Tonsillitis, Causes, Symptoms, Diagnosis, Treatment

Tonsillitis is an inflammation of the pharyngeal tonsils. The inflammation may affect other areas of the back of the throat, including the adenoids and the lingual tonsils. Acute tonsillitis is an infection of the tonsils triggered by one of the several types of bacteria or viruses, and peritonsillar abscesses can also occur. Chronic tonsillitis is a tenacious infection of the tonsils which may result in tonsil stones. Recurrent tonsillitis ensues when an individual suffers from several incidents of tonsillitis per year. Both chronic and recurrent tonsillitis involve repeated occurrences of inflamed tonsils which can impact severely on a patient’s quality of life.[rx,rx]Tonsillitis due to Streptococcus bacteria classically happens in children aged between 5 and 15 years, while viral tonsillitis is more prevalent in younger children.[rx] Multiple studies report that the average prevalence of carrier status of school children for group A Streptococcus is 15.9%.[rx,rx]

Types of Tonsillitis

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Tonsils in humans include, from anterior (front), superior (top), posterior (back), and inferior (bottom)

Type	Epithelium	capsule	Crypts	Location
Adenoids (also termed “pharyngeal tonsils”)	Ciliated pseudostratified columnar(respiratory epithelium)	Incompletely encapsulated	No crypts, but small folds	Roof of pharynx
Tubal tonsils	Ciliated pseudostratified columnar (respiratory epithelium)			Roof of pharynx
Palatine tonsils	Non-keratinized stratified squamous	Incompletely encapsulated	Long, branched^[rx]	Sides of oropharynx between palatoglossal and palatopharyngeal arches
Lingual tonsils	Non-keratinized stratified squamous	Incompletely encapsulated	Long, branched^[rx]	Behind terminal sulcus (tongue)

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Terminology and ICD10 Classification

One problem with comparison of different studies is the di fferent and imprecise terminology. This is evident not only in different countries and different languages, but also within the German literature various terms are called synonymous or different. The following definitions correspond to the majority (teaching) opinion and are used consistently within this paper as such

