Tonsillitis/Pharyngitis

Question 1

Acute tonsillitis is primarily an infection of which of the following?

1 - adenoid tonsils
2 - palatine tonsils
3 - tubal tonsils
4 - lingual tonsils

Answer 1

2 - palatine tonsils
- located in oropharynx

Can also cause adenoiditis and pharyngitis

Question 2

What is the incidence of tonsillitis?

1 - 5 in 100,000
2 - 50 in 100,000
3 - 500 in 100,000
4 - 5000 in 100,000

Answer 2

3 - 500 in 100,000

Question 3

Does tonsillitis affect males or females more?

Answer 3

• equally affected

Question 4

What age does tonsillitis typically occur?

1 - 1-3 y/o
2 - 1-7 y/o
3 - 6-15 y/o
4 - 10-20 y/o

Answer 4

3 - 6-15 y/o

Question 5

Is bacterial or viral cause of tonsillitis more common?

Answer 5

• viral

viral = 70% of cases
bacterial = 30%

But both can cause them

Question 6

Virus are the most common cause of tonsillitis. All of the following can cause tonsillitis, but which is the most common?

1 - rhinovirus
2 - coronavirus
3 - parainfluenza
4 - adenovirus (4%)
5 - influenza virus type A and B
6 - herpes simplex virus
7 - epstein-Barr virus (glandular fever)

Answer 6

1 - rhinovirus

Rhinovirus, coronavirus and parainfluenza account for 25% of all causes of tonsillitis

Question 7

Which of the following bacteria is the most common bacterial cause of tonsillitis?

1 - Streptococcus pneumoniae
2 - S. aureus
3 - Group B streptococci
4 - Haemophilus influenzae

Answer 7

3 - Group B streptococci

Often referred to as strep throat and causes purulent appearance

Streptococcus pneumoniae is also a common

Question 8

Which of the following does not typically occur in the pathophysiology of tonsillitis?

1 - micro-organisms infiltrate palatine tonsils epithelium
2 - B and T cells phagocytes micro-organisms
3 - macrophages present micro-organisms antigens to B and T cells stimulating an immune response
4 - phospholipase A2 (inflammatory cytokines are produced.
5 - pyrexia, oropharyngeal swelling, pain and erythema occur following immune response

Answer 8

2 - B and T cells phagocytes micro-organisms

Macrophages phagocytose the micro-organisms and present the antigens to B and T cells

Question 9

Patients can have all of the following symptoms in tonsillitis, but which is by far the most common?

1 - coryzal symptoms (nasal congestion, headache, earache, cough).
2 - fever >38ºC
3 - dysphagia
4 - sore throat and refusal of foods
5 - enlarged lymph nodes
6 - odynophagia (painful swallow)

Answer 9

4 - Sore throat and refusal of foods
- occurs in 99% of patients

Question 10

In tonsillitis, is a cough more common if the cause is viral or bacterial?

Answer 10

• viral

If no cough, suspect bacterial cause

Question 11

In tonsillitis, is a high temperature more common if the cause is viral or bacterial?

Answer 11

• bacterial

Question 12

In a patient with tonsillitis, which of the following may be visible upon examining the pharynx?

1 - severely inflamed tonsils
2 - enlarged and painful anterior cervical lymph nodes
3 - purulent tonsils
4 - all of the above

Answer 12

4 - all of the above

Question 13

If there is pus on the tonsils, is this more likely to be bacterial or viral as the cause?

Answer 13

• bacterial

Question 14

Which of the following patients should NOT have a throat examination in someone presenting with symptoms of tonsillitis?

1 - suspect asthma exacerbation
2 - suspect anaphylaxis
3 - suspect epiglottitis
4 - suspect sepsis

Answer 14

3 - suspect epiglottis
- epiglottis folds over when we swallow, blocking the trachea so we do not aspirate food into the lungs

Suspect epiglottis if a young child, muffled voice and excessive drooling and pooling of saliva.

Call for an anaesthetist and an ENT surgeon.

Question 15

Is tonsillitis is suspected, is the diagnosis confirmed with testing or is this clinical diagnosis?

Answer 15

• clinical

Question 16

Although diagnosis is typically clinical, all of the following may be useful, EXCEPT which one?

1 - Blood tests:
2 - FBC, Urea & Electrolytes, CRP
3 - Glandular fever screen
4 - Neck CT
5 - Blood cultures

Answer 16

4 - Neck CT

Glandular fever screen tests for the Epstein-Barr virus

Question 17

Tonsillitis is typically a clinical diagnosis, however, according to NICE, which of the following requires an antigen test in patients who are immunocompromised, such as very old or young, with severe symptoms?

1 - rhinovirus
2 - group A streptococci
3 - influenza virus type A and B
4 - herpes simplex virus
5 - epstein-Barr virus (glandular fever)

Answer 17

2 - group A streptococci

If antigen is negative, then a throat swab should be performed

Question 18

If a child presents with tonsillitis, which 2 scoring systems can be used to help identify the risk of a group A streptococci infection, aka strep throat?

