Definitions

Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually

extendstotheadenoidandthelingualtonsils;therefore,thetermpharyngitismayalso
be used. Pharyngotonsillitis and adenotonsillitis are considered equivalent for the
purposes of this article. Lingual tonsillitis refers to isolated inflammation of the
lymphoidtissueatthetonguebase.

A"carrierstate"isdefinedbyapositivepharyngealcultureofgroupAbetahemolytic
Streptococcus pyogenes (GABHS), without evidence of an antistreptococcal
immunologicresponse.

PathophysiologyandEtiology
Viral or bacterial infections and immunologic factors lead to tonsillitis and its
complications.Overcrowdedconditionsandmalnourishmentpromotetonsillitis.Most
episodesofacutepharyngitisandacutetonsillitisarecausedbyvirusessuchasthe
following:
Herpessimplexvirus
EpsteinBarrvirus(EBV)
Cytomegalovirus
Otherherpesviruses
Adenovirus
Measlesvirus

In one study showing that EBV may cause tonsillitis in the absence of systemic
mononucleosis,EBVwasfoundtoberesponsiblefor19%ofexudativetonsillitisin
children.

Bacteriacause1530%ofcasesofpharyngotonsillitis.Anaerobicbacteriaplayan
importantroleintonsillardisease.Mostcasesofbacterialtonsillitisarecausedby
groupAbetahemolytic Streptococcuspyogenes (GABHS). Spyogenes adheresto
adhesinreceptorsthatarelocatedonthetonsillarepithelium.Immunoglobulincoating
ofpathogensmaybeimportantintheinitialinductionofbacterialtonsillitis.

Mycoplasmapneumoniae,Corynebacteriumdiphtheriae,andChlamydiapneumoniae
rarelycauseacutepharyngitis.Neisseriagonorrheamaycausepharyngitisinsexually
activepersons. Arcanobacteriumhaemolyticum isanimportantcauseofpharyngitis
inScandinaviaandtheUnitedKingdombutisnotrecognizedassuchintheUnited
States. A rash similar to that of scarlet fever accompanies A haemolyticum
pharyngitis.

Recurrenttonsillitis

A polymicrobial flora consisting of both aerobic and anaerobic bacteria has been
observedincoretonsillarculturesincasesofrecurrentpharyngitis,andchildrenwith
recurrentGABHStonsillitishavedifferentbacterialpopulationsthanchildrenwho
havenothadasmanyinfections.Othercompetingbacteriaarereduced,offeringless
interferencetoGABHSinfection.Streptococcuspneumoniae,Staphylococcusaureus,
and Haemophilus influenzae are the most common bacteria isolated in recurrent
tonsillitis,andBacteroidesfragilisisthemostcommonanaerobicbacteriumisolated
inrecurrenttonsillitis.

Themicrobiologiesofrecurrenttonsillitisinchildrenandadultsaredifferent;adults
show more bacterial isolates, with a higher recovery rate of Prevotella species,
Porphyromonas species, and B fragilis organisms , whereas children show more
GABHS.Also,adultsmoreoftenhavebacteriathatproducebetalactamase.

Chronictonsillitis

Apolymicrobialbacterialpopulationisobservedinmostcasesofchronictonsillitis,
withalphaandbetahemolyticstreptococcalspecies, Saureus,Hinfluenzae, and
Bacteroidesspecieshavingbeenidentified.Astudythatwasbasedonbacteriologyof
thetonsillarsurfaceandcorein30childrenundergoingtonsillectomysuggestedthat
antibioticsprescribed6monthsbeforesurgerydidnotalterthetonsillarbacteriology
at the time of tonsillectomy. [4] A relationship between tonsillar size and chronic
bacterialtonsillitisisbelievedtoexist.Thisrelationshipisbasedonboththeaerobic
bacterialloadandtheabsolutenumberofBandTlymphocytes.Hinfluenzaeisthe
bacteriummostoftenisolatedinhypertrophictonsilsandadenoids.Withregardto
penicillin resistance or betalactamase production, the microbiology of tonsils
removedfrompatientswithrecurrentGABHSpharyngitishasnotbeenshowntobe
significantly different from the microbiology oftonsilsremovedfrom patients with
tonsillarhypertrophy.

Localimmunologicmechanismsareimportantinchronictonsillitis.Thedistribution
ofdendriticcellsandantigenpresentingcellsisalteredduringdisease,withfewer
dendriticcellsonthesurfaceepitheliumandmoreinthecryptsandextrafollicular
areas.Studyofimmunologicmarkersmaypermitdifferentiationbetweenrecurrent
andchronictonsillitis.Suchmarkersinonestudyindicatedthatchildrenmoreoften
experience recurrent tonsillitis, whereas adults requiring tonsillectomy more often
experiencechronictonsillitis.
Radiation exposure may relate to the development of chronic tonsillitis. A high
prevalenceofchronictonsillitiswasnotedfollowingtheChernobylnuclearreactor
accidentintheformerSovietUnion.

