Tonsilitis Flashcards
Cause
The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.
Other causes:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Present
A typical presentation of acute tonsillitis is with:
Sore throat
Fever (above 38°C)
Pain on swallowing
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).
Scoring
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)
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
Treatment
Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score.
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.
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.
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.
Choice of Antibiotic
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.
Clarithromycin is the usual first-line choice in true penicillin allergy.
Complications
Peritonsillar abscess, also known as quinsy
Otitis media, if the infection spreads to the inner ear
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
Tonsilectomy Indications
The SIGN guidelines (2010) give the indications for tonsillectomy. The number of episodes of acute sore throat they specify for a tonsillectomy are:
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
Other indications are:
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
Tonsilectomy Treatment
Call the ENT registrar and get them involved early
Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch
Keep the patient calm and give adequate analgesia
Sit them up and encourage them to spit out the blood rather than swallowing
Make the patient nil by mouth in case an anaesthetic and operation is required
IV fluids for maintenance and resuscitation, if required
If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required.
Before going back to theatre there are two options for stopping less severe bleeds:
Hydrogen peroxide gargle
Adrenalin soaked swab applied topically
