Tonsilitis

Question 1

What is tonsilitis?

Answer 1

Inflammation and infection of the palatine tonsils. Note the same organisms can also cause acute pharyngitis which is simply inflammation of the oropharynx and is what we call a common cold if viral.

Question 2

What causes tonsilitis?

Answer 2

Viral 70% - Adenovirus, Coronavirus, Rhinovirus, Parainfluenza virus, Influenza type A and B, herpes simplex virus and Epstein-barr virus (glandular fever).

Bacterial 30% – Group A beta haemolytic strep, Haemophilus influenza, staphylococci and Escherichia coli. Strep pyogenes is most common and can also cause scarlet fever if it produces erythrogenic toxins.

Question 3

Describe the signs and symptoms of tonsilitis

Answer 3

If cold like symptoms, then likely viral (dry cough, runny nose etc.)
If puss, lymphadenopathy (jugulodigastric lymph node) and lack of URTI symptoms, then likely bacterial
Dysphagia and odynophagia
Otalgia as a referred pain

If tonsillar enlargement is unilateral think quinsy or cancer

Question 4

How should suspected tonsilitis be investigated?

Answer 4

Throat swab and Rapid strep test but neither are routine

Question 5

Describe the centor criteria

Answer 5

One point for each criterion met – the more points the more likely it is bacteria

1. Cough absent (can’t cough)
2. Tonsillar Exudate
3. Tender cervical lymphadenopathy
4. Temperature

Question 6

Describe the Fever PAIN criteria

Answer 6

1. Fever over 38
2. Purulence (pharyngeal or tonsillar exudate)
3. Attend rapidly (3 days or less)
4. Severely inflamed tonsils
5. Cough or coryza

Question 7

How should tonsilitis be managed?

Answer 7

Paracetamol and ibuprofen
Warm salt water gargles
If viral then usually self-limiting

If bacterial (Centor 3-4 or FeverPAIN 4 to 5) may need antibiotics – Phenoxymethylpenicillin or clarithromycin/erythromycin if penicillin allergic. Can give delayed antibiotics if unsure.

Question 8

What management can be offered to chronic tonsillitis sufferers?

Answer 8

In chronic cases a tonsillectomy may be indicated if all of these criteria are met.
Must be certain that the recurrent infections are due to tonsillitis, that they are disabling and prevent normal function, 7 events in last year or 5 per year for 2 years or 3 per year for 3 years.

Question 9

What complications can occur from tonsillitis?

Answer 9

Quinsy – sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus (hot potato moth open) and muffled voice. Antibiotics and aspiration by ENT specialist is needed.

Parapharyngeal abscess – serious but rare, diffuse swelling in the neck. US to identify then incise and drain under GA
Lemierre syndrome – acute sepsis and jugular vein thrombosis due to infection with fusobacterium species and a septic embolus.
Otitis media

Question 10

What is quinsy?

Answer 10

Quinsy (Peritonsillar abscess)
Definition – rare and dangerous side effect of tonsillitis resulting in an abscess that forms between one of your tonsils and the wall of your throat.

Question 11

What causes quinsy?

Answer 11

Usually because of severe strep pyogenes Tonsillitis. Can also be staph aureus and Haemophilus Influenza.

Question 12

What are the signs and symptoms of quinsy?

Answer 12

Deviated uvula away from lesion 
Drooling due to dysphagia 
Unilateral
Hot potatoe voice
Referred ear pain 
Trismus (inability to open mouth)

Question 13

How should quinsy be investigated?

Answer 13

Medical imaging to rule our complications such as CT and MRI

Complications
Retropharyngeal abscess
Mediastinitis
Sepsis

Question 14

How are quinsy’s managed?

Answer 14

Drainage by ENT surgeon due to internal carotid artery proximity
IV Antibiotics
Steroids sometimes useful

Question 15

What is adenoiditis?

Answer 15

Infection and inflammation of the pharyngeal tonsils. Children mostly as the adenoids are prominent in children and atrophy after puberty.

Question 16

What are the causes of infection in adenoiditis?

Answer 16

If viral recedes within 48 hours – adenovirus, rhinovirus and paramyxovirus
Bacteria – strep pyogenes, strep pneumoniae, Moraxella Catarrhalis and many staphylococcus types

Question 17

What are the signs and symptoms of adenoiditis?

Answer 17

Mouth breathing
Nasal tone to speech
May result in middle ear infections due to blockage of pharyngotympanic canal
Fever, runny nose

Question 18

What investigations can be done for adenoiditis if uncertain?

Answer 18

If uncertain can use optical fibre endoscopy to visualise inflammation

Question 19

What management should be offered for adenoiditis?

Answer 19

If viral then analgesics and antipyretics

If bacterial then antibiotics

Question 20

What complications can occur from adenoiditis?

Answer 20

Due to drainage of these nodes to the retropharyngeal lymph nodes this can lead to a retropharyngeal abscess and spread to the mediastinum

Question 21

What is the management for acute airway obstruction in adults?

Answer 21

• Give oxygen – Heliox is preferred as it contained helium and so is less dense requiring less work to breath with
• Nebulised adrenaline with saline
• Take standard obs
• Call on call ENT registrar and anaesthetist to help

Endotracheal intubation – first line intervention, move on quickly if this doesn’t work
In emergency – cricothyroidotomy – temporary measures pending formal tracheostomy. A wide bore cannula is inserted through the cricothyroid membrane and can sustain life for 30-45 mins

Question 22

Discuss hemorrhages as a post tonsillectomy complications and how they should be managed?

Answer 22

ENT should assess all post-tonsillectomy haemorrhages.

Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.

Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.

Question 23

What pain is normal post tonsillectomy?

Answer 23

The pain may increase for up to 6 days following a tonsillectomy.