Peritonsillarabscess

Apolymicrobialfloraisisolatedfromperitonsillarabscesses(PTAs).Predominant
organisms are the anaerobes Prevotella, Porphyromonas, Fusobacterium, and
Peptostreptococcusspecies.MajoraerobicorganismsareGABHS, Saureus,and H
influenzae.

Uhler et al, in an analysis of data from 460 patients with PTA, found a higher
incidenceoftheconditioninsmokersthaninnonsmokers.

Epidemiology
Tonsillitis most often occurs in children; however, the condition rarely occurs in
childrenyoungerthan2years.Tonsillitiscausedby Streptococcus speciestypically
occursinchildrenaged515years,whileviraltonsillitisismorecommoninyounger
children.Peritonsillarabscess(PTA)usuallyoccursinteensoryoungadultsbutmay
presentearlier.

Pharyngitisaccompaniesmanyupperrespiratorytractinfections.Between2.5%and
10.9%ofchildrenmaybedefinedascarriers.Inonestudy,themeanprevalenceof
carrierstatusofschoolchildrenforgroupAStreptococcus,acauseoftonsillitis,was
15.9%.[7,8]

According to Herzon et al, children account for approximately one third of

peritonsillar abscess episodes in the United States. [9] Recurrent tonsillitis was
reportedin11.7%ofNorwegianchildreninonestudyandestimatedinanotherstudy
toaffect12.1%ofTurkishchildren.[10]

Klugfoundseasonaland/oragebasedvariationsintheincidenceandcauseofPTA.
Among his conclusions, he reported that the incidence of PTA increased during
childhood, peaking in teenagers and then gradually falling until old age. He also
found that until age 14 years, girls were more affected than boys, but that the
conditionsubsequentlywasmorefrequentinmalesthaninfemales.[11]

KlugalsofoundasignificantlyhigherincidenceofFusobacteriumnecrophorumthan
of group A Streptococcus in patients aged 1524 years with PTA. However, the
incidenceofgroupAStreptococcuswassignificantlyhigherthanFnecrophorumin
childrenaged09yearsandinadultsaged3039years.[11]

AlthoughKlugdeterminedthattheincidenceofPTAdidnotsignificantlyvaryby
season,thepresenceofgroupA Streptococcus wassignificantlymorefrequentin
winterandspringthaninsummer,while Fnecrophorum tendedtobefoundmore
ofteninsummerthaninwinter.

History
Thepatient'shistorydeterminesthetypeoftonsillitis(ie,acute,recurrent,chronic)
thatispresent.
Individualswithacutetonsillitispresentwithfever,sorethroat,foulbreath,dysphagia
(difficultyswallowing),odynophagia(painfulswallowing),andtendercervicallymph
nodes. Airway obstruction may manifest as mouth breathing, snoring, sleep
disordered breathing, nocturnal breathing pauses, or sleep apnea. Lethargy and
malaisearecommon.Symptomsusuallyresolvein34daysbutmaylastupto2
weeksdespiteadequatetherapy.
Recurrent streptococcal tonsillitis is diagnosed when an individual has 7 culture
provenepisodesin1year,5infectionsin2consecutiveyears,or3infectionseach
yearfor3yearsconsecutively.Individualswithchronictonsillitismaypresentwith
chronicsorethroat,halitosis,tonsillitis,andpersistenttendercervicalnodes.Children
aremostsusceptibletoinfectionbythoseinthecarrierstate.
Individualswith peritonsillarabscess(PTA) presentwithseverethroatpain,fever,
drooling,foulbreath,trismus(difficultyopeningthemouth),andalteredvoicequality
(thehotpotatovoice).
PhysicalExamination
Physicalexaminationshouldbeginbydeterminingthedegreeofdistressregarding
airwayandswallowingfunction.Examinationofthepharynxmaybefacilitatedby
openingthemouthwithouttongueprotrusion,followedbygentlecentraldepression
ofthetongue.Fullassessmentoforalmucosa,dentition,andsalivaryductsmaythen
beperformedbygently"walking"atonguedepressoraboutthelateraloralcavity.
Flexiblefiberopticnasopharyngoscopymaybeusefulinselectedcases,particularly
withseveretrismus.(Theimagesbelowdepicttheoralexamination.)

Acutetonsillitis

Physicalexaminationinacutetonsillitisrevealsfeverandenlargedinflamedtonsils
that may have exudates. Group A betahemolytic Streptococcus pyogenes and
EpsteinBarr virus (EBV) can cause tonsillitis that may be associated with the
presence of palatal petechiae. Group A betahemolytic Streptococcus (GABHS)
pharyngitisusuallyoccursinchildrenaged515years.

