Tonsillitis

What is Tonsillitis?

The tonsils, also known as palatine or faucial tonsils, are located on the sides of your throat. They’re situated between two arch-like structures called the palatoglossal arch at the front and the palatopharyngeal arch at the back. These tonsils, made of lymphatic tissue (the body’s immune cells), are a part of a defence mechanism in your body known as Waldeyer’s ring, along with the adenoids (nasopharyngeal tonsil), tubal tonsil, and lingual tonsil. Their main job is to act as the first line of defense against harmful germs that you may breathe in or swallow.

Tonsillitis, which is an inflammation or swelling of the tonsils, is a common illness and accounts for about 1.3% of doctors’ visits. The main cause of tonsillitis is usually a viral or bacterial infection, and it often causes a sore throat. Tonsillitis that comes on quickly (acute tonsillitis) is diagnosed based on symptoms. However, it can be difficult to tell if it’s caused by bacteria or a virus, but it’s crucial to know because it affects whether or not you need antibiotics to help fight off the infection.

What Causes Tonsillitis?

Tonsillitis, which is an inflammation of the tonsils, usually results from either a viral or bacterial infection. The most common cause is viral, typically by the same types of viruses that cause the common cold, such as rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. These viruses are generally not very harmful and rarely lead to complications. However, other viruses like Epstein-Barr (the one that causes mononucleosis), cytomegalovirus, hepatitis A, rubella, and HIV can also cause tonsillitis.

Bacterial infections also cause tonsillitis, typically from a type of bacteria called group A beta-hemolytic Streptococcus (GABHS). Other types of bacteria, like Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza, can also be responsible. Bacterial tonsillitis can come from both oxygen-loving (aerobic) and oxygen-hating (anaerobic) types of bacteria.

In people who haven’t been vaccinated, Corynebacterium diphtheriae, which causes diphtheria, should be considered as a possible cause. In those who are sexually active, other potential causes can include HIV, syphilis, gonorrhea, and chlamydia. Tuberculosis has also been linked to recurrent tonsillitis, so doctors should assess patients’ risk factors.

Risk Factors and Frequency for Tonsillitis

Visiting a doctor due to a sore throat accounts for approximately 2% of outpatient appointments in the United States. While it’s more common in winter and early spring, it can happen at any time of the year. GABHS, a type of bacteria, is responsible for 5%-15% of adults and 15%-30% of kids between five and fifteen years old suffering from pharyngitis, which is inflammation of the throat. Viruses are the most common cause of this condition in children below five years old. However, it’s very unusual for GABHS to affect children under two years old.

• Approximately 2% of US outpatient visits are due to a sore throat.
• Sore throats occur most frequently in the winter and early spring but can happen anytime.
• GABHS bacteria cause pharyngitis in 5%-15% of adults and 15%-30% of kids aged 5-15.
• Viral pharyngitis is more frequent in children below five years old.
• GABHS is very rare in children under two years old.

Signs and Symptoms of Tonsillitis

Acute tonsillitis is a condition that often causes symptoms like fever, throat pain, and swelling of the tonsils, as well as the development of a whitish-yellow coating on the tonsils. Some people may experience discomfort or difficulty swallowing as a result of the throat swelling. Additionally, the lymph nodes located in the front of the neck can become tender and enlarged.

Doctors examine patients suffering from these symptoms by looking closely at their tonsils to identify key signs like swelling, redness, and any coating or discharge. Part of the examination also includes checking if the tonsils are so enlarged that they obstruct the back of the throat or interfere with swallowing and breathing. In such cases, further tests (like imaging) may be needed to assess how severe the condition is and if there is any risk to the patient’s airway. Any deviation in the uvula’s position can also hint at an abscess in a tonsil, which can be confirmed with a CT scan. Furthermore, doctors also ask about the patient’s vaccination history and sexual activity, and examine the ears and nose.

• Fever
• Throat pain
• Sore Tonsils
• Whitish-yellow coating on tonsils
• Swollen lymph nodes at the front of the neck
• Discomfort or difficulty swallowing

Testing for Tonsillitis

When a doctor suspects tonsillitis, which is an infection of the tonsils, they usually start with a physical examination. They also consider the patient’s risk factors based on a scoring system called the Centor Score. The Centor Score takes into account symptoms like fever, enlarged tonsils, tender neck lymph nodes, and absence of a cough. Each symptom adds one point to the score. The system has been updated to adjust for age, giving an extra point for kids aged 3 to 15 years, and subtracting a point for patients 45 years or older.

