Tonsillitis and Peritonsillar Abscess

Practice Essentials

Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. Most cases of bacterial tonsillitis are caused by group A beta-hemolytic Streptococcus pyogenes (GABHS).

Signs and symptoms

Tonsillitis

Individuals with acute tonsillitis present with the following:

• Fever
• Sore throat
• Foul breath
• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Tender cervical lymph nodes

Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnea.

Peritonsillar abscess

Individuals with peritonsillar abscess (PTA) present with the following:

• Severe throat pain
• Fever
• Drooling
• Foul breath
• Trismus (difficulty opening the mouth)
• Altered voice quality (the hot-potato voice)

Physical examination of a PTA almost always reveals unilateral bulging above and lateral to one of the tonsils.

See Clinical Presentation for more detail.

Diagnosis

Tonsillitis and PTA are clinical diagnoses. Testing is indicated when GABHS infection is suspected. Throat cultures are the criterion standard for detecting GABHS. For patients in whom acute tonsillitis is suspected to have spread to deep neck structures (ie, beyond the fascial planes of the oropharynx), radiologic imaging using plain films of the lateral neck or computed tomography (CT) scanning with contrast is warranted. In cases of PTA, CT scanning with contrast is indicated.

See Workup for more detail.

Management

Tonsillitis

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever.

Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin may be helpful. GABHS infection obligates antibiotic coverage.

Tonsillectomy is indicated for the individuals who have experienced the following:

• More than six episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year
• Five episodes of streptococcal pharyngitis in 2 consecutive years
• Three or more infections of the tonsils and/or adenoids per year for 3 years in a row despite adequate medical therapy
• Chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics

Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and because minimal additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform an adenoidectomy if adenoids are present and inflamed at the time of tonsillectomy. However, this point remains controversial.

Peritonsillar abscess

Treatment of PTA includes aspiration and incision and drainage (I&D). Antibiotics, either orally or intravenously, are required to treat PTA medically, although the condition is usually refractory to antibiotic therapy alone.

See Treatment and Medication for more detail.

• References

Background

In the first century AD, Celsus described tonsillectomy performed with sharp tools and followed by rinses with vinegar and other medicinals. Since that time, physicians have been documenting management of tonsillitis. Tonsillitis gained additional attention as a medical concern in the late 19th century. The consideration of quinsy in the differential diagnosis of George Washington's death and the discussion of tonsillitis in Kean's Domestic Medical Lectures, a home medical companion book published in the late 19th century, reflect the rise of tonsillitis as a medical concern.^{[1, 2]}

Understanding the disease process and management of this common malady remain important today. This article summarizes the current management of tonsillitis and highlights recent advances in the pathophysiology and immunology of this condition and its variations: acute tonsillitis (see the image below), recurrent tonsillitis, and chronic tonsillitis and peritonsillar abscess (PTA).^[3]

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Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with exudates. The uvula is midline.

Definitions

Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. Pharyngotonsillitis and adenotonsillitis are considered equivalent for the purposes of this article. Lingual tonsillitis refers to isolated inflammation of the lymphoid tissue at the tongue base.

A "carrier state" is defined by a positive pharyngeal culture of group A beta hemolytic Streptococcus pyogenes (GABHS), without evidence of an antistreptococcal immunologic response.

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Pathophysiology and Etiology

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Overcrowded conditions and malnourishment promote tonsillitis. Most episodes of acute pharyngitis and acute tonsillitis are caused by viruses such as the following:

• Herpes simplex virus
• Epstein-Barr virus (EBV)
• Cytomegalovirus
• Other herpes viruses
• Adenovirus
• Measles virus

In one study showing that EBV may cause tonsillitis in the absence of systemic mononucleosis, EBV was found to be responsible for 19% of exudative tonsillitis in children.

Bacteria cause 15-30% of cases of pharyngotonsillitis. Anaerobic bacteria play an important role in tonsillar disease. Most cases of bacterial tonsillitis are caused by group A beta-hemolytic Streptococcus pyogenes (GABHS). S pyogenes adheres to adhesin receptors that are located on the tonsillar epithelium. Immunoglobulin coating of pathogens may be important in the initial induction of bacterial tonsillitis.

Mycoplasma pneumoniae, Corynebacterium diphtheriae, and Chlamydia pneumoniae rarely cause acute pharyngitis. Neisseria gonorrhea may cause pharyngitis in sexually active persons. Arcanobacterium haemolyticum is an important cause of pharyngitis in Scandinavia and the United Kingdom but is not recognized as such in the United States. A rash similar to that of scarlet fever accompanies A haemolyticum pharyngitis.

Recurrent tonsillitis

A polymicrobial flora consisting of both aerobic and anaerobic bacteria has been observed in core tonsillar cultures in cases of recurrent pharyngitis, and children with recurrent GABHS tonsillitis have different bacterial populations than children who have not had as many infections. Other competing bacteria are reduced, offering less interference to GABHS infection. Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae are the most common bacteria isolated in recurrent tonsillitis, and Bacteroides fragilis is the most common anaerobic bacterium isolated in recurrent tonsillitis.

The microbiologies of recurrent tonsillitis in children and adults are different; 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, adults more often have bacteria that produce beta-lactamase.