Openmouthbreathingandvoicechange(ie,athickerordeepervoice)resultfrom
obstructivetonsillarenlargement.Thevoicechangewithacutetonsillitisisusually
not as severe as that associated with peritonsillar abscess (PTA). In PTA, the
pharyngealedemaandtrismuscauseahotpotatovoice.

Tender cervical lymph nodes and neck stiffness are observed in acute tonsillitis.
Examine skin and mucosa for signs of dehydration. Consider infectious
mononucleosis duetoEBVinanadolescentoryoungerchildwithacutetonsillitis,
particularly when it is accompanied by tender cervical, axillary, and/or inguinal
nodes; splenomegaly; severe lethargy and malaise; and lowgrade fever. A gray
membranemaycovertonsilsthatareinflamedfromanEBVinfection(seetheimage
below).Thismembranecanberemovedwithoutbleeding.Palatalmucosalerosions
andmucosalpetechiaeofthehardpalatemayalsobeobserved.

HSVpharyngitis

Anindividualwithherpessimplexvirus(HSV)pharyngitispresentswithred,swollen
tonsilsthatmayhaveaphthousulcersontheirsurfaces.Herpeticgingivalstomatitis,
herpeslabialis,andhypopharyngealandepiglotticlesionsmaybeobserved.

Peritonsillarabscess

Physicalexaminationofaperitonsillarabscess(PTA)almostalwaysrevealsunilateral
bulgingaboveandlateraltooneofthetonsils.Trismusisalwayspresentinvarying
severity. The abscess rarely is located adjacent to the inferior pole of the tonsil.
InferiorpolePTAisadifficultdiagnosistomake,andradiologicimagingwitha
contrastenhanced CT scan is helpful. Tender cervical adenopathy and torticollis
(neckturnedinthecockrobinposition)maybepresent.Ipsilateralotalgiamaybe
observed.
Complications
Bevigilantforsignsofimpendingcomplicationsfromtonsillitis(eg,mentalstatus
changes,severetrismus,highfevers).Whennecessary,performfurthertestsorother
diagnostic evaluations (eg, CBC counts, CT scanning) in patients with signs of
impendingcomplicationsfromtonsillitis.

Treatment of suspected streptococcal pharyngitis with appropriate antibiotics may

leadtocomplications,suchasacuterheumaticfeverandglomerulonephritis.

Acutetonsillitis

Untreatedorincompletelytreatedtonsillitiscanleadtopotentiallylifethreatening
complications.Acuteoropharyngealinfectionscanspreaddistallytothedeepneck
spacesandthenintothemediastinum.Suchcomplicationsmayrequirethoracotomy
and cervical exposure for drainage. Spread beyond the pharynx is suspected in
personswithsymptomsoftonsillitiswhoalsohavehighorspikingfevers,lethargy,
torticollis,trismus,orshortnessofbreath.Radiologicimagingusingplainfilmsofthe
lateralneckorCTscanswithcontrastiswarrantedforpatientsinwhomdeepneck
spreadofacutetonsillitis(beyondthefascialplanesoftheoropharynx)issuspected.

Themostcommoncomplicationisadjacentspreadjustbeyondthetonsillarcapsule.
Peritonsillar cellulitis develops when inflammation spreads beyond the lymphoid
tissueofthetonsiltoinvolvetheoropharyngealmucosa.Peritonsillarabscess(PTA),
historicallyreferredtoasquinsy,iscausedbypurulencetrappedbetweenthetonsillar
capsule and the lateral pharyngeal wall; the superior constrictor muscle primarily
comprisesthelateralpharyngealwallinthisarea.Mostoften,PTAspreadsintothe
retropharyngeal space or into the parapharyngeal space. Spread may result in
necrotizingfasciitis.TreatmentincludesIVantibiotics,surgicaldebridement,and,in
cases of associated toxic shock syndrome, possibly IV immunoglobulins. Distal
abscessspreadcanbelifethreatening.

Rarely,acutepharyngotonsillitismayleadtothrombophlebitisoftheinternaljugular
vein (Lemierre syndrome). The usual cause of this condition is Fusobacterium
necrophorum.Apatientwhoappearstoxicfollowingtonsillitispresentswithspiking
fevers and unilateral neck fullness and tenderness. CT scanning with contrast is
necessary to help make the diagnosis. A prolonged course of IV antibiotics and
treatmentofthesourceofinfection(eg,anabscess)arerequired.Anticoagulationis
controversial. Ligation or excision of the internal jugular vein is required after
multiplesepticembolibecomeevident.

GABHSpharyngitis

ComplicationsspecifictogroupAbetahemolyticStreptococcuspyogenes(GABHS)
pharyngitisarescarletfever,rheumaticfever,septicarthritis,andglomerulonephritis.

