Template:Short description Template:Infobox medical condition (new) Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic.<ref name="ICD11A">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="ICD11B">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=NCIThesaurus>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Acute tonsillitis typically has a rapid onset.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck.<ref name="inesss">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=NCIThesaurus/> Complications include peritonsillar abscess (quinsy).<ref name="inesss"/><ref name=Klug2016>Template:Cite journal</ref>
Tonsillitis is most commonly caused by a viral infection and about 5% to 40% of cases are caused by a bacterial infection.<ref name="inesss"/><ref name=Wind2016/><ref name=Lang2009>Lang 2009, p. 2083.</ref> When caused by the bacterium group A streptococcus, it is classed as streptococcal tonsillitis<ref name="ICD11C">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> also referred to as strep throat.<ref>Ferri 2015, p. 1646.</ref> Rarely bacteria such as Neisseria gonorrhoeae, Corynebacterium diphtheriae, or Haemophilus influenzae may be the cause.<ref name=Wind2016/> Typically the infection is spread between people through the air.<ref name=Lang2009/> A scoring system, such as the Centor score, may help separate possible causes.<ref name="inesss"/><ref name=Wind2016/> Confirmation may be by a throat swab or rapid strep test.<ref name="inesss"/><ref name=Wind2016>Template:Cite journal</ref>
Treatment efforts involve improving symptoms and decreasing complications.<ref name=Wind2016/> Paracetamol (acetaminophen) and ibuprofen may be used to help with pain.<ref name="inesss"/><ref name=Wind2016/> If strep throat is present the antibiotic penicillin by mouth is generally recommended.<ref name="inesss"/><ref name=Wind2016/> In those who are allergic to penicillin, cephalosporins or macrolides may be used.<ref name="inesss"/><ref name=Wind2016/> In children with frequent episodes of tonsillitis, tonsillectomy modestly decreases the risk of future episodes.<ref>Template:Cite journal</ref>
About 7.5% of people have a sore throat in any three-month period and 2% of people visit a doctor for tonsillitis each year.<ref name=Jones2014>Jones 2004, p. 674.</ref> It is most common in school-aged children and typically occurs in the colder months of autumn and winter.<ref name=Wind2016/><ref name=Lang2009/> The majority of people recover with or without medication.<ref name="inesss"/><ref name=Wind2016/> In 82% of people, symptoms resolve within one week, regardless if bacteria or viruses were present.<ref name=Cochrane2013/> 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.<ref name="Cochrane2013">Template:Cite journal</ref>
Signs and symptomsEdit
Those with tonsillitis usually experience sore throat, painful swallowing, malaise, and fever.<ref name="inesss"/><ref name=De2018>Template:Cite journal</ref><ref name=Bird2014/> Their tonsils – and often the back of the throat – appear red and swollen, and sometimes give off a white discharge.<ref name="inesss"/><ref name=Bird2014/><ref name=Stelter2014>Template:Cite journal</ref> Some also have tender swelling of the cervical lymph nodes.<ref name="inesss"/><ref name=Bird2014>Template:Cite journal</ref>
Many viral infections that cause tonsillitis will also cause cough, runny nose, hoarse voice, or blistering in the mouth or throat.<ref name=Bochner2017>Template:Cite journal</ref> Infectious mononucleosis can cause the tonsils to swell with red spots or white discharge that may extend to the tongue.<ref name=Fugl2019>Template:Cite journal</ref> This can be accompanied by fever, sore throat, cervical lymph node swelling, and enlargement of the liver and spleen.<ref name=Fugl2019/> Bacterial infections that cause tonsillitis can also cause a distinct "scarletiniform" rash, vomiting, and tonsillar spots or discharge.<ref name="inesss"/><ref name=Bochner2017/>
Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.Template:Clarify<ref>Nour p. ???.</ref>
CausesEdit
Viral infections cause 40 to 60% of cases of tonsillitis.<ref name=De2018/> 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.<ref name=Bochner2017/> Tonsillitis can also be part of the initial reaction to HIV infection.<ref name=Bochner2017/> An estimated 1 to 10% of the cases are caused by Epstein-Barr virus.<ref name=Bird2014/>
Tonsillitis can also stem from infection with bacteria, predominantly Group A β-hemolytic streptococci (GABHS), which causes strep throat.<ref name="inesss"/><ref name=De2018/> Bacterial infection of the tonsils usually follows the initial viral infection.<ref name=Bird2014/> 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.<ref name="inesss"/><ref>Template:Cite journal</ref> Less common bacterial causes include: Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, Fusobacterium sp., Corynebacterium diphtheriae, Treponema pallidum, and Neisseria gonorrhoeae.<ref name=merck>Template:MerckManual</ref><ref name=wetmore>Wetmore 2007, pp. 756–57.</ref><ref name=thuma>Thuma 2001, p. ???</ref><ref name=simon>Simon 2005, p. ????</ref>