Chronic tonsillitis

A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species having been identified. A study that was based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy suggested that antibiotics prescribed 6 months before surgery did not alter the tonsillar bacteriology at the time of tonsillectomy.^[4] A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes. H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids. With regard to penicillin resistance or beta-lactamase production, the microbiology of tonsils removed from patients with recurrent GABHS pharyngitis has not been shown to be significantly different from the microbiology oftonsilsremovedfrom patients with tonsillar hypertrophy.

Local immunologic mechanisms are important in chronic tonsillitis. The distribution of dendritic cells and antigen-presenting cells is altered during disease, with fewer dendritic cells on the surface epithelium and more in the crypts and extrafollicular areas. Study of immunologic markers may permit differentiation between recurrent and chronic tonsillitis. Such markers in one study indicated that children more often experience recurrent tonsillitis, whereas adults requiring tonsillectomy more often experience chronic tonsillitis.^[5]

Radiation exposure may relate to the development of chronic tonsillitis. A high prevalence of chronic tonsillitis was noted following the Chernobyl nuclear reactor accident in the former Soviet Union.

Peritonsillar abscess

A polymicrobial flora is isolated from peritonsillar abscesses (PTAs). Predominant organisms are the anaerobes Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species. Major aerobic organisms are GABHS, S aureus, and H influenzae.

Uhler et al, in an analysis of data from 460 patients with PTA, found a higher incidence of the condition in smokers than in nonsmokers.^[6]

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Epidemiology

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than 2 years. Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years, while viral tonsillitis is more common in younger children. Peritonsillar abscess (PTA) usually occurs in teens or young adults but may present earlier.

Pharyngitis accompanies many upper respiratory tract infections. Between 2.5% and 10.9% of children may be defined as carriers. In one study, the mean prevalence of carrier status of schoolchildren for group A Streptococcus, a cause of tonsillitis, 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 reported in 11.7% of Norwegian children in one study and estimated in another study to affect 12.1% of Turkish children.^[10]

Klug found seasonal and/or age-based variations in the incidence and cause of PTA. 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 condition subsequently was more frequent in males than in females.^[11]

Klug also found a significantly higher incidence of Fusobacterium necrophorum than of group A Streptococcus in patients aged 15-24 years with PTA. However, the incidence of group A Streptococcus was significantly higher than F necrophorum in children aged 0-9 years and in adults aged 30-39 years.^[11]

Although Klug determined that the incidence of PTA did not significantly vary by season, the presence of group A Streptococcus was significantly more frequent in winter and spring than in summer, while F necrophorum tended to be found more often in summer than in winter.^[11]

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Prognosis

Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including death, are rare.^[12] Historically, scarlet fever was a major killer at the beginning of the 20th century, and rheumatic fever was a major cause of cardiac disease and mortality. Although the incidence of rheumatic fever has declined significantly, cases that occurred in the 1980s and early 1990s support concern over a resurgence of this condition.

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History

The patient's history determines the type of tonsillitis (ie, acute, recurrent, chronic) that is present.

Individuals with acute tonsillitis present with fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. Symptoms usually resolve in 3-4 days but may last up to 2 weeks despite adequate therapy.

Recurrent streptococcal tonsillitis is diagnosed when an individual has 7 culture-proven episodes in 1 year, 5 infections in 2 consecutive years, or 3 infections each year for 3 years consecutively. Individuals with chronic tonsillitis may present with chronic sore throat, halitosis, tonsillitis, and persistent tender cervical nodes. Children are most susceptible to infection by those in the carrier state.

Individuals with peritonsillar abscess (PTA) present with severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and altered voice quality (the hot-potato voice).

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Physical Examination

Physical examination should begin by determining the degree of distress regarding airway and swallowing function. Examination of the pharynx may be facilitated by opening the mouth without tongue protrusion, followed by gentle central depression of the tongue. Full assessment of oral mucosa, dentition, and salivary ducts may then be performed by gently "walking" a tongue depressor about the lateral oral cavity. Flexible fiberoptic nasopharyngoscopy may be useful in selected cases, particularly with severe trismus. (The images below depict the oral examination.)

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Examination of the tonsils and pharynx.

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Oral mucosal examination.

Acute tonsillitis

Physical examination in acute tonsillitis reveals fever and enlarged inflamed tonsils that may have exudates (see the image below).

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Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with exudates. The uvula is midline.

Group A beta-hemolytic Streptococcus pyogenes and Epstein-Barr virus (EBV) can cause tonsillitis that may be associated with the presence of palatal petechiae. Group A beta-hemolytic Streptococcus (GABHS) pharyngitis usually occurs in children aged 5-15 years.

Open-mouth breathing and voice change (ie, a thicker or deeper voice) result from obstructive tonsillar enlargement. The voice change with acute tonsillitis is usually not as severe as that associated with peritonsillar abscess (PTA). In PTA, the pharyngeal edema and trismus cause a hot-potato voice.

Tender cervical lymph nodes and neck stiffness are observed in acute tonsillitis. Examine skin and mucosa for signs of dehydration. Consider infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when it is accompanied by tender cervical, axillary, and/or inguinal nodes; splenomegaly; severe lethargy and malaise; and low-grade fever. A gray membrane may cover tonsils that are inflamed from an EBV infection (see the image below). This membrane can be removed without bleeding. Palatal mucosal erosions and mucosal petechiae of the hard palate may also be observed.

View Image

Tonsillitis caused by Epstein-Barr infection (infectious mononucleosis). The enlarged inflamed tonsils are covered with gray-white patches.