Scarletfever

Scarletfevermanifestsasageneralized,nonpruritic,macularerythematousrashthat
 isworseontheextremitiesandsparestheface.Theclassicstrawberrytongueisbright
redandtenderbecauseofpapillarydesquamation.Therashlastsupto1weekandis
accompaniedbyfeverandarthralgias.Individualsatriskforthisrasharethosewho
donothaveantitoxinantibodiestotheexotoxinproducedbyGABHS.
Rheumaticfever

Rheumaticfever followsacutepharyngitisby24weeksandwasobservedinupto
3%ofstreptococcalpharyngitidesinthemid20thcentury.Today,farfewerpersons
experience this complication, largely because of appropriate antibiotic therapy.
Cardiac valvular vegetations affect the mitral and tricuspid valves, leading to
murmurs,persistentrelapsingfevers,andvalvularstenosisorincompetence.Athroat
swabdoesnotidentifythecausativeorganism,becauseapositiveresultmayreflect
colonization rather than pathogenicity. Elevated or rising titers of antistreptolysin
(ASO)antibodies,antiDNAsebeta,orantihyaluronidasearerequiredtomakethe
diagnosis.

Septicarthritis

Septic arthritis results in a painful hot joint that contains fluid with bacteria.
Arthrocentesisisdiagnosticandpartiallytherapeutic.TreatmentwithIVantibiotics
for6weeksisrequiredtopreventlongtermjointcomplications.

DiagnosticConsiderations
Consider infectious mononucleosis (MN) due to EpsteinBarr virus (EBV) in an
adolescentoryoungerchildwithacutetonsillitis,particularlywhenitisaccompanied
bytendercervical,axillary,and/oringuinalnodes;splenomegaly;severelethargyand
malaise;andlowgradefever.

Anindividualwithherpessimplexvirus(HSV)pharyngitispresentswithred,swollen
tonsilsthatmayhaveaphthousulcersontheirsurfaces.Herpeticgingivalstomatitis,
herpeslabialis,andhypopharyngealandepiglotticlesionsmaybeobserved.

DifferentialDiagnoses
GastroesophagealRefluxDisease
OphthalmologicManifestationsofLeukemias
LymphomasoftheHeadandNeck
MalignantNasopharyngealTumors
MalignantTonsilTumorSurgery

ApproachConsiderations
Tonsillitisandperitonsillarabscess(PTA)areclinicaldiagnoses.Testingisindicated
when group A betahemolytic Streptococcus pyogenes (GABHS) infection is
suspected. Throat cultures are the criterion standard for detecting GABHS. For
patientsinwhomacutetonsillitisissuspectedtohavespreadtodeepneckstructures
(ie,beyondthefascialplanesoftheoropharynx),radiologicimagingusingplainfilms
of the lateral neck or CTscans with contrast is warranted. Incases ofPTA, CT
scanningwithcontrastisindicated.
Test the patient's family members for the presence of streptococcal antibodies to
detect carriers of group A Streptococcus (especially family members who are
immunocompromised).

LabStudies
Throat cultures are the criterion standard for detecting group A betahemolytic
Streptococcus pyogenes (GABHS). GABHS is the principal organism for which
antibiotictherapy(sensitivity9095%)isdefinitelyindicated.Growingconcernsover
bacterialresistancemakemonitoringacutetonsillitiswiththroatswabsforcultureand
sensitivity an important endeavor. Relying only on clinical criteria, such as the
presence of exudate, erythema, fever, and lymphadenopathy, is not an accurate
methodfordistinguishingGABHSfromviraltonsillitis.AMonospotserumtest,CBC
count,andserumelectrolyteleveltestmaybeindicated.

Arapidantigendetectiontest(RADT),alsoknownastherapidstreptococcaltest,
detectsthepresenceofGABHScellwallcarbohydratefromswabbedmaterialandis
consideredlesssensitivethanthroatcultures;however,thetesthasaspecificityof
95%ormoreandproducesaresultinsignificantlylesstimethanthatrequiredfor
throatcultures.AnegativeRADTrequiresthatathroatculturebeobtainedbefore
excludingGABHSinfection.

AcultureorRADTisnotindicatedinmostcasesfollowingantibiotictherapyfor
acuteGABHSpharyngitis.Routinetestingofasymptomatichouseholdcontacts is
similarlynotusuallywarranted.

Serummaybeexaminedforantistreptococcalantibodies,includingantistreptolysinO
antibodiesandantideoxyribonuclease(antiDNAse)Bantibodies.Titersareusefulfor
documenting prior infection in persons diagnosed with acute rheumatic fever,
glomerulonephritis,orothercomplicationsofGABHSpharyngitis.

Laboratoryevaluationinchronictonsillitisreliesupondocumentationofresultsof
pharyngealswabsorculturestakenduringpriorepisodesoftonsillitis.Theusefulness
andcostofthroatswabsforpharyngitisaredebated.

