pharyngitis
- Difficulty taking oral intake
- Difficulty Swallowing secretions
- Otalgia (common innervation of ear and throat)
VI. Signs
- Fever
- Appears ill
- Mucus membranes dry
- Tonsils enlarged, beefy red, and with exudate
- Tender cervical adenopathy
- Splenomegaly in Epstein-Barr Virus
- Palatal Petechiae in Group A Streptococcal Pharyngitis
VII. Differential Diagnosis: Select Causes
- See Pharyngitis Causes for complete Pharyngitis differential
- Viral (70 to 95% of cases)
- Common viruses (e.g. Rhinovirus, Respiratory Syncytial Virus, Adenovirus, Coronavirus)
- Mononucleosis or Mononucleosis-Like Syndrome (Epstein Barr Virus, Cytomegalovirus)
- Acute HIV Infection
- Herpes Simplex Virus
- Coxsackie Virus A (Hand Foot and Mouth Disease)
-
Bacterial
- Group A Streptococcal Pharyngitis (5 to 15% of cases in adults, 15 to 30% of cases in children age 5 to 15 years)
- See Strep Score (Walsh Pharyngitis Criteria, McIsaac Decision Rule, Modified Centor Criteria)
- Still responsible for Acute Rheumatic Fever worldwide (but significantly reduced in U.S. with treatment)
- Other species of Streptococcus (Group C, G) can also cause Tonsillitis, but do not require treatment
- Staphylococcus aureus
- Hemophilus Influenzae (rare in U.S. given Immunizations)
- Gonorrhea
- Peritonsillar Abscess
- Retropharyngeal Abscess
- Lemierre Syndrome or Fusobacterium Necrophorum (Incidence as high as 21% in young adults)
- Diphtheria (rare in U.S. due to Immunizations)
- Ludwig Angina
- Epiglottitis
- Group A Streptococcal Pharyngitis (5 to 15% of cases in adults, 15 to 30% of cases in children age 5 to 15 years)
- Fungal
- Other
VIII. Labs
-
Streptococcal Rapid Antigen Test (with follow-up Throat Culture) or Point-Of-Care GAS Nucleic Acid Amplification Test
- See Group A Streptococcal Pharyngitis for protocols
- Consider Gonorrhea PCR
- Consider Epstein Barr Virus Infection
- Heterophil Agglutination (Monospot Test)
- Peripheral Blood Smear with Atypical lymphocytes
- Liver Function Test Elevation
IX. Imaging
- Indications: Evaluate for complications (e.g. abscess, Epiglottitis, Lemierre Syndrome, Ludwig Angina)
- Hemodynamic instability
- Toxic appearance
- Inability to swallow oral fluids or control secretions
- Trismus
- Asymmetric oropharyngeal swelling
- Modalities
- CT soft tissue neck with contrast
X. Management: General
- See Pharyngitis for symptomatic management
- See Group A Streptococcal Pharyngitis for specific Antibiotics for Streptococcal Pharyngitis
- Consider Dexamethasone single dose orally: 10 mg in adults and 0.6 mg/kg (up to 10 mg) in children
- Unresponsive to medications for Pharyngitis
- Consider Pharyngitis Causes
- Consider Point-Of-Care GAS Nucleic Acid Amplification Test
- Consider Monospot
- Consider STD Causes (Gonorrhea, Acute HIV Infection, HSV)
- Consider empiric Antibiotics for Lemierre Syndrome (Fusobacterium Necrophorum)
- Consider Clindamycin 300 mg orally four times daily (with or without Dexamethasone 10 mg orally once)
- Assess for Peritonsillar Abscess and Retropharyngeal Abscess
- Assess for Laryngeal pathology (e.g. Epiglottitis, Bacterial Tracheitis)
- Consider ENT referral
XI. Management: Tonsillectomy for Recurrent Tonsillitis
- See Tonsillectomy Indications
- Prognosis following Tonsillectomy
- Reduces Pharyngitis frequency (esp. Streptococcus)
- Effect lasts 2-3 years after surgery
XII. Complications
XIII. Resources
- Tonsillitis (Stat Pearls)