Tonsillitis

Tonsilitis
Classification and external resources

A culture positive case of Streptococcal pharyngitis with typical tonsillar exudate
ICD-10 J03, J35.0
ICD-9 463
DiseasesDB 13165
MedlinePlus 001043
eMedicine article/871977
MeSH D014069

Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics. It usually takes around three weeks to recover.

Contents

Symptoms

Common symptoms of tonsillitis include:[1][2][3][4]

In cases of acute tonsillitis, the surface of the tonsil may be bright red and with visible white areas or streaks of pus.[5]

Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.[6]

Causes

The most common causes of tonsillitis are the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, respiratory syncytial virus).[1][2][3][4] It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV.[1][2][3][4] The second most common causes are bacterial. The most common bacterial cause is Group A β-hemolytic streptococcus (GABHS), which causes strep throat.[1][2][3][4] Less common bacterial causes include: Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea.[1][2][3][4]

Under normal circumstances, as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils.[7][8] Within the tonsils, white blood cells of the immune system mount an attack that helps destroy the viruses or bacteria, and also causes inflammation and fever.[7][8] The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx.[9] This is the area in the back of the throat that lies between the voice box and the tonsils.

Tonsillitis may be caused by Group A streptococcal bacteria,[10] resulting in strep throat.[10] Viral tonsillitis may be caused by numerous viruses[10] such as the Epstein-Barr virus[10] (the cause of infectious mononucleosis)[11] or adenovirus.[10]

Sometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina.[12]

Treatment

Treatments to reduce the discomfort from tonsillitis symptoms include:[1][2][3][4][9][13][14]

If the tonsillitis is caused by group A streptococus, then antibiotics are useful with penicillin or amoxicillin being first line.[15] A macrolide such as erythromycin is used for patients allergic to penicillin. Patients who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria[16] 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.[17] 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 may last for up to two weeks. Chronic cases may be treated with tonsillectomy (surgical removal of tonsils) as a choice for treatment.[18]

Complications

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.[1][2][3][4][9]

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 (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 septicaemia infection (Lemierre's syndrome).

In chronic/recurrent cases (generally defined as seven episodes of tonsillitis in the preceding year, five episodes in each of the preceding two years or three episodes in each of the preceding three years),[19][20][21] 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 very rare cases of strep throat, diseases like rheumatic fever[22] or glomerulonephritis[23] can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations.[24][25] Tonsillitis associated with strep throat, if untreated, is hypothesized to lead to pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).[26]