ImagingStudies
Routineradiologicimagingisnotusefulincasesofacutetonsillitis.Forpatientsin
whomacutetonsillitisissuspectedtohavespreadtodeepneckstructures(ie,beyond
thefascialplanes oftheoropharynx),radiologicimagingusingplainfilms ofthe
lateralneckorCTscanswithcontrastiswarranted.

Incases ofperitonsillarabscess(PTA),CTscanningwithcontrastisindicatedin
general[13]forunusualpresentations(eg,aninferiorpoleabscess)andforpatientsat
highriskfordrainageprocedures(eg,patientswithcoagulopathyoranestheticrisk).

CT scanning may be used to guide needle aspiration for draining PTAs after an
unsuccessfulsurgicalattemptandfordrainingabscessesthatarelocatedinunusual
locations and are anticipated to be difficult to reach with standard surgical
approaches.HatchandWumentionedultrasonographyasanothermeansofguidance
inPTAdrainage.[14]
A study by Huang et al indicated that ultrasonography is an accurate means of
evaluatingpatientsforPTA,findingthatcomparedwithpatientsdiagnosedwithPTA
viatraditionalexaminationmethodsand/orCTscanning,thosewhowerediagnosed
with transcervical ultrasonography demonstrated significant reductions in surgical
drainageandlengthofhospitalstay.
ApproachConsiderations
Treatment of acute tonsillitis is largely supportive and focuses on maintaining
adequate hydration and caloric intake and controlling pain and fever. Inability to
maintainadequateoralcaloricandfluidintakemayrequireIVhydration,antibiotics,
andpaincontrol.Homeintravenoustherapyunderthesupervisionofqualifiedhome
healthprovidersortheindependentoralintakeabilityofpatientsensureshydration.
Intravenouscorticosteroidsmaybeadministeredtoreducepharyngealedema.
Airwayobstructionmayrequiremanagementbyplacinganasalairwaydevice,using
intravenouscorticosteroids,andadministeringhumidifiedoxygen.Observethepatient
inamonitoredsettinguntiltheairwayobstructionisclearlyresolving.
Tonsillectomy is indicated for individuals who have experienced more than 6
episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5
episodesin2consecutiveyears,or3ormoreinfectionsoftonsilsand/oradenoidsper
yearfor3yearsinarowdespiteadequatemedicaltherapy,orchronicorrecurrent
tonsillitisassociatedwiththestreptococcalcarrierstatethathasnotrespondedtobeta
lactamaseresistantantibiotics.
Tonsillitisandits complications arefrequentlyencountered.Antibioticscuremost
patientswithbacterialtonsillitis,andsurgeryusuallycurespatientswithinfections
andcomplicationsthatarerefractorytomedicalmanagement.Betterunderstandingof
the immunology of tonsillitis, actively tracking patterns of bacterial and viral
pathogenicity and resistance, and exploring novel technologies for tonsillectomy
allowphysicianstocontinuetobuildontheirlongexperiencewiththeseconditions.

Consider transfer of patient care when tonsillitis or its complications cannot be

managedsafelyandexpediently.Ensureairwayprotectionfortransfer.Ensurethat
appropriately trained personnel accompany the patient during transfer. Children
youngerthan3yearsmayrequiretransferbecauseofthespecialcareneededduring
tonsillitisoritscomplications.Patientswithsyndromicdiagnoses(eg,trisomy21)and
patientswithhematologicproblemsmaybenefitfromtransfertofacilitiesthathave
theavailabilityofsubspecialistcare.
Dischargeofthepatientfromthehospitaloccursafterthepatientandcaregiverscan
demonstratecompliancewithoralpainmedicationandantibiotics.Toconfirmclinical
improvement,followupcarebytelephonecontactorphysicalexaminationmaybe
usefulin24weeksaftertheacuteepisode.Followupthroatswabsandculturesare
usuallynotnecessary,unlessfamilyorpersonalhistoryofrheumaticfeverexists,
significantrecurrenttonsillitisisevident,orfamilymemberscontinuetoreinfecteach
other.

Consultationswithinfectiousdisease,hematologic,andpediatricsubspecialistsare
valuableinselectedcases.

Corticosteroids
Corticosteroids may shorten the duration of fever and pharyngitis in cases of
infectiousmononucleosis(MN).InseverecasesofMN,corticosteroidsorgamma
globulin may be helpful. Symptoms of MN may last for several months.
Corticosteroids are also indicated for patients with airway obstruction, hemolytic
anemia,andcardiacandneurologicdisease.Informpatientsofcomplicationsfrom
steroiduse.