HSV pharyngitis

An individual with herpes simplex virus (HSV) pharyngitis presents with red, swollen tonsils that may have aphthous ulcers on their surfaces. Herpetic gingival stomatitis, herpes labialis, and hypopharyngeal and epiglottic lesions may be observed.

Peritonsillar abscess

Physical examination of a peritonsillar abscess (PTA) almost always reveals unilateral bulging above and lateral to one of the tonsils. Trismus is always present in varying severity. The abscess rarely is located adjacent to the inferior pole of the tonsil. Inferior pole PTA is a difficult diagnosis to make, and radiologic imaging with a contrast-enhanced CT scan is helpful. Tender cervical adenopathy and torticollis (neck turned in the cock-robin position) may be present. Ipsilateral otalgia may be observed.

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Complications

Be vigilant for signs of impending complications from tonsillitis (eg, mental status changes, severe trismus, high fevers). When necessary, perform further tests or other diagnostic evaluations (eg, CBC counts, CT scanning) in patients with signs of impending complications from tonsillitis.

Treatment of suspected streptococcal pharyngitis with appropriate antibiotics may lead to complications, such as acute rheumatic fever and glomerulonephritis.

Acute tonsillitis

Untreated or incompletely treated tonsillitis can lead to potentially life-threatening complications. Acute oropharyngeal infections can spread distally to the deep neck spaces and then into the mediastinum. Such complications may require thoracotomy and cervical exposure for drainage. Spread beyond the pharynx is suspected in persons with symptoms of tonsillitis who also have high or spiking fevers, lethargy, torticollis, trismus, or shortness of breath. Radiologic imaging using plain films of the lateral neck or CT scans with contrast is warranted for patients in whom deep neck spread of acute tonsillitis (beyond the fascial planes of the oropharynx) is suspected.

The most common complication is adjacent spread just beyond the tonsillar capsule. Peritonsillar cellulitis develops when inflammation spreads beyond the lymphoid tissue of the tonsil to involve the oropharyngeal mucosa. Peritonsillar abscess (PTA), historically referred to as quinsy, is caused by purulence trapped between the tonsillar capsule and the lateral pharyngeal wall; the superior constrictor muscle primarily comprises the lateral pharyngeal wall in this area. Most often, PTA spreads into the retropharyngeal space or into the parapharyngeal space. Spread may result in necrotizing fasciitis. Treatment includes IV antibiotics, surgical debridement, and, in cases of associated toxic shock syndrome, possibly IV immunoglobulins. Distal abscess spread can be life threatening.

Rarely, acute pharyngotonsillitis may lead to thrombophlebitis of the internal jugular vein (Lemierre syndrome). The usual cause of this condition is Fusobacterium necrophorum. A patient who appears toxic following tonsillitis presents with spiking 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 treatment of the source of infection (eg, an abscess) are required. Anticoagulation is controversial. Ligation or excision of the internal jugular vein is required after multiple septic emboli become evident.

GABHS pharyngitis

Complications specific to group A beta-hemolytic Streptococcus pyogenes (GABHS) pharyngitis are scarlet fever, rheumatic fever, septic arthritis, and glomerulonephritis.

Scarlet fever

Scarlet fever manifests as a generalized, nonpruritic, macular erythematous rash that is worse on the extremities and spares the face. The classic strawberry tongue is bright red and tender because of papillary desquamation. The rash lasts up to 1 week and is accompanied by fever and arthralgias. Individuals at risk for this rash are those who do not have antitoxin antibodies to the exotoxin produced by GABHS.

Acute poststreptococcal glomerulonephritis

Acute poststreptococcal glomerulonephritis (AGN) occurs in 10-15% of pharyngitis cases that are caused by the type-12 serotype. AGN follows GABHS by 1-2 weeks. Urinalysis to detect excreted protein may allow detection of subclinical renal injury for persons with recurrent tonsillitis.

Rheumatic fever

Rheumatic fever follows acute pharyngitis by 2-4 weeks and was observed in up to 3% of streptococcal pharyngitides in the mid-20th century. Today, far fewer persons experience this complication, largely because of appropriate antibiotic therapy. Cardiac valvular vegetations affect the mitral and tricuspid valves, leading to murmurs, persistent relapsing fevers, and valvular stenosis or incompetence. A throat swab does not identify the causative organism, because a positive result may reflect colonization rather than pathogenicity. Elevated or rising titers of antistreptolysin (ASO) antibodies, anti-DNAse beta, or antihyaluronidase are required to make the diagnosis.

Septic arthritis

Septic arthritis results in a painful hot joint that contains fluid with bacteria. Arthrocentesis is diagnostic and partially therapeutic. Treatment with IV antibiotics for 6 weeks is required to prevent long-term joint complications.

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Approach Considerations

Tonsillitis and peritonsillar abscess (PTA) are clinical diagnoses. Testing is indicated when group A beta-hemolytic Streptococcus pyogenes (GABHS) infection is suspected. Throat cultures are the criterion standard for detecting GABHS. For patients in whom acute tonsillitis is suspected to have spread to deep neck structures (ie, beyond the fascial planes of the oropharynx), radiologic imaging using plain films of the lateral neck or CT scans with contrast is warranted. In cases of PTA, CT scanning with contrast is indicated.

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).