Based on the Centor Score, the doctor will determine the next steps. If the patient scores 0 to 1, they usually don’t need more tests or antibiotics. If they score 2 to 3, the doctor might order a rapid strep test or throat culture to confirm the infection. For scores of 4 and above, the doctor usually considers further testing and starting antibiotics treatment.

The rapid strep test is a common way to test for Group A Streptococcus bacteria, which often cause tonsillitis. However, while this test is usually reliable, it may sometimes give a false negative result. In these cases, a throat culture can provide more certainty. Rarely, other infections like gonorrhea, chlamydia, or HIV could cause symptoms similar to tonsillitis, so the doctor might take a swab from the throat for testing just in case. If the doctor suspects mononucleosis, caused by the Epstein-Barr virus, they might also perform a mononucleosis spot test.

In complicated infections, which may include symptoms like unstable vital signs, appearance of being very ill, trouble swallowing, inability to eat or drink, or lockjaw, more extensive tests might be necessary. This might involve a CT scan of the neck with intravenous contrast to rule out serious complications such as an abscess, Lemierre disease, or epiglottitis. Blood tests, including a complete blood count and basic metabolic panel to check kidney function, might also be considered.

Treatment Options for Tonsillitis

Tonsillitis, or inflammation of the tonsils, generally gets better on its own. It’s often caused by viruses, so the best course of treatment is usually to manage the symptoms, not the disease itself. This includes staying hydrated and taking over-the-counter medications like NSAIDs (non-steroidal anti-inflammatory drugs) to alleviate pain.

Short-term use of corticosteroid, a class of drug, can also be beneficial to lessen pain and speed up recovery. Usually, doctors prescribe a single dose of a corticosteroid called dexamethasone. While corticosteroids are generally safe, they should be used carefully in people with certain medical conditions like diabetes. Natural remedies and specific supplements, like zinc gluconate, have not shown consistent or significant benefits.

If doctors suspect that a bacterial infection is causing the tonsillitis, antibiotics might be used. The most common bacterial culprit is Streptococcus pyogenes, and the go-to treatment for this is usually penicillin. For those allergic to penicillin, other antibiotics such as azithromycin or cephalosporins can be used. However, it’s essential to remember that antibiotics come with risks, including bacterial resistance, stomach upset, diarrhea, certain types of infection, and cost. Plus, they only modestly reduce the duration and severity of symptoms.

Some people are more likely to benefit from antibiotics, especially those at high risk of complications like rheumatic heart disease and rheumatic fever. This includes certain groups like native populations in Australia and lower income communities.

People who continually get tonsillitis (defined as five or more episodes in a year) may need further treatment. This could involve a surgical procedure like a tonsillectomy (removal of the tonsils) or tonsillotomy (‘partial’ removal). The American Academy of Otolaryngology, Head, and Neck Surgery provides guidelines on when these surgeries might be the best course of action. While tonsillectomy can offer short-term benefits like fewer sick days and less discomfort, its long-term benefits are less clear.

What else can Tonsillitis be?

When a doctor is trying to diagnose tonsillitis, there are many other medical conditions that they need to consider. These conditions can present similar symptoms and they include:

• Pharyngitis (a type of sore throat)
• Retropharyngeal Abscess (a collection of pus in the back of the throat)
• Epiglottitis (swelling of the flap at the base of the tongue)
• Ludwig Angina (a type of bacterial infection)
• Dental or Peritonsillar Abscess (a collection of pus due to a bacterial infection, found in or around the tonsils)
• Kawasaki Disease (a rare childhood illness that affects the blood vessels)
• Coxsackie Virus (a common virus that can cause painful sores in the throat)
• Primary HIV Infection (the first stage of HIV/AIDS)
• Epstein-Barr Virus (a common virus that can cause mononucleosis)
• Oral Candidiasis (a yeast infection in the mouth and throat)

In order to differentiate between these conditions, the doctor relies on the patient’s medical history and other clinical signs and symptoms.

What to expect with Tonsillitis

The outcome for patients who have acute tonsillitis, when no complications are involved, is generally excellent. Most cases get better on their own in healthy people, leaving minimal lasting effects. However, individuals who frequently experience these infections may need to have surgery. Despite this, their long-term outlook is typically good.

