Tonsillitis

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Tonsillitis, also described as pharyngitis, refers to inflammation of the pharyngeal tonsils, which are lymph glands located in the back of the throat that are visible through the mouth. Typically, tonsillitis happens suddenly (acute). Some patients experience recurrent acute episodes of tonsillitis, while others develop persistent (chronic) tonsillitis.

Tonsillitis is often caused by viral or bacterial infection (see “What Causes Tonsillitis?” below). Tonsillitis is common in children; most children in the United States experience at least one episode. Antibiotics help treat bacterial tonsillitis, and have significantly reduced complications such as rheumatic fever, a noncontagious acute fever that causes inflammation, especially of the heart, blood vessels, and joints.

What Are the Symptoms of Tonsillitis?

Common symptoms include fever, sore throat, and swollen lymph nodes, but the type of tonsillitis determines what symptoms may occur.

Acute tonsillitis—Tonsillitis most often occurs in children, but rarely in those younger than two-years-old. Symptoms of acute tonsillitis include:

Fever
Sore throat
Bad breath
Difficulty swallowing (called dysphagia)
Painful swallowing (called odynophagia)
Dehydration
Tender lymph nodes in the neck
Mouth breathing, snoring, or sleep apnea
Tiredness, lethargy, and malaise
White patches, pus, and/or redness of the tonsils

A fine red rash over the body suggests that scarlet fever may be complicating a case of tonsillitis. These symptoms usually clear up in three to four days, but may last up to two weeks, even with therapy. Some patients experience recurrent actue tonsillitis in which symptoms return shortly after completing antibiotic therapy.

Chronic tonsillitis—Symptoms of chronic tonsillitis include:

Chronic sore throat
Bad breath
Tonsil stones (debris that has collected on your tonsils)
Persistently tender lymph nodes in the neck

Peritonsillar abscess—Peritonsillar abscess is a severe case of tonsillitis in which an abscess or pocket of pus develops around the tonsil. It is usually found in adolescents and adults, but can occur occasionally in children. Symptoms of peritonsillar tonsillitis include:

Fever
Severe throat pain
Drooling
Difficulty opening the mouth (called trismus)
Muffled voice quality
One tonsil may appear larger than the other

What Causes Tonsillitis?

Up to 70 percent of cases of acute tonsillitis are caused by viruses, which often include adenoviruses, influenza viruses, parainfluenza viruses, enteroviruses, and Mycoplasma. Children and young adults infected with the Epstein-Barr virus (EBV), with infectious mononucleosis, may develop tonsillitis. Herpes simplex virus, cytomegalovirus, and the measles virus have also been associated with tonsillitis.

Bacteria cause 15 to 30 percent of tonsillitis cases. Group A beta-hemolytic streptococcus (GABHS) is the most common bacteria associated with tonsillitis. Bacterial tonsillitis is often referred to as strep throat. It is believed that GABHS is spread through airborne droplets when someone who is infected coughs or sneezes, or through shared food or drinks. Individuals are most infectious early in the course of the disease.

What Are the Treatment Options?

Patients with symptoms of tonsillitis should see their primary care provider or an ENT (ear, nose, and throat) specialist, or otolaryngologist. To determine whether a patient has a viral or bacterial infection, a doctor will typically swab the tonsils or pharynx (rapid strep testing). However, false negatives can occur with this test, so it is recommended that doctors obtain a throat culture in patients with negative rapid strep testing but who also show symptoms of streptococcal disease. Patients with a throat culture that is positive for GABHS, but without tonsillitis symptoms, are likely strep carriers.

Viral tonsillitis usually gets better without additional treatment. Hydration and pain control are important, and hospitalization may be required in severe cases, particularly when a patient becomes dehydrated or has an airway obstruction.

Bacterial tonsillitis is usually treated with antibiotics, which help GABHS tonsillitis get better faster, and prevent complications such as rheumatic fever. Common antibiotics used to treat tonsillitis include penicillins, cephalosporins, macrolides, and clindamycin.

In certain situations determined by your ENT specialist, surgery may be recommended to remove the tonsils. Typically, children who have seven episodes of tonsillitis in one year, or five episodes per year for two consecutive years, or three episodes per year for three consecutive years, are considered candidates for tonsillectomy. If a patient has a severe case of tonsillitis—peritonsillar abscess—surgery may be needed to drain the abscess around the tonsil.

What Questions Should I Ask My Doctor?

What are the common symptoms of tonsillitis?
How do I know if my child is a strep carrier?
What tests are typically performed in a child with suspected tonsillitis?
When can my child return to school and activities following a strep throat infection?
Do all cases of tonsillitis require antibiotic therapy?
When is surgery necessary for the treatment of tonsillitis?

Reference
Mitchell, RB, Archer, SA, Ishman, SL, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg. 2019; February (Suppl).