Anaerobic bacteria have been implicated in tonsillitis, and a possible role in the acute inflammatory process is supported by several clinical and scientific observations.<ref>Template:Cite journal</ref>
Sometimes tonsillitis is caused by an infection of spirochaeta and treponema, which is called Vincent's angina or Plaut-Vincent angina.Template:Primary source inline<ref>Template:Primary source inline Template:Cite journal — fusospirillum complex (Plaut-Vincent angina) Van Cauwenberge studied the tonsils of 126 patients using direct microscope observation. The results showed that 40% of acute tonsillitis was caused by Vincent's angina and 27% of chronic tonsillitis was caused by Spirochaeta</ref>
Within the tonsils, white blood cells of the immune system destroy the viruses or bacteria by producing inflammatory cytokines like phospholipase A2,Template:Primary source inline<ref name="pmid22297210">Template:Primary source inline Template:Cite journal</ref> which also lead to fever.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx.<ref name="inesss"/><ref name=medline>Template:MedlinePlusEncyclopedia</ref>
DiagnosisEdit
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.<ref name="inesss"/><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> An acute sore throat may be diagnosed as tonsillitis, pharyngitis, or tonsillopharyngitis (also called pharyngotonsillitis), depending upon the clinical findings.<ref name="inesss"/>
In primary care settings, the Centor criteria are used to determine the likelihood of group A beta-hemolytic streptococcus (GABHS) infection in an acute tonsillitis and the need of antibiotics for tonsillitis treatment.<ref name="inesss"/><ref name=Bird2014/> However, the Centor criteria have their weaknesses in making precise diagnosis for adults. The Centor criteria are also ineffective in diagnosis for tonsillitis in children and in secondary care settings (hospitals).<ref name=Bird2014/> 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:
- Presence of tonsillar exudate
- Painful neck lymph nodes
- History of fever
- Age between five and fifteen years
- Absence of cough
The possibility of GABHS infection increases with increasing score. The probability for getting GABHS is 2 to 23% for the score of 1, and 25 to 85% for the score of 4.<ref name=Bird2014/> The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing the throat and plating them on blood agar medium. This small percentage of false-negative results are part of the characteristics of the tests used but are also possible if the person has received antibiotics prior to testing. Identification requires 24 to 48 hours by culture but rapid screening tests (10–60 minutes), which have a sensitivity of 85–90%, are available. In 40% of the people without any symptoms, the throat culture can be positive. Therefore, throat culture is not routinely used in clinical practice for the detection of GABHS.<ref name=Bird2014/>
Centor and McIsaac scores are equally ineffective at identifying patients who need antibiotics presenting with pharyngitis at hospitals. Too many true positive cases are missed and too many false positives are treated, leading to the over prescription of antibiotics.<ref>Template:Cite journal</ref>
Bacterial culture may need to be performed in cases of a negative rapid streptococcal test.<ref>Template:Cite journal</ref> An increase in antistreptolysin O (ASO) streptococcal antibody titer following the acute infection can provide retrospective evidence of GABHS infection and is considered definitive proof of GABHS infection, but not necessarily of the tonsils.<ref>Template:Cite journal</ref> Epstein Barr virus serology can be tested for those who may have infectious mononucleosis with a typical lymphocyte count in full blood count result.<ref name="Bird2014" /> Blood investigations are only required for those with hospital admission requiring intravenous antibiotics.<ref name="Bird2014" />
Nasoendoscopy can be used for those with severe neck pain and inability to swallow any fluids to rule out masked epiglotitis and supraglotitis. Routine nasoendscopy is not recommended for children.<ref name=Bird2014/>
TreatmentEdit
Treatments to reduce the discomfort from tonsillitis include:<ref name="inesss"/><ref name=wetmore/><ref name=thuma/><ref name=simon/><ref name=medline/>
- pain and fever reducing medications such as paracetamol (acetaminophen) and ibuprofen