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Lab Studies

Throat cultures are the criterion standard for detecting group A beta-hemolytic Streptococcus pyogenes (GABHS). GABHS is the principal organism for which antibiotic therapy (sensitivity 90-95%) is definitely indicated. Growing concerns over bacterial resistance make monitoring acute tonsillitis with throat swabs for culture and sensitivity an important endeavor. Relying only on clinical criteria, such as the presence of exudate, erythema, fever, and lymphadenopathy, is not an accurate method for distinguishing GABHS from viral tonsillitis. A Monospot serum test, CBC count, and serum electrolyte level test may be indicated.

A rapid antigen detection test (RADT), also known as the rapid streptococcal test, detects the presence of GABHS cell wall carbohydrate from swabbed material and is considered less sensitive than throat cultures; however, the test has a specificity of 95% or more and produces a result in significantly less time than that required for throat cultures. A negative RADT requires that a throat culture be obtained before excluding GABHS infection.

A culture or RADT is not indicated in most cases following antibiotic therapy for acute GABHS pharyngitis. Routine testing of asymptomatic household contacts is similarly not usually warranted.

Serum may be examined for antistreptococcal antibodies, including antistreptolysin-O antibodies and antideoxyribonuclease (anti-DNAse) B antibodies. Titers are useful for documenting prior infection in persons diagnosed with acute rheumatic fever, glomerulonephritis, or other complications of GABHS pharyngitis.

Laboratory evaluation in chronic tonsillitis relies upon documentation of results of pharyngeal swabs or cultures taken during prior episodes of tonsillitis. The usefulness and cost of throat swabs for pharyngitis are debated.

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Imaging Studies

Routine radiologic imaging is not useful in cases of acute tonsillitis. For patients in whom acute tonsillitis is suspected to have spread to deep neck structures (ie, beyond the fascial planes of the oropharynx), radiologic imaging using plain films of the lateral neck or CT scans with contrast is warranted.

In cases of peritonsillar abscess (PTA), CT scanning with contrast is indicated in general^[13] for unusual presentations (eg, an inferior pole abscess) and for patients at high risk for drainage procedures (eg, patients with coagulopathy or anesthetic risk).

CT scanning may be used to guide needle aspiration for draining PTAs after an unsuccessful surgical attempt and for draining abscesses that are located in unusual locations and are anticipated to be difficult to reach with standard surgical approaches. Hatch and Wu mentioned ultrasonography as another means of guidance in PTA drainage.^[14]

A study by Huang et al indicated that ultrasonography is an accurate means of evaluating patients for PTA, finding that compared with patients diagnosed with PTA via traditional examination methods and/or CT scanning, those who were diagnosed with transcervical ultrasonography demonstrated significant reductions in surgical drainage and length of hospital stay.^[15]

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Approach Considerations

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever. Inability to maintain adequate oral caloric and fluid intake may require IV hydration, antibiotics, and pain control. Home intravenous therapy under the supervision of qualified home health providers or the independent oral intake ability of patients ensures hydration. Intravenous corticosteroids may be administered to reduce pharyngeal edema.

Airway obstruction may require management by placing a nasal airway device, using intravenous corticosteroids, and administering humidified oxygen. Observe the patient in a monitored setting until the airway obstruction is clearly resolving.

Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5 episodes in 2 consecutive years, or 3 or more infections of tonsils and/or adenoids per year for 3 years in a row despite adequate medical therapy, or chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics.

Tonsillitis and its complications are frequently encountered. Antibiotics cure most patients with bacterial tonsillitis, and surgery usually cures patients with infections and complications that are refractory to medical management. Better understanding of the immunology of tonsillitis, actively tracking patterns of bacterial and viral pathogenicity and resistance, and exploring novel technologies for tonsillectomy allow physicians to continue to build on their long experience with these conditions.

Consider transfer of patient care when tonsillitis or its complications cannot be managed safely and expediently. Ensure airway protection for transfer. Ensure that appropriately trained personnel accompany the patient during transfer. Children younger than 3 years may require transfer because of the special care needed during tonsillitis or its complications. Patients with syndromic diagnoses (eg, trisomy 21) and patients with hematologic problems may benefit from transfer to facilities that have the availability of subspecialist care.

Discharge of the patient from the hospital occurs after the patient and caregivers can demonstrate compliance with oral pain medication and antibiotics. To confirm clinical improvement, follow-up care by telephone contact or physical examination may be useful in 2-4 weeks after the acute episode. Follow-up throat swabs and cultures are usually not necessary, unless family or personal history of rheumatic fever exists, significant recurrent tonsillitis is evident, or family members continue to reinfect each other.

Consultations with infectious disease, hematologic, and pediatric subspecialists are valuable in selected cases.

A study by Battaglia et al indicated that medical therapy alone for uncomplicated peritonsillar abscess presenting in the emergency department is equally as effective as medical treatment plus surgery but is also associated with less pain and opioid use and fewer days off from work. This was particularly true in patients presenting without trismus. Medical treatment included the use of intravenous (IV) fluids, weight-appropriate IV ceftriaxone, clindamycin, and dexamethasone, with the patients subsequently discharged on clindamycin for 10 days. Surgical treatment consisted of drainage.^[16]

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Corticosteroids

Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin may be helpful. Symptoms of MN may last for several months. Corticosteroids are also indicated for patients with airway obstruction, hemolytic anemia, and cardiac and neurologic disease. Inform patients of complications from steroid use.

