Tonsillitis

Question 1

What is Waldeyer’s ring?

Answer 1

Collection of lymphatic tissue in pharynx

–> pharyngeal tonsil, 2x tubal tonsils, 2x palatine tonsils, lingual tonsil

Question 2

What is tonsillitis?

Answer 2

Inflammation of palatine tonsils

Question 3

What are the viral and bacterial causes of tonsillitis?

Answer 3

Viral: adenovirus, rhinovirus, influenza, parainfluenza

Bacterial (approx 1/3): S. pyogenes (group A strep - most common), S. aureus, M. catarrhalis

Question 4

What are the symptoms of tonsillitis?

Answer 4

Sore throat
Odynophagia (painful swallowing)
Dysphagia
Earache
Fever
Malaise
Headache
Halitosis

Question 5

What are the signs of tonsillitis?

Answer 5

Swollen, erythematous tonsils +/- purulent exudate
Thick or ‘hot potato’ voice
Trismus (quinsy)
Bilateral cervical lymphadenopathy

Question 6

What is the Centor criteria used for?

Answer 6

In GP to assess for likelihood of bacterial infection

Question 7

What are the features of the Centor criteria?

Answer 7

Consider antibiotics if 2 or more of:

• history of pyrexia
• tonsillar exudate
• no cough
• tender anterior cervical lymphadenopathy

Question 8

How is tonsillitis diagnosed?

Answer 8

Clinically

Only do investigations if complications suspected

Question 9

How is uncomplicated tonsillitis managed?

Answer 9

Analgesia –> topical Difflam spray + paracetamol +/- NSAIDs
Hydration –> may need admitted for IV fluids if cannot swallow
Antibiotics if indicated

Question 10

Which antibiotics are given for a suspected bacterial tonsillitis?

Answer 10

Penicillin 5-7 days

Question 11

Which antibiotics should be avoided in tonsillitis and why?

Answer 11

Amoxicillin

–> causes a rash if patient has glandular fever

Question 12

What are the indications for a tonsillectomy?

Answer 12

• episodes that are disabling + prevent normal functioning
• 7 or more episodes in last year, 5 or more episodes in each of last 2 years, 3 or more episodes in each of last 3 years
• suspected malignancy
• presence of sleep apnoea
• previous quinsy

Question 13

How is a tonsillectomy performed?

Answer 13

Cold steel excision or diathermy

Question 14

What is the main complication after a tonsillectomy?

Answer 14

Bleeding

–> primary (first 24 hours) or secondary (day 4-7)

Question 15

How is bleeding post tonsillectomy managed?

Answer 15

Usually conservatively with antibiotics and hydrogen peroxide mouthwash

Question 16

Which two serious complications are associated with bacterial tonsillitis?

Answer 16

Peritonsillar abscess (quinsy)
Deep neck space infection

Question 17

What are the clinical features of quinsy?

Answer 17

Severe sore throat --> worse on one side
Severe odynophagia
May be stertor + trismus
Examination difficult due to trismus 
--> extensive erythema + soft palate swelling
--> uvula deviated to opposite side

Question 18

How is quinsy managed?

Answer 18

Admit
IV antibiotics
Regular analgesia + topical analgesic throat sprays
Needle aspiration or incision + drainage

Question 19

What is a deep neck space infection?

Answer 19

Infection spreads from tonsils into surrounding potential spaces between fascial planes of the neck

Question 20

What are the two different types of deep neck space infection?

Answer 20

Parapharyngeal abscess –> space posterolateral to nasopharynx (most common)
Retropharyngeal abscess –> space anterior to prevertebral fascia (from necrotising lymph nodes in children)

Question 21

How does deep neck space infection present?

Answer 21

Similar to quinsy but with associated:

• reduced neck movement
• cervical pain
• torticollis in children (asymmetrical head/neck position)

Question 22

Which investigations should be done for deep neck space infection?

Answer 22

CT with IV contrast (gold standard)

Bloods + cultures

Question 23

How is a deep neck space infection managed?

Answer 23

Manage airway if compromised

IV antibiotics + surgical drainage