- warm salt water gargle, lozenges, honey, or warm liquids
There are no antiviral medical treatments for virally caused tonsillitis.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
AntibioticsEdit
If the tonsillitis is caused by group A streptococcus, then antibiotics are useful, with penicillin or amoxicillin being primary choices.<ref name="inesss"/><ref name=Bird2014/> Cephalosporins and macrolides are considered good alternatives to penicillin in the acute care setting.<ref name="inesss"/><ref>Template:Cite journal</ref> A macrolide, such as azithromycin or erythromycin, is used for people allergic to penicillin.<ref name="inesss"/> If penicillin therapy fails, bacterial tonsillitis may respond to treatment effective against beta-lactamase producing bacteria such as clindamycin or amoxicillin-clavulanate.<ref>Template:Cite journal</ref> Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins.<ref>Template:Cite journal</ref> There is no significant difference in efficacy of various groups of antibiotics for treating tonsillitis.<ref name=Bird2014/> Intravenous antibiotics can be for those who are hospitalized with inability to swallow and presented with complications.Template:Citation needed Oral antibiotics can be resumed immediately if the person is clinically improved and able to swallow orally.<ref name=Bird2014/> Antibiotic treatment is usually taken for seven to ten days.<ref name="inesss"/><ref name=Wind2016/>
Pain medicationEdit
Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to treat throat pain in children and adults.<ref name="inesss"/><ref name=Bird2014/> Codeine is avoided in children under 12 years of age to treat throat pain or following tonsilectomy.<ref>Template:Cite press release</ref><ref>Template:Cite journal</ref> NSAIDs (such as ibuprofen) and opioids (such as codeine and tramadol) are equally effective at relieving pain, however, precautions should be taken with these pain medications. NSAIDs can cause peptic ulcer disease and kidney damage.Template:Citation needed Opioids can cause respiratory depression in those who are vulnerable.<ref name=Bird2014/> Anaesthetic mouthwash can also be used for symptomatic relief.<ref name=Bird2014/>
CorticosteroidsEdit
Corticosteroids reduce tonsillitis pain and improve symptoms in 24 to 48 hours. Oral corticosteroids are recommended unless the person is unable to swallow medications.<ref name=Bird2014/>
SurgeryEdit
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When tonsillitis recurs frequently, often arbitrarily defined as at least five episodes of tonsillitis in a year,<ref>Template:Cite journal</ref> or when the palatine tonsils become so swollen that swallowing is difficult as well as painful, a tonsillectomy can be performed to surgically remove the tonsils. A randomised controlled trial of tonsillectomy versus medical treatment (antibiotics and pain killers) in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
Children have had only a modest benefit from tonsillectomy for repeated cases of tonsillitis.<ref>Template:Cite journal</ref>
PrognosisEdit
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.
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.<ref name=wetmore/><ref name=thuma/><ref name=simon/><ref name=medline/>
An abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis.Template:Citation needed This is termed a peritonsillar abscess (or quinsy).
Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading infectious thrombophlebitis (Lemierre's syndrome).Template:Citation needed
In strep throat, diseases like post-streptococcal glomerulonephritisTemplate:Primary source inline<ref>Template:Primary source inline Template:Cite journal</ref> can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations.<ref>Template:Cite journal</ref><ref>Template:Cite journal — Medical Journal of Australia commentary on Cochrane analysis</ref>
EpidemiologyEdit
Tonsillitis occurs throughout the world, without racial or ethnic differences.<ref name= Sommers1078>Sommers 2015, p. 1078.</ref> Most children have tonsillitis at least once during their childhood,<ref name= Sommers1077>Sommers 2015, p. 1077.</ref> although it rarely occurs before the age of two.<ref name= Sommers1078/> It most typically occurs between the ages of four and five; bacterial infections most typically occur at a later age.<ref name= Sommers1078/>
Society and cultureEdit
Tonsillitis is described in the ancient Greek Hippocratic Corpus.<ref>Dean-Jones 2013</ref>
Recurrent tonsillitis can interfere with vocal function and the ability to perform among people who use their voices professionally.<ref>Sataloff & Hawkshaw 2019.</ref><ref>Stadelman-Cohen 2019, pp. 30–52.</ref>
ReferencesEdit
- Tonsillitt Velbehagklinikk 26 July 2022
Books citedEdit
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