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Antibiotics

Antibiotics are reserved for secondary bacterial pharyngitis. Because of the risk of a generalized papular rash, avoid ampicillin and related compounds when infectious mononucleosis (MN) is suspected. Similar reactions from oral penicillin–based antibiotics (eg, cephalexin) have been reported. Therefore, initiate therapy with another antistreptococcal antibiotic, such as erythromycin.

Administer antibiotics if conditions support a bacterial etiology, such as the presence of tonsillar exudates, presence of a fever, leukocytosis, contacts who are ill, or contact with a person who has a documented group A beta-hemolytic Streptococcus pyogenes (GABHS) infection. In many cases, bacterial and viral pharyngitis are clinically indistinguishable. Waiting 1-2 days for throat culture results has not been shown to diminish the usefulness of antibiotic therapy in preventing rheumatic fever.

GABHS infection

GABHS infection obligates antibiotic coverage. Bisno et al stated in practice guidelines for the diagnosis and management of GABHS that the desired outcomes of therapy for GABHS pharyngitis are the prevention of acute rheumatic fever, the prevention of suppurative complications, the abatement of clinical symptoms and signs, the reduction in transmission of GABHS to close contacts, and the minimization of potential adverse effects of inappropriate antimicrobial therapy.^[17]

Administering oral penicillin for 10 days is the best treatment of acute GABHS pharyngitis.^[18] Intramuscular penicillin (ie, benzathine penicillin G) is required for persons who may not be compliant with a 10-day course of oral therapy. Penicillin is optimal for most patients (barring allergic reactions) because of its proven safety, efficacy, narrow spectrum, and low cost.

Other antibiotics proven effective for GABHS pharyngitis are the penicillin congeners, many cephalosporins, macrolides, and clindamycin. Clindamycin may be of particular value because its tissue penetration is considered equivalent for both oral 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. Reduced-frequency dosing is recommended to improve compliance with medication regimens. A consensus on the efficacy of such dosing has not yet been formulated.

Most cases of acute pharyngitis are self-limited, with clinical improvement observed in 3-4 days. Clinical practice guidelines state that avoiding antibiotic therapy for this time period is safe and a delay of up to 9 days from symptom onset to antimicrobial treatment should still prevent the major complication of GABHS (ie, acute rheumatic fever).

Recurrent tonsillitis may be managed with the same antibiotics as acute GABHS pharyngitis. If the infection recurs shortly after a course of an oral penicillin agent, then consider IM benzathine penicillin G. Clindamycin and amoxicillin/clavulanate have been shown to be effective in eradicating GABHS from the pharynx in persons experiencing repeated bouts of tonsillitis. A 3- to 6-week course of an antibiotic against beta-lactamase–producing organisms (eg, amoxicillin/clavulanate) may allow tonsillectomy to be avoided.

Carrier state should be treated when the family has a history of rheumatic fever, a history of glomerulonephritis in the carrier, a "ping pong" spread of infection between household contacts of the carrier, familial anxiety regarding the implications of GABHS carriage, infectious outbreak within a closed community such as a school, an outbreak of acute rheumatic fever, or when tonsillectomy may be under consideration to treat the chronic carriage of GABHS.

Peritonsillar abscess

Peritonsillar cellulitis may respond to oral antibiotics. Antibiotics, either orally or intravenously, are required to treat peritonsillar abscess (PTA) medically, although most PTAs are refractory to antibiotic therapy alone. Penicillin, its congeners (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 10-day course of an oral antibiotic is prescribed.

Beta-lactamase resistance

Beta-lactamase resistance of streptococcal species may now be observed in up to a third of community-based streptococcal infections. This resistance is probably due to the presence of copathogens that are beta-lactamase–producing organisms, such as H influenzae and Moraxella catarrhalis. These organisms are able to degrade the beta-lactam ring of penicillin and make an otherwise sensitive GABHS act resistant to beta-lactam antibiotics. In one study, erythromycin did not inhibit nearly half of S pyogenes isolates. The limited precision of many throat swabs may reduce the usefulness of these samples.

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Tonsillectomy

Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5 episodes in 2 consecutive years or 3 or more infections for 3 years in a row, or chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics. Tonsillectomy may be considered for children when multiple antibiotic allergies or intolerances are seen, as well as for children with periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA), or a history of peritonsillar abscess.^[19]

Time missed from school or work and severity of illness (eg, whether hospitalization was required) are important considerations in recommending tonsillectomy.

Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and because minimal additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform an adenoidectomy if adenoids are present and inflamed at the time of tonsillectomy. However, this point remains controversial.

Recurrent tonsillitis after tonsillectomy is extremely rare. Tonsillectomy reduces the bacterial load of group A beta-hemolytic Streptococcus pyogenes (GABHS) and may also allow an increase in alpha-Streptococcus, which can be protective against GABHS infection. Recurrent tonsillitis is usually due to regrowth of tonsillar tissue, which is treated by excision.

Tonsillectomy with or without adenoidectomy is the treatment for chronic tonsillitis. In cases of chronic tonsillitis, specific technical considerations for tonsillectomy include awareness of a higher intraoperative and perioperative bleeding risk and awareness that dissection may be more difficult because of fibrosis and scarring of the tonsillar capsule. Such considerations may affect instrument selection and discharge decisions.