Antibiotics
Antibioticsarereservedforsecondarybacterialpharyngitis.Becauseoftheriskofa
generalizedpapularrash,avoidampicillinandrelatedcompoundswheninfectious
mononucleosis (MN) is suspected. Similar reactions from oral penicillinbased
antibiotics (eg, cephalexin) have been reported. Therefore, initiate therapy with
anotherantistreptococcalantibiotic,suchaserythromycin.

Administerantibioticsifconditionssupportabacterialetiology,suchasthepresence
oftonsillarexudates,presenceofafever,leukocytosis,contactswhoareill,orcontact
withapersonwhohasadocumentedgroupAbetahemolyticStreptococcuspyogenes
(GABHS) infection. In many cases, bacterial and viral pharyngitis are clinically
indistinguishable.Waiting12daysforthroatcultureresultshasnotbeenshownto
diminishtheusefulnessofantibiotictherapyinpreventingrheumaticfever.

GABHSinfection

GABHS infection obligates antibiotic coverage. Bisno et al stated in practice

guidelinesforthediagnosisandmanagementofGABHSthatthedesiredoutcomesof
therapy for GABHS pharyngitis are the prevention of acute rheumatic fever, the
prevention of suppurative complications, the abatement of clinical symptoms and
signs, thereduction in transmission of GABHS to close contacts, and the
minimizationofpotentialadverseeffectsofinappropriateantimicrobialtherapy.[16]

Administering oral penicillin for 10 days is the best treatment of acute GABHS
pharyngitis. [17] Intramuscularpenicillin(ie,benzathinepenicillinG)isrequiredfor
personswhomaynotbecompliantwitha10daycourseoforaltherapy.Penicillinis
optimalformostpatients(barringallergicreactions)becauseofitsprovensafety,
efficacy,narrowspectrum,andlowcost.

Other antibiotics proven effective for GABHS pharyngitis are the penicillin
congeners,manycephalosporins,macrolides,andclindamycin.Clindamycinmaybe
ofparticularvaluebecauseitstissuepenetrationisconsideredequivalentforbothoral
and IV administration. Clindamycin is effective even for organisms that are not
rapidly dividing (Eagle effect), which explains its great efficacy for GABHS
infection. Vancomycin and rifampin have also been useful. Reducedfrequency
dosing is recommended to improve compliance with medication regimens. A
consensusontheefficacyofsuchdosinghasnotyetbeenformulated.

Mostcasesofacutepharyngitisareselflimited,withclinicalimprovementobserved
in34days.Clinicalpracticeguidelinesstatethatavoidingantibiotictherapyforthis
timeperiodissafeandadelayofupto9daysfromsymptomonsettoantimicrobial
treatmentshouldstillpreventthemajorcomplicationofGABHS(ie,acuterheumatic
fever).

Recurrent tonsillitis may be managed with the same antibiotics as acute GABHS
pharyngitis.Iftheinfectionrecursshortlyafteracourseofanoralpenicillinagent,
thenconsiderIMbenzathinepenicillinG.Clindamycinandamoxicillin/clavulanate
havebeenshowntobeeffectiveineradicatingGABHSfromthepharynxinpersons
experiencing repeated bouts of tonsillitis. A 3 to 6week course of an antibiotic
againstbetalactamaseproducingorganisms(eg,amoxicillin/clavulanate)mayallow
tonsillectomytobeavoided.

Carrierstateshouldbetreatedwhenthefamilyhasahistoryofrheumaticfever,a
historyofglomerulonephritisinthecarrier,a"pingpong"spreadofinfectionbetween
household contacts of the carrier, familial anxiety regarding the implications of
GABHScarriage,infectiousoutbreakwithinaclosedcommunitysuchasaschool,an
outbreakofacuterheumaticfever,orwhentonsillectomymaybeunderconsideration
totreatthechroniccarriageofGABHS.

Peritonsillarabscess

Peritonsillar cellulitis may respondtooralantibiotics.Antibiotics, either orally or

intravenously,arerequiredtotreatperitonsillarabscess(PTA)medically,although
mostPTAsarerefractorytoantibiotictherapyalone.Penicillin,itscongeners(eg,
amoxicillin/clavulanic acid, cephalosporins), and clindamycin are appropriate
antibiotics. In rare cases of spontaneous PTA rupture, mouthwashes are still
recommended for hygienic reasons. A 10day course of an oral antibiotic is
prescribed.

Betalactamaseresistance

Betalactamaseresistanceofstreptococcalspeciesmaynowbeobservedinuptoa
thirdofcommunitybasedstreptococcalinfections.Thisresistanceisprobablydueto
thepresenceofcopathogensthatarebetalactamaseproducingorganisms,suchasH
influenzaeandMoraxellacatarrhalis.Theseorganismsareabletodegradethebeta
lactamringofpenicillinandmakeanotherwisesensitiveGABHSactresistantto
betalactamantibiotics.Inonestudy,erythromycindidnotinhibitnearlyhalfof S
pyogenes isolates. The limited precision of many throat swabs may reduce the
usefulnessofthesesamples.