Acute tonsillitis – English synonyms: severe tonsillitis [rx], true tonsillitis, acute sore throat [rx]; refers to a viral or bacterial tonsillitis with odynophagia, swelling and redness of the tonsils, possibly with tonsillar exudate, cervical lymphadenopathy and fever >38.3°C rectal [rx], [rx]. An odynophagia for 24 to 48 hours, as part of prodromal symptoms of a common cold due to viral infection of the upper respiratory tract, is excluded from the definition of “acute tonsillitis” [rx]. Depending on the stage and appearance of the deposits, or the exudate on the tonsils, one can distinguish the catarrhal angina with redness and swelling of the tonsils (early stage) from the follicular angina with stipple-like fibrin deposits from the lacunar angina with confluent deposits (late stage) [rx], [rx]. The diagnosis of “acute tonsillitis” can be made purely clinical by a specialist [rx]. Smears, blood tests or viral evidence is not necessary in most cases [rx], [rx], [rx], [rx], [rx].
Chronic tonsillitis – English synonyms: chronic (hyperplastic) tonsillitis; although this term yields 1287 hits within a Medline search, it is unclear and misleading and should not be used [rx]. Similarly, the term “Chronic tonsillitis with acute exacerbation”. Here, it seems likely that it is a chronic change in the tonsils with phased acute deterioration [rx]. It is better to speak in such cases of (chronic) recurrent tonsillitis [rx], [rx], because there exists no real chronic tonsillitis with consistent symptoms for more than 4 weeks under adequate treatment and reconstruction of the mucosa (as in rhinosinusitis).
Acute recurrent tonsillitis – English synonyms: recurrent tonsillitis, recurrent throat infections [rx]; refers to recurrences of acute tonsillitis. These are, in contrast to a single attack of acute tonsillitis, usually caused by many different bacterial pathogens [rx], [rx] and flare up again a few weeks after cessation of an antibiotic therapy [rx]. Depending on the frequency and severity of such episodes, there is an indication for tonsillectomy.
Peritonsillar abscess – English synonyms: peritonsillitis; peritonsillar abscess; quinsy [rx], [rx]; called an acute tonsillitis with formation of an abscess, typically on one side [rx]. The abscess may form in the intratonsillar, para-/peritonsillar or retrotonsillar spaces. The pathogens are typically staphylococci [rx], streptococci and fusobacterium necrophorum [rx]. In contrast to acute tonsillitis, viruses play no role in an abscess [rx].
Tonsil hyperplasia – English synonyms: tonsillar hyperplasia [rx], (idiopathic) tonsillar hypertrophy [rx]; refers to the abnormal enlargement of the palatal tonsils. This is to be distinguished from the physiological pediatric palatine tonsil hyperplasia [rx], [rx]. The pediatric tonsil hyperplasia is not a sign or consequence of recurrent inflammation [rx], [172]. Also, children with tonsilar hyperplasia do not suffer with an above average frequency of acute tonsillitis [rx], [rx] or middle ear infections [rx]. A pediatric tonsil is only “pathologically” hyperplastic if one of the cardinal symptoms occur, namely rhonchopathy (with or without OSA), rarely dysphagia84 and even more rarely dysphonia [rx].
Sore throat episodes – English synonyms: acute sore throat, throat infection; here it must be addressed in the context of the international literature, since there are over 16,000 articles, which deal with the unclear and imprecise term. The problem is that the term “sore throat” clinically does not distinguish between acute tonsillitis and pharyngitis. Thus, neither the cause nor the exact location must be determined [rx]. Some authors (including the often cited paper by Paradise, JL [rx]distinguish between “severely affected throat infections” and “moderately affected throat infections” [rx]. It still remains unclear whether it is an acute (bacterial) tonsillitis, which however is solely the basis of the indication for tonsillectomy [rx].
Tonsillectomy – English synonyms: (extracapsular) tonsillectomy; means that the entire tonsil, including its capsule and possibly also parts of the palatal arch, are removed from the tonsillar fossa. There is no longer any lymphatic tissue between the anterior and posterior palatal arch [rx]. Since the late 1960s, with the discovery of the tonsil as a focus of infection [rx], [rx], [rx], [rx], this form of tonsil operation is recognized as the gold standard in the fields and is still cited as the most common surgery in the world [rx] .

Causes of Tonsillitis

Because the tonsils are the first line of defense against invaders from the outside world, they are susceptible to infection themselves. Tonsillitis is typically viral, but can sometimes be bacterial. Whether viral or bacterial, tonsillitis can be contagious and spread from person to person. However, if the condition is caused by a secondary illness, such as sinusitis or hay fever, it is unlikely to be infectious.

Viral causes

Tonsillitis can be caused by bacteria or viruses. Tonsillitis is most commonly caused by a viral infection. The most common types of virus to infect the tonsils are:

Adenovirus – which is associated with the common cold and sore throat.
Rhinovirus – which is the most common cause of the common cold.
Influenza – which is often referred to as flu.
Respiratory syncytial virus – which often causes acute respiratory tract infections.
Coronavirus – which has two subtypes that infect humans ,one of which causes SARS.
Epstein-Barr virus
herpes simplex virus
cytomegalovirus

Bacterial causes

The most common type of bacteria to infect the tonsils is Streptococcus pyogenes. But, less often, it can be caused other species, including

Staphylococcus aureus
Mycoplasma pneumonia
Chlamydia pneumonia
Bordetella pertussis
Fusobacterium
Neisseria gonorrhoeae

Symptoms of Tonsillitis

The typical symptoms of acute tonsillitis include the following

Sore throat
Swollen and very red tonsils with a yellowish coating
Difficulty swallowing
Swollen and painful lymph nodes in the neck
Fever over 38°C (100.4°F)
Headache
Fatigue and tiredness
Loss of appetite
Bad breath
Red, swollen tonsils
White or yellow coating or patches on the tonsils
Difficult or painful swallowing
Fever
Enlarged, tender glands (lymph nodes) in the neck
A scratchy, muffled or throaty voice
Stomachache, particularly in younger children
Stiff neck