Surgery is rarely required for acute lingual tonsillitis, but surgery is indicated for frequent and disabling episodes of this uncommon malady. Tonsillar hypertrophy that persists after resolution of mononucleosis and causes obstructive airway symptoms may necessitate tonsillectomy.

A literature review by Morad et al indicated that in the short-term (< 12 mo), children with recurrent throat infections who undergo tonsillectomy/adenotonsillectomy demonstrate greater reductions in sore throat days, clinician contacts, diagnosed group A streptococcal infections, and school absences than do such children treated with watchful waiting. However, quality-of-life scores did not significantly differ between the two groups, and the evidence was not strong enough to determine whether the greater tonsillectomy/adenotonsillectomy-associated benefits would persist in the longer term.^{[20, 21]}

A study by Wang et al indicated that tonsillectomy increases the risk of deep neck infections. Using a health insurance research database search, the investigators found patients to be at 1.71-fold greater risk of deep neck infection after undergoing tonsillectomy.^[22]

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 incidence of posttonsillectomy bleeding in children, but not in adults. In the study, Suzuki et al found that the rate of reoperation for bleeding was 1.2% for children aged 15 years or younger who received intravenous steroids, versus 0.5% for patients in the same age group who did not. Among patients older than 15 years, however, the reoperation rate was not significantly higher in the steroid patients than in the controls (1.7% vs. 1.4%).^{[23, 24]}

A retrospective study by Spektor et al indicated that the risk of postoperative bleeding in children undergoing tonsillectomy is increased when the surgery is performed on a child with recurrent tonsillitis (4.5 times increased risk), on a child with attention deficit hyperactivity disorder (8.7 times increased risk), or on an older child (twice the bleeding risk in children aged 11 years or above).^[25]

Similarly, a study by Kshirsagar et al indicated that in children undergoing outpatient tonsillectomy with or without adenoidectomy, the risk of immediate postoperative bleeding is increased by older age (age between 9 and 18 years) and obesity, with the latter making the likelihood of hemorrhage about 2.3 times greater.^[26]

A literature review by De Luca Canto et al indicated that respiratory compromise is 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, the risk of respiratory complications is 4.9 times higher in those who have obstructive sleep apnea than in children who do not, but the risk of postoperative bleeding is lower.^{[27, 28]}

A study by Galindo Torres et al of tonsillectomy in adults found bleeding to be the complication that recurred the most (5.21% of tonsillectomies). Bleeding risk did not seem to have a statistically significant association with whether the tonsillar pillars were sutured or not or with surgical indication. Tonsillitis was the most frequent indication for surgery (74.85%).^[29]

Peritonsillar abscess

Treatment of peritonsillar abscess (PTA) includes aspiration and incision and drainage (I&D). The term quinsy tonsillectomy refers to tonsillectomy performed to treat PTA. Bilateral tonsillectomy is usually performed in these cases, and the abscessed tonsil is usually easier to remove during surgery than the inflamed contralateral tonsil. The abscessed tonsil is easier to remove because the abscess partially dissects the tonsil from the pharyngeal musculature.

When PTA is suspected, aspiration with a needle may be attempted to confirm the diagnosis and to remove some of the purulence. The area of the PTA is first anesthetized by infiltration with local anesthetic or by spray or sponge application of topical anesthesia (eg, Americaine, benzocaine). Sedation may be helpful but should be administered only in a facility that is appropriately staffed and equipped.

Tonsillectomy is indicated for PTA associated with chronic or recurrent tonsillitis or for exposure of the abscess in unusual cases. Newer techniques and technologies offer improved recovery and reduced complications from surgery.^[30] Acute tonsillectomy is generally regarded as a safe and effective treatment of PTA. Some physicians advocate immediate tonsillectomy for younger patients with PTA. Removing "hot" tonsils (ie, those that are acutely infected) carries the expectation of higher intraoperative blood loss and a higher risk of immediate and delayed post-tonsillectomy hemorrhage.

During surgery, if the abscess cannot be located in the usual superior lateral region of the tonsillar fossa, then careful exploration with needle aspiration may locate the collection, allowing for wide exposure and drainage. Tonsillectomy may be required for exposure in such cases. A CT scan with contrast may be indicated.

Fleshy or pale, granular tonsillar tissue may indicate a neoplasm. Immunohistopathologic examination is indicated in such cases.

Aspiration

An 18-gauge needle on a 1 mL tuberculin syringe is placed into the pointing area, taking care not to penetrate the pharyngeal mucosa more than 1 inch in order to prevent injury to the vessels and nerves of the parapharyngeal space. Bending a sheathed needle at 2 points may prevent deeper injury during aspiration.^[31] If attempt at aspiration from 3 different peritonsillar sites does not locate the abscess, the patient should be treated with oral or IV antibiotics. If symptoms persist after 24-48 hours of therapy, CT scanning with contrast may be performed.

Once purulence is detected, complete aspiration may be attempted. Sufficient material should be available for Gram stain and cultures with antibiotic sensitivities. Not all patients need microbiologic evaluation. For those who are immunosuppressed or who have developed a PTA after several days of appropriate antibiotic therapy, aspirated material should be sent for Gram stain, culture, and sensitivity tests.

