Tonsillitis and tonsillectomy

Question 1

Define tonsillitis.

Answer 1

Acute infection of parenchyma of palatine tonsils. May occur in isolation or as part of generalised pharyngitis.

Question 2

How common is tonsillitis?

Answer 2

Very common - more common in children 5-15yrs

Question 3

What is the aetiology of tonsillitis?

Answer 3

Viral

• Most common - rhinovirus, coronavirus, adenovirus
• Less common - influenza, parainfluenza, enteroirus, herpes virus (EBV if actually infectious mononucleosis)
• Associated with IM infection

Bacterial

• Group A beta-haemolytic streptococci (15-30%)
• Mycoplasma pneumoniae
• Neisseria gonorrhoea

Question 4

What criteria is used to distinguish between viral and bacterial tonsillitis?

Answer 4

FEVERPAIN score (more commonly used)

or

CENTOR criteria

The Centor criteria give an indication of the likelihood of a sore throat being due to bacterial infection. The criteria are:

• Tonsillar exudate
• Tender anterior cervical adenopathy
• Fever over 38°C (100.5°F) by history
• Absence of cough.

If 3 or 4 of Centor criteria are met, the positive predictive value is 40% to 60%. The absence of 3 or 4 of the Centor criteria has a fairly high negative predictive value of 80%.

Question 5

What ia the management if fever pain score is 2-3 vs 4-5?

Answer 5

• FeverPAIN score 2-3: consider delayed antibiotic prescription
• FeverPAIN score 4-5: consider immediate antibiotic prescription

Question 6

What investigations would you do for tonsillitis?

Answer 6

NB: these are usually not done as they are not cost effective compared to treatment based on scoring systems.

• Rapid streptococcal antigen test - usually done first; identification of GABHS
• Throat culture - not necessary, more routine in US; results only in 48hrs

Question 7

What percentage of tonsillitis is bacterial?

Answer 7

10-30%

Question 8

What are the signs of tonsillitis?

Answer 8

• Fever >38oC
• Tonsillar exudate - particularly GABHS, usually bacterial but also common in infectious mononucleosis
• Tonsillar erythema
• Tonsillar enlargement
• Enlarged anterior cervical lymph nodes -

Question 9

What are the symptoms of tonsillitis?

Answer 9

• Pain on swallowing
• Sudden onset sore throat
• Headache
• Nausea
• Abdominal pain
• Cough or runny nose suggest viral

Question 10

What is the management of tonsillitis?

Answer 10

Viral -

• analgesia (paracetamol 500-100mg/4-6hrs, max 4g OR ibuprofen 200-400mg/4-6hrs, max 2.4g)

Bacterial -

• analgesia
• antibiotics - phenoxymethylpenicillin 500mg 2-3 times a day for 10days OR amoxicillin 250-500mg TDS for 10days
• corticosteroids - dexamethasone 10mg IM/IV single dose in severe symptoms

Recurrent episodes -

• tonsillectomy
• antibiotics

Question 11

What are the risk factors for tonsillitis?

Answer 11

• Age 5-15 yrs
• Contact with infected people in enclosed spaces (e.g. child care, schools, prison)

Question 12

What is the importance of the anterior arch? What happens at the *** area?

Answer 12

Abscess collection

Question 13

What are the criteria for tonsillectomy?

Answer 13

SIGN criteria:

• 7+ episodes in one year
• 5+ episodes each year for 2yrs consecutively
• 3+ episodes each year for 3yrs consecutively
• 2+ peritonsillar abscesses ever

Question 14

Which criteria is used to distinguish tonsillitis from quinsy?

Answer 14

Liverpool peritonsillar abscess score

If LPS_>_4 then quinsy>tonsillitis

Question 15

What is shown?

Answer 15

Quinsy - collection of pus in peritonsillar space

Affected tonsil pushed inferomedially into oropharyngeal space

Question 16

What is the management of quinsy?

Answer 16

Analgesia

I&D/aspirate

IV abx

Dex 6.6mg IV, especially if trismus (spasm of jaw muscles, making it shut closed)

Question 17

What are the components of the FeverPAIN score?

Answer 17