Less common symptoms include

nausea
fatigue
stomach ache
vomiting
furry tongue
bad breath (halitosis)
voice changes
difficulty opening the mouth (trismus)
loss of appetite
anxiety/fear of choking

In cases of acute tonsillitis, the surface of the tonsil may be bright red and with visible white areas or streaks of pus.^[rx]Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.^[rx]If it is a viral infection, typical cold symptoms such as a cough or a stuffy nose are likely too. The throat is often inflamed (pharyngitis) as well, not only the tonsils. It is considered to be tonsillitis if the inflammation mostly affects the tonsils. Tonsillitis can also cause atypical symptoms, especially in children. These may include stomach ache, nausea or vomiting.

Diagnosis of Tonsillitis

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Glasgow Benefit Inventory scores

		Total score	General	Social	Physical
Total	Minimum	–25	–29.17	–66.67	–50
	Lower quartile	11.11	8.33	0	33.33
	Median	16.67	16.67	0	33.33
	Arithmetic mean	18.52	18.1	0.17	38.54
	Upper quartile	25	25	0	50
	Maximum	55.56	70.83	50	83.33
Men	Minimum	–22.22	–29.17	–16.67	33.33
	Lower quartile	11.11	8.33	0	33.33
	Median	18.06	16.67	0	33.33
	Arithmetic mean	16.44	15.8	0	35.42
	Upper quartile	22.92	25	0	50
	Maximum	33.33	45.83	16.67	66.67
Women	Minimum	–25	–25	–66.67	–50
	Lower quartile	11.11	8.33	0	33.33
	Median	16.67	16.67	0	33.33
	Arithmetic mean	19.21	18.87	0.23	39.58
	Upper quartile	25	26.04	0	54.17
	Maximum	55.56	70.83	50	83.33

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Treatment of Tonsillitis

At-home care strategies to use during the recovery time include the following:

Encourage rest – Encourage your child to get plenty of sleep.
Provide adequate fluids – Give your child plenty of water to keep his or her throat moist and prevent dehydration.
Provide comforting foods and beverage – Warm liquids — broth, caffeine-free tea or warm water with honey — and cold treats like ice pops can soothe a sore throat.
Prepare a saltwater gargle – If your child can gargle, a saltwater gargle of 1 teaspoon (5 milliliters) of table salt to 8 ounces (237 milliliters) of warm water can help soothe a sore throat. Have your child gargle the solution and then spit it out.
Humidify the air – Use a cool-air humidifier to eliminate dry air that may further irritate a sore throat, or sit with your child for several minutes in a steamy bathroom.
Offer lozenges – Children older than age 4 can suck on lozenges to relieve a sore throat.
Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat.
Treat pain and fever. Talk to your doctor about using ibuprofen (Advil, Children’s Motrin, others) or acetaminophen (Tylenol, others) to minimize throat pain and control a fever. Low fevers without pain do not require treatment.
Except for certain diseases – children and teenagers should not take aspirin because when used to treat symptoms of cold or flu-like illnesses, it has been linked to Reye’s syndrome, a rare but potentially life-threatening condition.

Treatments to reduce the discomfort from tonsillitis include:^[rx]^[1x]^[rx^[rx]^[rx]^[rx]^[rx]

pain and fever reducing medications such as paracetamol (acetaminophen) and ibuprofen. warm salt water gargle, lozenges, or warm liquids. When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however, symptoms may last for up to two weeks.