Incision and drainage

After needle aspiration, incision and drainage may be performed using a knife. The handle of a knife with an attached No. 15 blade is taped 1 inch from the tip to prevent deep penetration through the mucosa. A gentle curvilinear incision, not more than half an inch deep, is fashioned along the perimeter of the tonsillar capsule and through the point from which pus was evacuated. A widely tipped blunt clamp (eg, Kelly clamp) is used to widely open the loculated pockets of purulence. A sponge-covered finger to break loculations is ideal. Rinsing with half-strength hydrogen peroxide solution aids hemostasis. When the patient is dehydrated and uncomfortable, this well-intentioned procedure is not greeted with enthusiasm from the patient.

Sedation, hydration, analgesia, and anesthesia (at the least, topical or local) are important. There may be a role for intravenous dexamethasone in reducing pain after drainage.^[32] Some adults and most children require deeper levels of sedation or general anesthesia for safe and adequate aspiration or drainage. An institution with a carefully designed policy for incision and drainage of PTA with conscious sedation, including appropriate indications, staff, and criteria, may offer sedation to children.

Exposure of the posterior oropharynx for aspiration and incision and drainage is achieved by using the nondominant hand to grasp the tongue with a sponge while the patient opens his or her mouth. In patients with severe trismus, a tongue blade may be used to depress the midportion of the tongue. Magnifying and illuminating loupes, such as the LumiView, are the best sources of light. A headlight or mirror is also effective. Arranging the instruments in order of use on a tray adjacent to the physician's dominant hand facilitates rapid accomplishment of this procedure. In experienced hands, this procedure should take fewer than 3 minutes from aspiration to rinsing with peroxide.

After the procedure, the patient is observed in accordance with sedation and anesthetic protocols. Hospitalization for adults and for older children is rarely required. The patient is discharged with a prescription for an oral antibiotic (10-day course of therapy), a prescription for an oral narcotic for pain control (taking care to avoid antiplatelet agents), and instructions to maintain hydration and control fever. Antibiotic therapy may be altered after cultures return. A follow-up office visit or telephone call is made in 2-4 weeks after the procedure to confirm symptomatic resolution.

A retrospective study by Windfuhr and Zurawski indicated that incisional drainage as a first-line treatment for peritonsillar abscess decreases the hemorrhage rate from that associated with abscess tonsillectomy (0.3% vs 5.1%, respectively) and significantly reduces inpatient treatment days (4 vs 7 days, respectively). The study involved 775 patients, including 443 who underwent abscess tonsillectomy and 332 who were treated with incisional drainage.^[33]

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Diet and Activity

Hydration is important, and the oral route is usually adequate. Intravenous fluids may be required for severe dehydration. Hyperalimentation is rarely necessary. Adequate rest for adults and children with tonsillitis accelerates recovery. In order to reduce risk of splenic rupture in persons diagnosed with systemic mononucleosis, patients must be cautioned against activities that may cause abdominal injury.

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Prevention

Avoidance of contact with individuals who are ill or patients who are immunocompromised is useful.

The use of the antipneumococcal vaccine may help to prevent acute tonsillitis; however, to date, experience is insufficient to determine whether prevention is likely to occur.

• References

Guidelines Summary

In 2012, the Infectious Diseases Society of America (IDSA) released updated guidelines for the diagnosis and management of group A streptococcal (GAS) pharyngitis. Recommendations for diagnosis and testing are summarized as follows^[17] :

• Testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed to distinguish between GAS and viral pharyngitis
• In children and adolescents, negative RADT results should be backed up by a throat culture; positive results are highly specific and do not require a backup culture
• In adults, routine use of backup throat cultures for those with a negative RADT is not necessary because the risk of subsequent acute rheumatic fever is low in adults with acute pharyngitis
• Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis
• In general, testing for GAS pharyngitis is not recommended for children or adults with a clinical presentation that strongly suggests a viral etiology (eg, cough, rhinorrhea, hoarseness, oral ulcers)
• Acute rheumatic fever is rare in children under age 3 years, and the incidence and classic presentation of streptococcal pharyngitis are uncommon in this age group; thus, testing for GAS pharyngitis is not indicated for children under age 3 years; however, children under age 3 years who have other risk factors, such as an older sibling with GAS infection, may be considered for testing
• Diagnostic testing or treatment of asymptomatic close contacts of patients with acute streptococcal pharyngitis is not routinely recommended

ISDA guideline recommendations for treatment include the following^[17] :

• Patients with confirmed GAS pharyngitis should be treated for a duration likely to eradicate GAS from the pharynx (usually 10 days) with an appropriate narrow-spectrum antibiotic
• Penicillin or amoxicillin is the drug of choice for those without a contraindication
• Alternative agents for penicillin-allergic individuals include a first-generation cephalosporin, clindamycin, or clarithromycin for 10 days, or azithromycin for 5 days 
• An analgesic such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) may be considered as an adjunct to an appropriate antibiotic for treatment of moderate to severe symptoms or control of high fever; aspirin should be avoided in children
• Adjunctive therapy with a corticosteroid is not recommended
• In patients with recurrent episodes of pharyngitis, consider the possibility that they are a chronic pharyngeal GAS carrier who is experiencing repeated viral infections
• Efforts to identify GAS carriers are not justified because they have a low risk of transmitting GAS pharyngitis to their close contacts and little or no risk for the development of acute rheumatic fever
• Tonsillectomy is not recommended to reduce the frequency of GAS pharyngitis

In joint guidelines for appropriate antibiotic use for acute respiratory tract infection in adults, published in 2016, the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) note that adult patients may be assured that antibiotics are usually not needed for a sore throat because they do little to alleviate symptoms and may have adverse effects.^[34]

