Tonsillitis

Question 1

What is tonsillitis?

Answer 1

Inflammation due to infection of the tonsils

Question 2

When do the tonsils start to atrophy?

Answer 2

Early adulthood

Question 3

How common is this condition and which age groups does it affect?

Answer 3

It is a very common condition, most frequent in children aged 5-10 years and young adults between 15 and 25 years.

Question 4

Risk factors?

Answer 4

Immune deficiency and a family history of tonsillitis or atopy.

Question 5

Symptoms?

Answer 5

• Pain in the throat is sometimes severe and may last more than 48 hours, along with pain on swallowing.
• Pain may be referred to the ears.
• Small children may complain of abdominal pain.
• Headache.
• Loss of voice or changes in the voice.

Question 6

Signs?

Answer 6

• The throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them.
• Possibly a high temperature.
• Swollen regional lymph glands.
• Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and dysphagia.
• Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior cervical glands.

Question 7

How would you differentiate this between Coxsackie infection of the mouth?

Answer 7

If due to infection with Coxsackievirus, small blisters develop on the tonsils and the roof of the mouth. The blisters erupt in a few days and are followed by a scab, which may be very painful.

Question 8

If one of your differentials is Glandular fever, how could you investigate this?

Answer 8

Monospot test

Question 9

For diagnosis, why do we not culture Group A beta-haemolytic streptococcus (GABS)?

Answer 9

It is inefficient as a diagnostic criterion, as it is too slow and it fails to differentiate between infection and carriage

Question 10

What is the diagnostic criteria? How many of the criteria is needed to indicate antibiotics?

Answer 10

The Centor Criteria is the diagnostic criteria:

• History of fever.
• Tonsillar exudates.
• No cough.
• Tender anterior cervical lymphadenopathy.

Patients with one or none of these criteria are unlikely to have GABS. Consideration of antibiotic prescription should be limited to patients with three or four criteria

Question 11

Indications for antibiotics from NICE?

Answer 11

• Features of marked systemic upset secondary to the acute sore throat.
• Unilateral peritonsillitis.
• A history of rheumatic fever.
• An increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency).
• Acute tonsillitis with three or more Centor criteria present

Question 12

What is the antibiotic of choice? If the patient is penicillin-allergic, what other antibiotic can be used?

Answer 12

The antibiotic of choice is a 5-10 day course of phenoxymethylpenicillin.
Alternative first choices for penicillin allergy or intolerance are clarithromycin or erythromycin.

Question 13

When should you refer a patient to ENT for tonsillectomy?

Answer 13

NICE has recommended that for people with severe recurrent tonsillitis (a frequency of more than seven episodes per year for one year, five per year for two years, or three per year for three years, and for whom there is no other explanation for the recurrent symptoms).

Question 14

When may a patient need hospital admission?

Answer 14

• Breathing difficulty.
• Clinical dehydration.
• Peritonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre’s syndrome (as there is a risk of airway compromise or rupture of the abscess).
• Signs of marked systemic illness or sepsis.
• A suspected rare cause such as Kawasaki disease, diphtheria, or yersinial pharyngitis.

Question 15

What surgical methods can be used in tonsillectomy?1

Answer 15

• Cold steel - this is the traditional method which involves removal of the tonsils by blunt dissection followed by haemostasis using ligatures.
• Diathermy - this uses radiofrequency energy applied directly to the tissue. It can be bipolar (the current passes between the two tips of the forceps) or monopolar (the current passes between the forceps’ skin and a plate attached to the patient’s skin). The heat generated may be used to dissect the tonsils away from the pharyngeal wall and also to promote haemostasis. Diathermy is sometimes used as an adjunct to cold steel surgery to achieve haemostasis.
• Coblation - this involves passing a radiofrequency bipolar electric current through normal saline. The resulting plasma field of sodium ions can be used to dissect tissue by disrupting intercellular bonds and causing tissue vaporisation. This method generates less heat than diathermy.