Tonsillitis

Question 1

What is Tonsillitis?

Answer 1

Inflammation of the Tonsils; a form of Pharyngitis where there is intense acute inflammation of the tonsils, often with purulent exudate in bacterial tonsillitis.

Question 2

Differential Diagnoses of Tonsillitis (3).

Answer 2

1. Mimic : Infectious Mononucleosis.
2. Bacterial : Cervical Lymphadenopathy.
3. Viral : Headache, Apathy and Abdominal Pain.

Question 3

Epidemiology of Tonsillitis (2).

Answer 3

1. Peak : 5-10 (most) and 15-20.

2. Over 50% are Bacterial with S. pyogenes.

Question 4

Aetiology of Tonsillitis (4).

Answer 4

1. Commonest : Viral.
2. Bacterial : Commonest is Streptococcus pyogenes.
3. Bacterial : 2nd Commonest and commonest of Otitis Media and Rhinosinusitis = S. pneumonia.
4. Bacterial : Other - M. catarrhalis, H. influenza, S. aureus.

Question 5

Why is CENTOR Criteria used in Tonsillitis management?

Answer 5

Used to estimate the probability that Tonsillitis is due to a bacterial infection (whether antibiotics will be needed).

Question 6

What is CENTOR Criteria?

Answer 6

1. Fever above 38C.
2. Tonsillar Exudates.
3. Absence of Cough.
4. Tender Anterior Cervical Lymph Nodes.
   Each 1 gives 1 point.
   A score of 3+ gives a 40-60% probability of bacterial Tonsillitis.

Question 7

What is the alternative scoring system to CENTOR Criteria?

Answer 7

FeverPAIN Score.
1. Fever during the previous 24 hours.
2. Purulence (Pus on Tonsils).
3. Attended within 3 Days of Onset of Symptoms.
4. Inflamed Tonsils.
5. No Cough/Coryza.
Each 1 gives 1 point.
A score of 4-5 gives a 62-65% and a score of 2-3 gives a 34-40% probability of bacterial Tonsillitis.

Question 8

Clinical Features of Acute Tonsillitis.

Answer 8

1. Pharyngitis.
2. Fever.
3. Malaise.
4. Lymphadenopathy.

Question 9

Anatomy of Tonsils (2).

Answer 9

1. Ring of lymphoid tissue in pharynx that make up Adenoids (top), Tubal Tonsils (second top), Palatine Tonsils (sides) and Lingual Tonsils (tongue).
2. Palatine Tonsils are typically infected and enlarged.

Question 10

Pathology of Streptococci (2).

Answer 10

1. Gram-Positive.

2. Alpha-Haemolytic means Partial Haemolysis. Beta-Haemolytic means Complete Haemolysis.

Question 11

Examples of Alpha-Haemolytic Streptococci (2).

Answer 11

1. S. pneumonia (Pneumonia, Meningitis, Otitis Media).

2. S. viridians.

Question 12

Examples of Beta-Haemolytic Streptococci (3).

Answer 12

1. Group A e.g. S. pyogenes (Erysipelas, Impetigo, Cellulitis, Type II Necrotising Fasciitis, Rheumatic Fever, Post-Streptococcal Glomerulonephritis, Toxins = Scarlet Fever).
2. Group B e.g. S. agalactiae (neonatal meningitis and septicaemia).
3. Group D e.g. Enterococcus.

Question 13

Examination of Tonsillitis Patient (3).

Answer 13

1. Red, Inflamed and Enlarged Tonsils.
2. With/out exudates.
3. Otoscopy and Cervical Lymphadenopathy in Kids.

Question 14

Management of Tonsillitis (3).

Answer 14

1. Exclude other serious pathology e.g. Meningitis, Epiglottitis, Peritonsillar Abscess.
2. Use CENTOR Criteria/FeverPAIN Score to calculate efficacy of antibiotics.
3. Delayed Prescription (prescription to be collected if no improvement with viral doubt).

Question 15

Management of Viral Tonsillitis (4).

Answer 15

1. No antibiotics.
2. Parents = Advice and Safety-Netting.
3. Paracetamol (pain) and Ibuprofen (fever).
4. Return if pain has not settled after 3 days or fever rises above 38.3.

Question 16

Management of Bacterial Tonsillitis (4).

Answer 16

1. Penicillin V (Phenoxymethylpenicillin) 500mg QDS 10 Day Course (Syrup in Kids due to taste).
2. Clarithromycin 250-500mg BD for 5 days.
3. Antibiotics indicated if CENTOR is 3+ or FeverPAIN is 4+; risk of serious infections; immunocompromised; co-morbidity; rheumatic fever.

Question 17

Indications of Tonsillectomy (4).

Answer 17

NICE (only if all criteria fulfilled) :

1. Sore throats are due to tonsillitis and not recurrent URTIs.
2. 5+ episodes of sore throat annually.
3. Symptoms occurring for at least 1 year.
4. Episodes are disabling and prevent normal functioning.

Other :

1. Recurrent Febrile Convulsions (secondary to Tonsillitis).
2. Obstructive Sleep Apnoea, Stridor, Dysphagia (secondary to enlarged tonsils).
3. Peritonsillar Abscess (Quinsy) is unresponsive to steroid treatment.

Question 18

Complications of Tonsillectomy (2).

Answer 18

1. Primary (within 24 hours) = Haemorrhage in 2-3% of cases (due to inadequate haemostats) and pain.
2. Secondary (within 1-10 days) = Haemorrhage (due to infection) and pain.

Question 19

Complications of Tonsillitis (7).

Answer 19

1. Chronic Tonsillitis.
2. Quinsy (Peritonsillar Abscess).
3. Otitis Media (infection spreads to inner ear).
4. Scarlet Fever.
5. Rheumatic Fever.
6. Post-Streptococcal Glomerulonephritis.
7. Post-Streptococcal Reactive Arthritis.

Question 20

Clinical Features of Quinsy (4).

Answer 20

1. Severe Throat Pain (Lateralising to 1 Side).
2. Deviation of Uvula (to unaffected side).
3. Trismus (difficulty opening mouth).
4. Reduced neck mobility.

Question 21

Management of Quinsy (3).

Answer 21

1. Needle Aspiration.
2. Incision and Drainage with IV Antibiotics.
3. Tonsillectomy.