Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. Complications include peritonsillar abscess (quinsy). Tonsillitis is most commonly caused by a viral infection, and about 5% to 40% of cases are caused by a bacterial infection. When caused by the bacterium group A streptococcus, it is classed as streptococcal tonsillitis also referred to as strep throat. Rarely, bacteria such as Neisseria gonorrhoeae, Corynebacterium diphtheriae, or Haemophilus influenzae may be the cause. Typically, the infection is spread between people through the air. A scoring system, such as the Centor score, may help separate possible causes. Confirmation may be by a throat swab or rapid strep test. Treatment efforts aim to improve symptoms and decrease complications. Paracetamol (acetaminophen) and ibuprofen may be used to help with pain. If strep throat is present the antibiotic penicillin by mouth is generally recommended. In those who are allergic to penicillin, cephalosporins or macrolides may be used. In children with frequent episodes of tonsillitis, tonsillectomy modestly decreases the risk of future episodes. Approximately 7.5% of people experience a sore throat in any three months, and 2% visit a doctor for tonsillitis each year. It is most common in school-aged children and typically occurs in the colder months of autumn and winter. The majority of people recover with or without medication. In 82% of people, symptoms resolve within one week, regardless of whether bacteria or viruses were present. Antibiotics probably reduce the number of people experiencing sore throat or headache, but the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised.
Signs and symptoms
Those with tonsillitis usually experience sore throat, painful swallowing, malaise, and fever. Their tonsils – and often the back of the throat – appear red and swollen, and sometimes give off a white discharge. Some also have tender swelling of the cervical lymph nodes. Many viral infections that cause tonsillitis will also cause cough, runny nose, hoarse voice, or blistering in the mouth or throat. Infectious mononucleosis can cause the tonsils to swell with red spots or white discharge that may extend to the tongue. This can be accompanied by fever, sore throat, cervical lymph node swelling, and enlargement of the liver and spleen. Bacterial infections that cause tonsillitis can also cause a distinct "scarlatiniform" rash, vomiting, and tonsillar spots or discharge. Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.
Causes
Viral infections cause 40 to 60% of cases of tonsillitis. Many viruses can cause inflammation of the tonsils (and the rest of throat) including adenovirus, rhinovirus, coronavirus, influenza virus, parainfluenza virus, coxsackievirus, measles virus, Epstein-Barr virus, cytomegalovirus, respiratory syncytial virus, and herpes simplex virus. Tonsillitis can also be part of the initial reaction to HIV infection. An estimated 1 to 10% of the cases are caused by Epstein-Barr virus. Tonsillitis can also stem from infection with bacteria, predominantly Group A β-hemolytic streptococci (GABHS), which causes strep throat. Bacterial infection of the tonsils usually follows the initial viral infection. When tonsillitis recurs after antibiotic treatment for streptococcus bacteria, it is usually due to the same bacteria as the first time, which suggests that the antibiotic treatment was not fully effective. Less common bacterial causes include: Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, Fusobacterium sp., Corynebacterium diphtheriae, Treponema pallidum, and Neisseria gonorrhoeae. Anaerobic bacteria have been implicated in tonsillitis. Several clinical and scientific observations support a possible role in the acute inflammatory process. Sometimes tonsillitis is caused by an infection of spirochaeta and treponema, which is called Vincent's angina or Plaut-Vincent angina. Within the tonsils, white blood cells of the immune system destroy the viruses or bacteria by producing inflammatory cytokines like phospholipase A2, which also lead to fever. The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx.
Diagnosis There is no firm distinction between a sore throat that is specifically tonsillitis and a sore throat caused by inflammation in both the tonsils and also nearby tissues. An acute sore throat may be diagnosed as tonsillitis, pharyngitis, or tonsillopharyngitis (also called pharyngotonsillitis), depending upon the clinical findings.
In primary care settings, the Centor criteria are used to determine the likelihood of group A beta-hemolytic streptococcus (GABHS) infection in acute tonsillitis and the need for antibiotics for tonsillitis treatment. However, the Centor criteria have their weaknesses in making a precise diagnosis for adults. The Centor criteria are also ineffective for diagnosing tonsillitis in children and secondary care settings (hospitals). A modified version of the Centor criteria, which modified the original Centor criteria in 1998, is often used to aid in diagnosis. The original Centor criteria had four major criteria, but the modified Centor criteria have five. The five major criteria of the modified Centor score are:
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