Tonsillectomy
Tonsillectomy is indicated for individuals who have experienced more than 6
episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5
episodesin2consecutiveyearsor3ormoreinfectionsfor3yearsinarow,orchronic
or recurrent tonsillitis associated with the streptococcal carrier state that has not
respondedtobetalactamaseresistantantibiotics.Tonsillectomymaybeconsidered
forchildrenwhenmultipleantibioticallergiesorintolerancesareseen,aswellasfor
childrenwithperiodicfever,aphthousstomatitis,pharyngitisandadenitis(PFAPA),
orahistoryofperitonsillarabscess.[18]

Timemissedfromschoolorworkandseverityofillness(eg,whetherhospitalization
wasrequired)areimportantconsiderationsinrecommendingtonsillectomy.

Becauseadenoidtissuehassimilarbacteriologytothepharyngealtonsilsandbecause
minimaladditionalmorbidityoccurswithadenoidectomyiftonsillectomyisalready
beingperformed,mostsurgeonsperformanadenoidectomyifadenoidsarepresent
andinflamedatthetimeoftonsillectomy.However,thispointremainscontroversial.

Recurrenttonsillitisaftertonsillectomyisextremelyrare.Tonsillectomyreducesthe
bacterialloadofgroupAbetahemolyticStreptococcuspyogenes(GABHS)andmay
also allow an increase in alphaStreptococcus, which can be protective against
GABHSinfection.Recurrenttonsillitisisusuallyduetoregrowthoftonsillartissue,
whichistreatedbyexcision.

Tonsillectomywithorwithoutadenoidectomyisthetreatmentforchronictonsillitis.
In cases of chronic tonsillitis, specific technical considerations for tonsillectomy
include awareness of a higher intraoperative and perioperative bleeding risk and
awarenessthatdissectionmaybemoredifficultbecauseoffibrosisandscarringofthe
tonsillarcapsule.Suchconsiderationsmayaffectinstrumentselectionanddischarge
decisions.

Surgeryis rarelyrequiredforacutelingualtonsillitis,butsurgeryis indicatedfor

frequentanddisablingepisodesofthisuncommonmalady.Tonsillarhypertrophythat
persistsafterresolutionofmononucleosisandcausesobstructiveairwaysymptoms
maynecessitatetonsillectomy.

AliteraturereviewbyMoradetalindicatedthatintheshortterm(<12mo),children
with recurrent throat infections who undergo tonsillectomy/adenotonsillectomy
demonstrategreaterreductionsinsorethroatdays,cliniciancontacts,diagnosedgroup
Astreptococcalinfections,andschoolabsencesthandosuchchildrentreatedwith
watchfulwaiting.However,qualityoflifescoresdidnotsignificantlydifferbetween
thetwogroups,andtheevidencewasnotstrongenoughtodeterminewhetherthe
greater tonsillectomy/adenotonsillectomyassociated benefits would persist in the
longerterm.[19,20]

AstudybyWangetalindicatedthattonsillectomyincreasestheriskofdeepneck
infections.Usingahealthinsuranceresearchdatabasesearch,theinvestigatorsfound
patients to be at 1.71fold greater risk of deep neck infection after undergoing
tonsillectomy.[21]
A retrospective cohort study of 61,430 patients who underwent tonsillectomy
indicates that the use of intravenous steroids on the day of surgery increases the
incidenceofposttonsillectomybleedinginchildren,butnotinadults.Inthestudy,
Suzukietalfoundthattherateofreoperationforbleedingwas1.2%forchildrenaged
15yearsoryoungerwhoreceivedintravenoussteroids,versus0.5%forpatientsinthe
same age group who did not. Among patients older than 15 years, however, the
reoperationratewasnotsignificantlyhigherinthesteroidpatientsthaninthecontrols
(1.7%vs.1.4%).[22,23]

AretrospectivestudybySpektoretalindicatedthattheriskofpostoperativebleeding
inchildrenundergoingtonsillectomyisincreasedwhenthesurgeryisperformedona
childwithrecurrenttonsillitis(4.5timesincreasedrisk),onachildwithattention
deficithyperactivitydisorder(8.7timesincreasedrisk),oronanolderchild(twicethe
bleedingriskinchildrenaged11yearsorabove).[24]

Similarly,astudybyKshirsagaretalindicatedthatinchildrenundergoingoutpatient
tonsillectomywithorwithoutadenoidectomy,theriskofimmediatepostoperative
bleedingisincreasedbyolderage(agebetween9and18years)andobesity,withthe
lattermakingthelikelihoodofhemorrhageabout2.3timesgreater.[25]