References

  1. ^ a b c d e f g Tonsillopharyngitis at Merck Manual of Diagnosis and Therapy Professional Edition
  2. ^ a b c d e f g Wetmore RF. (2007). "Tonsils and adenoids". In Bonita F. Stanton; Kliegman, Robert; Nelson, Waldo E.; Behrman, Richard E.; Jenson, Hal B.. Nelson textbook of pediatrics. Philadelphia: Saunders. ISBN 1-4160-2450-6. 
  3. ^ a b c d e f g Thuma P. (2001). "Pharyngitis and tonsillitis". In Hoekelman, Robert A.. Primary pediatric care. St. Louis: Mosby. ISBN 0-323-00831-3. 
  4. ^ a b c d e f g Simon HB (2005). "Bacterial infections of the upper respiratory tract". In Dale, David. ACP Medicine, 2006 Edition (Two Volume Set) (Webmd Acp Medicine). WebMD Professional Publishing. ISBN 0-9748327-6-6. 
  5. ^ Tonsillitis and Adenoid Infection MedicineNet. Retrieved on 2010-01-25
  6. ^ S. G. Nour; Mafee, Mahmood F.; Valvassori, Galdino E.; Galdino E. Valbasson; Minerva Becker (2005). Imaging of the head and neck. Stuttgart: Thieme. pp. 716. ISBN 1-58890-009-6. 
  7. ^ a b van Kempen MJ, Rijkers GT, Van Cauwenberge PB (May 2000). "The immune response in adenoids and tonsils". Int. Arch. Allergy Immunol. 122 (1): 8–19. doi:10.1159/000024354. PMID 10859465. 
  8. ^ a b Perry M, Whyte A (September 1998). "Immunology of the tonsils". Immunology Today 19 (9): 414–21. doi:10.1016/S0167-5699(98)01307-3. PMID 9745205. 
  9. ^ a b c MedlinePlus Encyclopedia Tonsillitis
  10. ^ a b c d e Putto A (1987). "Febrile exudative tonsillitis: viral or streptococcal?". Pediatrics 80 (1): 6–12. PMID 3601520. 
  11. ^ Renn CN, Straff W, Dorfmüller A, Al-Masaoudi T, Merk HF, Sachs B (2002). "Amoxicillin-induced exanthema in young adults with infectious mononucleosis: demonstration of drug-specific lymphocyte reactivity". Br. J. Dermatol. 147 (6): 1166–70. doi:10.1046/j.1365-2133.2002.05021.x. PMID 12452866.  -Renn studied 4 patients who where treated amoxicillin for throat infection and lymphadenopathy. Infectious mononucleosis was present in the patient’s blood due to trace of Epstein-Barr antibodies. The three tests performed where the patched test, intracutaneous test, and lymphocyte transformation test. The results of the patched test assas the caused of their rash were 1 out of 4 patients. The intracutaneous showed 2 out of 4 patients with positive results that pointed to amoxicillin. The LTT results showed 3 out of 4 that pointed to amoxicillin
  12. ^ Van Cauwenberge P (1976). "[Significance of the fusospirillum complex (Plaut-Vincent angina)]" (in Dutch; Flemish). Acta Otorhinolaryngol Belg 30 (3): 334–45. PMID 1015288.  — 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
  13. ^ Boureau, F. et al. (1999). "Evaluation of Ibuprofen vs Paracetamol Analgesic Activity Using a Sore Throat Pain Model". Clinical Drug Investigation 17: 1–8. doi:10.2165/00044011-199917010-00001. 
  14. ^ Praskash, T. et al. (2001). "Koflet lozenges in the Treatment of Sore Throat". The Antiseptic 98: 124–7. 
  15. ^ Touw-Otten FW, Johansen KS (1992). "Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries". Fam Pract 9 (3): 255–62. doi:10.1093/fampra/9.3.255. PMID 1459378. 
  16. ^ Brook I (2009). "The role of beta-lactamase-producing-bacteria in mixed infections". BMC Infect Dis 9: 202. doi:10.1186/1471-2334-9-202. PMC 2804585. PMID 20003454. http://www.biomedcentral.com/1471-2334/9/202. 
  17. ^ Brook I (2007). "Microbiology and principles of antimicrobial therapy for head and neck infections". Infect Dis Clin North Am 21 (2): 355–91. doi:10.1016/j.idc.2007.03.014. PMID 17561074. http://linkinghub.elsevier.com/retrieve/pii/S0891-5520(07)00026-8. 
  18. ^ Paradise JL, Bluestone CD, Bachman RZ, et al. (1984). "Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials". N. Engl. J. Med. 310 (11): 674–83. doi:10.1056/NEJM198403153101102. PMID 6700642. 
  19. ^ Scottish Intercollegiate Guidelines Network. (January 1999). "6.3 Referral Criteria for Tonsillectomy". Management of Sore Throat and Indications for Tonsillectomy. Scottish Intercollegiate Guidelines Network. ISBN 1-899893-66-0. http://www.sign.ac.uk/guidelines/fulltext/34/section6.html.  — notes though that these criteria "have been arrived at arbitrarily" from:
    Paradise JL, Bluestone CD, Bachman RZ, et al. (1984). "Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials". N. Engl. J. Med. 310 (11): 674–83. doi:10.1056/NEJM198403153101102. PMID 6700642. 
  20. ^ Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Rockette HE, Kurs-Lasky M (2002). "Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children". Pediatrics 110 (1 Pt 1): 7–15. doi:10.1542/peds.110.1.7. PMID 12093941.  — this later study by the same team looked at less severely affected children and concluded "modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations"
  21. ^ Wolfensberger M, Mund MT (2004). "[Evidence based indications for tonsillectomy]" (in German). Ther Umsch 61 (5): 325–8. PMID 15195718.  — review of literature of the past 25 years concludes "No consensus has yet been reached, however, about the number of annual episodes that justify tonsillectomy"
  22. ^ Del Mar CB, Glasziou PP, Spinks AB (2004). Del Mar, Chris. ed. "Antibiotics for sore throat". Cochrane Database Syst Rev (2): CD000023. doi:10.1002/14651858.CD000023.pub2. PMID 15106140. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000023/frame.html.  — Meta-analysis of published research
  23. ^ Zoch-Zwierz W, Wasilewska A, Biernacka A, et al. (2001). "[The course of post-streptococcal glomerulonephritis depending on methods of treatment for the preceding respiratory tract infection]" (in Polish). Wiad. Lek. 54 (1–2): 56–63. PMID 11344703. 
  24. ^ Ohlsson, A.; Clark, K (September 28 2004). "Antibiotics for sore throat to prevent rheumatic fever: Yes or No? How the Cochrane Library can help". CMAJ 171 (7): 721–3. doi:10.1503/cmaj.1041275. PMC 517851. PMID 15451830. http://www.cmaj.ca/cgi/content/full/171/7/721.  — Canadian Medical Association Journal commentary on Cochrane analysis
  25. ^ Danchin, MH; Curtis, N; Nolan, TM; Carapetis, JR (2002). "Treatment of sore throat in light of the Cochrane verdict: is the jury still out?". MJA 177 (9): 512–5. PMID 12405896. http://www.mja.com.au/public/issues/177_09_041102/dan10028_fm.html.  — Medical Journal of Australia commentary on Cochrane analysis
  26. ^ Pickering, Larry K., ed (2006). "Group A streptococcal infections". Red Book: 2006 Report of the Committee on Infectious Diseases (Red Book Report of the Committee on Infectious Diseases). Amer Academy of Pediatrics. ISBN 1-58110-194-5. 

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