Tonsilitis Flashcards
What is tonsilitis?
Tonsillitis refers to inflammation of the tonsils.
What is the most common cause of tonsilitis?
The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.
What bacteria cause tonsilitis?
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.
Other causes:
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
What is Waldeyer’s tonsillar ring?
In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils on either side at the back of the throat.
What are the clinical features of tonsilitis?
A typical presentation of acute tonsillitis is with:
- Sore throat
- Fever (above 38°C)
- Pain on swallowing
How does tonsilitis present on examination?
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).
Briefly describe the CENTOR criteria
The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics.
A score of 3 or more gives a 40-60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present:
- Fever over 38ºC
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymph nodes (lymphadenopathy)
Briefly describe FeverPAIN score
The FeverPAIN score is an alternative to the Centor criteria.
A score of 2-3 gives a 34- 40% probability and 4-5 gives a 62-65% probability of bacterial tonsillitis:
- Fever during previous 24 hours
- P- purulence (pus on tonsils)
- A- attended within 3 days of the onset of symptoms
- I- inflamed tonsils (severely inflamed)
- N- no cough or coryza
When should someone be admitted to hospital with tonsilitis?
Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
What scoring criteria is used to assess tonsilitis?
When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score.
Briefly describe the management of viral tonsilitis
Educate patients with likely viral tonsillitis and give safety net advice about when to seek medical advice. Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered.
When should antibiotics be prescribed?
Note: using the CENTOR criteria or FeverPAIN
Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever.
When is a delayed prescription appropriate?
Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.
What antibiotics are used for tonsilitis?
Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.
What antibiotics are used for tonsilitis if penicillin allergic?
Clarithromycin is the usual first-line choice in true penicillin allergy.