AliteraturereviewbyDeLucaCantoetalindicatedthatrespiratorycompromiseis
the most frequent complication occurring in children (9.4%) following
adenotonsillectomy, with secondary hemorrhage being the second most frequent
(2.6%). The investigators also found that in children who undergo
adenotonsillectomy,theriskofrespiratorycomplicationsis4.9timeshigherinthose
who have obstructive sleep apnea than in children who do not, but the risk of
postoperativebleedingislower.
DietandActivity
Hydrationisimportant,andtheoralrouteisusuallyadequate.Intravenousfluidsmay
berequiredforseveredehydration.Hyperalimentationisrarelynecessary.Adequate
restforadultsandchildrenwithtonsillitisacceleratesrecovery.Inordertoreducerisk
ofsplenicruptureinpersonsdiagnosedwithsystemicmononucleosis,patientsmust
becautionedagainstactivitiesthatmaycauseabdominalinjury.

Prevention
Avoidance of contact with individuals who are ill or patients who are
immunocompromisedisuseful.

The use of the antipneumococcal vaccine may help to prevent acute tonsillitis;
however,todate,experienceisinsufficienttodeterminewhetherpreventionislikely
tooccur.

MedicationSummary
Medicationsthatareusedtomanagetonsillitisincludeantibiotics,antiinflammatory
agents (eg, corticosteroids), antipyretics and analgesics (eg, acetaminophen,
ibuprofen),andimmunologicagents(eg,gammaglobulin).

Corticosteroids
Corticosteroids have antiinflammatory properties and cause profound and varied
metabolic effects. These agents modify the body's immune response to diverse
stimuli. Corticosteroids reduce inflammation, which may impair swallowing and
breathing.

Dexamethasone(Baycadron)
Dexamethasoneisashortacting,rapidonsetglucocorticoid.

Prednisone

Prednisonedecreasesinflammationbysuppressingmigrationofpolymorphonuclear
leukocytesandreducingcapillarypermeability.

Prednisolone(Pediapred,Millipred,Orapred)

Prednisolonedecreasesinflammationbysuppressingmigrationofpolymorphonuclear
leukocytesandreducingcapillarypermeability.

Antibiotics
Antibiotic therapy must be comprehensive and cover all likely pathogens in the
contextofthisclinicalsetting.

PenicillinGbenzathine(BicillinLA)

Penicillin interferes with synthesis of cell wall mucopeptides during active

multiplication,whichresultsinbactericidalactivity.

Clarithromycin(Biaxin)

Clarithromycininhibitsbacterialgrowth,possiblybyblockingdissociationofpeptidyl
tRNA from ribosomes causing RNAdependent protein synthesis to arrest. It is a
semisyntheticmacrolidewithtwicedailydosing.

Clindamycin(Cleocin)

Clindamycin is an oral or parenteral antibiotic that is used for the treatment of

anaerobicorsusceptiblestreptococcal,pneumococcal,orstaphylococcalspecies.Itis
consideredtohavegoodabsorptionintothebloodstreaminbothoralandparenteral
forms.

Vancomycin

Vancomycinisindicatedforpatientswhocannotreceiveorhavefailedtorespondto
penicillinsandcephalosporinsorwhohaveinfectionswithresistantstaphylococci.To
avoidtoxicity,thecurrentrecommendationistoassayvancomycintroughlevelsafter
thethirddose,drawn30minutespriortothenextdosing.Usecreatinineclearance
(CrCl)toadjustthedoseinpatientsdiagnosedwithrenalimpairment.Itisusedin
conjunctionwithgentamicinforprophylaxisinpenicillinallergicpatientsundergoing
gastrointestinalorgenitourinaryprocedures.

Rifampin(Rifadin)

RifampinisaninhibitorofbacterialDNAdependentRNApolymeraseactivity.
Amoxicillin(Moxatag)

Amoxicillin is an oral antibiotic with specific activity against penicillinresistant

organisms;itisoftencombinedwiththebetalactamaseinhibitorclavulanicacid.

Amoxicillinandclavulanate(Augmentin,Amoclan,AugmentinXR)

Amoxicillin is a thirdgeneration aminopenicillin. Combined with the betalactam

clavulanicacid,itislesssusceptibletodegradationbybetalactamasesproducedby
microorganisms.

Metronidazole(Flagyl)

Metronidazole is effective in patients with tonsillitis and mononucleosis, for

shorteningfeverdurationandreducingtonsillarsize,andinmanagementofacute
episodesofnonstreptococcaltonsillitis.

Ampicillinandsulbactam(Unasyn)

Thisisadrugcombinationofabetalactamaseinhibitorwithampicillin.Itinterferes
with bacterial cell wall synthesis during active replication, causing bactericidal
activityagainstsusceptibleorganisms.Itisanalternativetoamoxicillin/clavulanateif
thepatientisunabletotakemedicationorally.