Antibiotics

If the tonsillitis is caused by group A streptococcus, then antibiotics are useful, with penicillin^[rx] or amoxicillin being primary choices.^[rx] Cephalosporins and macrolides are considered good alternatives to penicillin in the acute setting.^[rx] A macrolide such as azithromycin or erythromycin is used for people allergic to penicillin.
Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria^[rx] such as clindamycin or amoxicillin-clavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can “shield” group A streptococcus from penicillins.^[rx] There is no significant differences in efficacy of various groups of antibiotics in the tonsilitis treatment.^[rx] Intravenous antibiotics can be for those who are hospitalised with inability to swallow and presented with complications. Oral antibiotics can be resumed immediately if the person is clinically improved and able to swallow orally.^[rx]

Painkillers

Paracetamol is recommended for the pain treatment. Although Nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen and opioids such as codeine and tramadol are equally effective, precuations have to be taken because NSAID can cause peptic ulcer disease and is bad for kidneys.
Opioids can cause respiratory depression for those who are vulnerable.^[rx] Similarly, in children, paracetamol and NSAIDs can be used except for codeine need to be used with precautions.^[rx] Anaesthetic mouthwash can also be used for symptomatic relief.^[rx]

Corticosteroids

Corticorsteroids are helpful in the reduction of pain and improvement of symptoms in 24 to 48 hours. Oral corticosteroids are recommended unless the person is unable to swallow medications.^[rx]

Surgery

Chronic cases can be treated with tonsillectomy (the surgical removal of tonsils) as a choice for treatment.^[rx] Children have had only a modest benefit from tonsillectomy for chronic cases of tonsillitis.^[rx]The main goal of treatment is to relieve the symptoms and prevent complications. The following medicines can be used to treat acute tonsillitis
Medication for relieving pain and lowering fever, like ibuprofen or acetaminophen (paracetamol)
Antibiotics (for bacterial tonsillitis only)
Antibiotics can make the tonsillitis go away a little sooner. Also, people who take antibiotics for tonsillitis stop being contagious within 24 hours after starting the treatment. Antibiotics can also lower the risk of developing complications – even though these are rare anyway. Because antibiotics have side effects and only help a little against the symptoms, you can often do without them.

Intraoperative image after extracapsular tonsillectomy on both sides. Bare muscle fibers are apparent. Hemostasis was achieved by swap compression and punctual bipolation.

Tonsillotomy

Partial tonsillectomy, tonsillotomy, means that only the medial portions of the tonsils are removed. This requires that the (well perfused) lymphatic tissues be severed, and the remaining crypts must remain open to the oropharynx [rx], [rx]. Active lymphatic tissue, with secondary follicles and crypts, remains in the tonsillar fossa on both sides [rx].

Intraoperative image after partial removal of the tonsils on both sides with radiofrequency current

Intracapsular tonsillectomy

Intracapsular/subcapsular or subtotal tonsillectomy; describes a method in which the lymphatic active tissue of the tonsil, including all crypts and follicles, is removed [rx], [rx]. However, the capsule of the tonsil is not broken and thus the underlying muscles are not exposed [rx]. At the end of the operation there is an empty tonsillar fossa without the typical scarring [rx]. A closer look at the literature, however, is striking that the intracapsular tonsillectomy is partially equated with tonsillotomy [rx], [rx], [rx], [rx], [rx], [rx].

Postoperative image of the left side 3 months after intracapsular tonsillectomy

Cryptolysis

Describes a procedure in which the tonsil tissue ring is laid bare around the crypt superficially and the crypt shrinks in the course. The lymphatic active tissue remains present and still intact. Most authors state that this intervention is to be performed on an outpatient basis under local anaesthesia and with the CO₂ or diode laser or radio-frequency current [rx], [rx], [rx], [rx], [rx]. Indications should be tonsil stones or foetor from the mouth.

Thermal or cryotherapy of the palatine tonsils

Synonyms, or techniques – interstitial (electro)coagulation to the palatine tonsils, laser coagulation, thermal coagulation, cryocoagulation [rx], [rx], photodynamic therapy, ultrasound therapy [rx], radiofrequency-induced thermotherapy [rx], temperature-controlled tonsil treatment [rx], [rx], tonsil thermotherapy; means that the tonsil tissue defined interstitially is heated (or cooled) and then scarring subsequently results in shrinkage of the lymphatic tissue. Most authors see the indications with hyperplastic tonsils. No tissue is removed and a large part of the lymphatic tissue remains allegedly functional.

References

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