The 2011 clinical practice guidelines on tonsillectomy in children released by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) offers the following recommendations^[19] :

• If there have been fewer than seven episodes of recurrent throat infection in the past year or fewer than five episodes per year in the past 2 years or fewer than three episodes per year in the past 3 years, watchful waiting is preferred over tonsillectomy
• Tonsillectomy is indicated for recurrent throat infection of at least seven episodes in the past year or at least five episodes per year for 2 years or at least three episodes per year for 3 years with documentation of one or more of the following: temperature above 38.3°C, cervical adenopathy, tonsillar exudate, and/or positive test for Group A β-hemolytic streptococcus (GABHS)
• Tonsillectomy may be considered in children who do not meet the above criteria but have multiple antibiotic allergies/intolerances, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or a history of peritonsillar abscess

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Medication Summary

Medications that are used to manage tonsillitis include antibiotics, anti-inflammatory agents (eg, corticosteroids), antipyretics and analgesics (eg, acetaminophen, ibuprofen), and immunologic agents (eg, gamma globulin).

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Dexamethasone (Baycadron)

• Dosing, Interactions, etc.

Clinical Context:  Dexamethasone is a short-acting, rapid-onset glucocorticoid.

• References

Prednisone

• Dosing, Interactions, etc.

Clinical Context:  Prednisone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

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Prednisolone (Pediapred, Millipred, Orapred)

• Dosing, Interactions, etc.

Clinical Context:  Prednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

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Class Summary

Corticosteroids have anti-inflammatory 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.

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Penicillin G benzathine (Bicillin L-A)

• Dosing, Interactions, etc.

Clinical Context:  Penicillin interferes with synthesis of cell wall mucopeptides during active multiplication, which results in bactericidal activity.

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Clarithromycin (Biaxin)

• Dosing, Interactions, etc.

Clinical Context:  Clarithromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. It is a semisynthetic macrolide with twice-daily dosing.

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Clindamycin (Cleocin)

• Dosing, Interactions, etc.

Clinical Context:  Clindamycin is an oral or parenteral antibiotic that is used for the treatment of anaerobic or susceptible streptococcal, pneumococcal, or staphylococcal species. It is considered to have good absorption into the bloodstream in both oral and parenteral forms.

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Vancomycin

• Dosing, Interactions, etc.

Clinical Context:  Vancomycin is indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci. To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose, drawn 30 minutes prior to the next dosing. Use creatinine clearance (CrCl) to adjust the dose in patients diagnosed with renal impairment. It is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

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Rifampin (Rifadin)

• Dosing, Interactions, etc.

Clinical Context:  Rifampin is an inhibitor of bacterial DNA-dependent RNA polymerase activity.

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Amoxicillin (Moxatag)

• Dosing, Interactions, etc.

Clinical Context:  Amoxicillin is an oral antibiotic with specific activity against penicillin-resistant organisms; it is often combined with the beta-lactamase inhibitor clavulanic acid.

• References

Amoxicillin and clavulanate (Augmentin, Amoclan, Augmentin XR)

• Dosing, Interactions, etc.

Clinical Context:  Amoxicillin is a third-generation aminopenicillin. Combined with the beta-lactam clavulanic acid, it is less susceptible to degradation by beta-lactamases produced by microorganisms.

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Metronidazole (Flagyl)

• Dosing, Interactions, etc.

Clinical Context:  Metronidazole is effective in patients with tonsillitis and mononucleosis, for shortening fever duration and reducing tonsillar size, and in management of acute episodes of nonstreptococcal tonsillitis.

• References

Ampicillin and sulbactam (Unasyn)

• Dosing, Interactions, etc.

Clinical Context:  This is a drug combination of a beta-lactamase inhibitor with ampicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin/clavulanate if the patient is unable to take medication orally.

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Class Summary

Antibiotic therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

• References

Immune globulin intravenous (Gammagard, Gamunex-C, Octagam)

• Dosing, Interactions, etc.

Clinical Context:  Intravenous immune globulin is pooled human immune globulin. Because of a shortage of supply, it is reserved for use for severe infections. It should be used in accordance with institutional policies. Its use in the past was more common for various indications.

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Class Summary

These agents are used to improve clinical aspects of the disease. It stimulates immune cells, reducing the severity of infection.

• References

Aspirin (Bayer Aspirin, Ecotrin, Aspercin, Ascriptin, Bufferin)

• Dosing, Interactions, etc.

Clinical Context:  Aspirin lowers elevated body temperature by dilating peripheral vessels, enhancing the dissipation of excess heat. It also acts on the heat-regulating center of the hypothalamus to reduce fever.

• References

Ibuprofen (Motrin, Advil, NeoProfen, Caldolor, Ultraprin)

• Dosing, Interactions, etc.

Clinical Context:  Ibuprofen is one of the few nonsteroidal anti-inflammatory drugs (NSAIDs) indicated for reduction of fever.

• References

Acetaminophen (Tylenol, APAP 500, Mapap, FeverAll)

• Dosing, Interactions, etc.

Clinical Context:  Acetaminophen reduces fever by acting directly on hypothalamic heat-regulating centers, thereby bringing about increased dissipation of body heat with vasodilation and sweating.

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Class Summary

Pain and fever control are essential to quality patient care. Analgesics with antipyretic properties ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.

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