Tonsillitis is inflammation of the tonsils
most commonly caused by viral or bacterial infection. Symptoms may include sore throat
and fever. When caused by a bacterium belonging to the group A streptococcus, it is typically
referred to as strep throat. The overwhelming majority of people recover completely, with
or without medication. In 40%, symptoms will resolve in three days, and within one week
in 85% of people, regardless of whether streptococcal infection is present or not. Signs and symptoms
Common signs and symptoms include: sore throat
red, swollen tonsils pain when swallowing
high temperature coughing
chills a general sense of feeling unwell
white pus-filled spots on the tonsils swollen lymph nodes in the neck
pain in the ears or neck Less common symptoms include:
nausea stomach ache
vomiting furry tongue
bad breath voice changes
difficulty opening the mouth In cases of acute tonsillitis, the surface
of the tonsil may be bright red and with visible white areas or streaks of pus.
Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.
Causes The most common cause is viral infection and
includes adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus.
It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or
HIV. The second most common cause is bacterial infection of which the predominant is Group
A β-hemolytic streptococcus, which causes strep throat. Less common bacterial causes
include: Staphylococcus aureus,Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia
pneumoniae, Bordetella pertussis, Fusobacterium sp., Corynebacterium diphtheriae, Treponema
pallidum, and Neisseria gonorrhoeae. Anaerobic bacteria have been implicated in
tonsillitis and a possible role in the acute inflammatory process is supported by several
clinical and scientific observations. Under normal circumstances, as viruses and
bacteria enter the body through the nose and mouth, they are filtered in the tonsils. 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.
Sometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case
called Vincent’s angina or Plaut-Vincent angina. Diagnosis
The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by
swabbing both tonsillar surfaces and the posterior pharyngeal wall and plating them on sheep
blood agar medium. The isolation rate can be increased by incubating the cultures under
anaerobic conditions and using selective growth media. A single throat culture has a sensitivity
of 90%-95% for the detection of GABHS. This small percentage of false-negative results
are part of the characteristics of the tests used but are also possible if the patient
has received antibiotics prior to testing. Identification requires 24 to 48 hours by
culture but rapid screening tests, which have a sensitivity of 85-90%, are available. Older
antigen tests detect the surface Lancefield group A carbohydrate. Newer tests identify
GABHS serotypes using nucleic acid probes or polymerase chain reaction. Bacterial culture
may need to be performed in cases of a negative rapid streptococcal test.
True infection with GABHS, rather than colonization, is defined arbitrarily as the presence of
>10 colonies of GABHS per blood agar plate. However, this method is difficult to implement
because of the overlap between carriers and infected patients. An increase in antistreptolysin
O streptococcal antibody titer 3–6 weeks following the acute infection can provide
retrospective evidence of GABHS infection and is considered definitive proof of GABHS
infection. Increased values of secreted Phospholipase
A2 and altered fatty acid metabolism in patients with tonsillitis may have diagnostic utility.
Treatment Treatments to reduce the discomfort from tonsillitis
symptoms include: pain relief, anti-inflammatory, fever reducing
medications sore throat relief, and iced/cold liquids)
If the tonsillitis is caused by group A streptococcus, then antibiotics are useful with penicillin
or amoxicillin being primary choices. Cephalosporins and macrolides are considered good alternatives
to penicillin in the acute setting. A macrolide such as erythromycin is used for people allergic
to penicillin. Individuals who fail penicillin therapy may respond to treatment effective
against beta-lactamase producing bacteria 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. 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. Chronic cases may
be treated with tonsillectomy as a choice for treatment.
Prognosis Since the advent of penicillin in the 1940s,
a major preoccupation in the treatment of streptococcal tonsillitis has been the prevention
of rheumatic fever, and its major effects on the nervous system and heart. Recent evidence
would suggest that the rheumatogenic strains of group A beta hemolytic strep have become
markedly less prevalent and are now only present in small pockets such as in Salt Lake City.
This brings into question the rationale for treating tonsillitis as a means of preventing
rheumatic fever. Complications may rarely include dehydration
and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and pharyngitis
due to the spread of infection. An abscess may develop lateral to the tonsil
during an infection, typically several days after the onset of tonsillitis. This is termed
a peritonsillar abscess. Rarely, the infection may spread beyond the tonsil resulting in
inflammation and infection of the internal jugular vein giving rise to a spreading septicaemia
infection. In chronic/recurrent cases, or in acute cases
where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy
can be performed to remove the tonsils. Patients whose tonsils have been removed are still
protected from infection by the rest of their immune system.
In strep throat, very rarely diseases like rheumatic fever or glomerulonephritis can
occur. These complications are extremely rare in developed nations but remain a significant
problem in poorer nations. Tonsillitis associated with strep throat, if untreated, is hypothesized
to lead to pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.
References External links