1 - Wells Score
2 - Centor Score
3 - CURB65
4 - FeverPAIN score

Answer 18

2 - Centor Score
4 - FeverPAIN score

Question 19

Which of the following are likely differentials in a patient with suspected tonsillitis?

1 - Viral upper respiratory tract infection
2 - Peritonsillar abscess (quinsy)
3 - Epiglottitis
4 - Retropharyngeal abscess
5 - Primary HIV infection
6 - all of the above

Answer 19

6 - all of the above

Question 20

All of the following are typical treatments for patients with suspected tonsillitis, EXCEPT which one?

1 - antibiotics
2 - reassurance that symptoms will subside <1 week
3 - paracetamol / NSAIDs (oral spray)
4 - adequate fluid intake/ resuscitation
5 - dexamethasone

Answer 20

1 - antibiotics
Typically only used if bacterial confirmed or with a high suspicion, benzylpenicillin is typical choice

Dexamethasone = typically given as a one off IV dose

Fluid resuscitation is important as patients can present with hypovolaemic shock due to lack of fluid intake

Question 21

Antibiotics are not typically used in the treatment of tonsillitis. However, if any of the following criteria are identified they can be used. Which one of the following is NOT one of the NICE guidelines?

1 - marked systemic upset secondary to the acute sore throat
2 - unilateral peritonsillitis abscess (quinsy)
3 - history of rheumatic fever
4 - history of asthma
5 - immunodeficiency
6 - acute sore throat/acute pharyngitis/acute tonsillitis when >3 or more Centor criteria are present

Answer 21

4 - history of asthma

Both the Centor and FeverPAIN criteria are used to quantify the likelihood of isolating Streptococci

Question 22

The CENTOR criteria is used to estimates the probability that pharyngitis is caused by Group A Strep, and suggests management course. Which of the following is NOT one of these criteria?

1 - Haemoptysis
2 - Presence of tonsillar exudate (pus)
3 - Lymphadenopathy
4 - History of fever or pyrexia
5 - Absence of cough

Answer 22

1 - Haemoptysis

Question 23

The CENTOR criteria is used to estimates the probability that pharyngitis is streptococcal, and suggests management course. A CENTOR score greater that what would indicates antibiotics should be prescribed?

1 - >6
2 - >5
3 - >3
4 - >1

Answer 23

3 - >3

IV: Benzypenicillin or PO: Penicillin V (Phenoxymethylpenillin)
Avoid amoxicillin
Type IV Hypersensitivity reaction causing Rash

Question 24

All of the following are potential complications of tonsillitis, but which is the least likely?

1 - Acute otitis media
2 - Acute post-streptococcal glomerulonephritis
3 - Acute sinusitis
4 - Peritonsillar abscess (quinsy)

Answer 24

2 - Acute post-streptococcal glomerulonephritis
- very rare, but patients present with haematuria, oedema, vomiting and anorexia.

Following can also occur but are rare:
- Scarlet fever
- Acute rheumatic fever
- Streptococcal toxic shock syndrome

Question 25

Why should penicillins be avoided if you suspect a patient has glandular fever?

1 - results in anaphylaxis
2 - can cause respiratory depression
3 - leads to systemic rash, suggesting penicillin allergy
4 - need to treat with antivirals

Answer 25

3 - leads to systemic rash, suggesting penicillin allergy

Patients are then identified as having a penicillin allergy

Question 26

A peritonsillar abscess also known as a quinsy is when an abscess forms in the peritonsillar space (between the capsule of the tonsil and the superior constrictor muscle) and is a common complication in tonsillitis. Is this typically unilateral or bilateral?

Answer 26

• unilateral

Causes a hot potato voice and trismus (difficulty opening mouth)

Question 27

What is a peritonsillar abscess also known as a quinsy is when an abscess forms in the peritonsillar space (between the capsule of the tonsil and the superior constrictor muscle) and is a common complication in tonsillitis. Which of the following is NOT a common symptom patients with peritonsillar abscess present with?

1 - sore throat
2 - arthralgia
3 - dehydration
4 - sepsis/systemtic unwell symptoms

Answer 27

2 - arthralgia

Treated in same manner as patients with tonsillitis

Question 28

In a peritonsillar abscess also known as a quinsy, is the treatment always the same as in tonsillitis?

Answer 28

• no

Typically treated in the same way, BUT may also need to aspirate, incision and drain

Can be malignancy in older adults

Question 29

The indications for Tonsillectomy includes all of the following, EXCEPT which one?

1 - sore throats due to acute-tonsillitis
2 - sore throat is disabling and preventing normal functioning
3 - ≥ 7 episodes in the last year
4 - ≥ 5 episodes each year for two years
5 - ≥ 3 episodes each year for three years
4 - haemoptysis

Answer 29

4 - haemoptysis

Other indications for Tonsillectomy:
- recurrent peritonsillar abscesses
- sleep disordered breathing/sleep apnoea