In the era of antibiotics, even those patients who experience complications, such as a peritonsillar abscess (a collection of pus near the tonsils) and Lemierre syndrome (a rare infection that can spread through the bloodstream), have great chances for long-term recovery.

Complications caused by Group A Streptococcus bacteria, such as rheumatic fever and glomerulonephritis, can result in lasting health issues like heart valve disease and reduced kidney function. But these complications are extremely rare in developed countries, thanks largely to the development of penicillin treatment.

If the symptoms of tonsillitis don’t get better, other health problems might be considered. This list includes HIV, tuberculosis, gonorrhea, chlamydia, syphilis, mononucleosis, Kawasaki disease, abscess, and Lemierre syndrome. The overall prognosis in these specific cases will be determined by the specifics of that underlying health issue.

Possible Complications When Diagnosed with Tonsillitis

Tonsillitis usually improves with appropriate treatment, but it can lead to complications. Although uncommon, issues such as abscesses, rheumatic fever, scarlet fever, and acute glomerulonephritis can occur after tonsillitis.

In cases of peritonsillar abscesses, a pus-filled area develops between the muscle at the back of the throat and the tonsil. These are often linked to tonsillitis, but one does not necessarily cause the other. To prevent abscesses, antibiotics are used to treat tonsillitis. Young adults, teenagers, and smokers tend to be more susceptible to these abscesses. Treatment usually involves a mix of antibiotics, steroids, and draining the abscess.

Sometimes tonsillitis can lead to rheumatic fever or heart disease, particularly when it’s caused by group A streptococcus. Rheumatic fever is an inflammation triggered by the immune system in response to the infection. It usually affects kids between 5 and 18 years old. It is hardly seen in developed countries, but is common in developing countries. Symptoms include arthritis, heart inflammation, or Sydenham chorea, which is a disorder of involuntary limb and facial muscle movements, and difficulties in speaking and walking. Erythema marginatum, a skin rash, and subcutaneous nodules might also appear.

An immune disorder called post-streptococcal glomerulonephritis may occur after a strep throat. Symptoms entail swelling, high blood pressure, protein in the urine, low protein levels in the blood, increased inflammation markers, and decreased levels of a key immune system protein called complement. This illness mainly affects children in developing countries, but it can affect everyone, especially in overcrowded conditions. Even though the illness often resolves by itself, older patients might carry a worse prognosis. Antibiotics help to stop the illness from spreading but do not change its course.

Finally, Lemierre disease is a rare complication of throat infections. It typically starts as a simple sore throat, which eventually develops into a severe infection, where blood clots form in the internal jugular vein and septic emboli (tiny blood clots) scatter throughout the body. It commonly results from an infection with Fusobacterium necrophorum, but can occur with Staphylococcal and Streptococcal infections too. With today’s antibiotics, the risk of death is fairly low, though complications such as ARDS (a severe lung condition), bone infection, and meningitis can occur.

Uncommon but Possible Tonsillitis Complications:

• Peritonsillar abscesses
• Rheumatic fever
• Scarlet fever
• Acute glomerulonephritis
• Lemierre disease
• ARDS (severe lung condition)
• Bone infection
• Meningitis

Preventing Tonsillitis

If you’re diagnosed with tonsillitis, your doctor will explain what causes the illness and discuss the details of your diagnosis. They will discuss about antibiotics, how they can help, but also talk about possible side effects. When it comes to throat infections like tonsillitis, many are caused by viruses. This means that antibiotics, which are designed to treat infections caused by bacteria, may not always be necessary. Therefore, your doctor may decide to use a careful strategy when it comes to prescribing antibiotics.

Your doctor will use a guideline called the Centor criteria to help them decide whether a throat infection requires antibiotics or not. They’ll also talk about the course of the disease, how it should progress, and how they plan to manage your symptoms. This can help prevent unnecessary use of antibiotics and return visits to the doctor.

In some serious states, infections like tonsillitis can lead to rheumatic heart disease and rheumatic fever. These can be prevented with antibiotics, most often penicillin. But in developed countries, these serious complications are very rare, so doctors may not always give antibiotics for every case of tonsillitis. Taking antibiotics can reduce the length of the illness by, at most, one day but these medications can have side effects like stomach upset, diarrhea, and even increase the risk of a serious bacterial infection called Clostridium difficile (or C.diff for short).

If your doctor does decide that antibiotics are the best course of treatment, they will discuss this decision with you, so that you understand the reasoning, benefits, and potential risks behind this decision.