Summary

Acute Tonsillitis is inflammation of the palatine tonsils, usually part of a wider pharyngitis. It is extremely common in children and young adults. The majority of cases (70-80%) are Viral (Adenovirus, Rhinovirus, EBV) and self-limiting. Bacterial cases (Group A Beta-Haemolytic Streptococcus - GABHS) require antibiotics to shorten duration and prevent complications like Rheumatic Fever (though rare in developed nations). The key clinical skill is distinguishing bacterial from viral infection using the Centor or FeverPAIN criteria. Major complications include Peritonsillar Abscess (Quinsy), which presents with trismus and requires drainage, and Deep Neck Space Infections. Recurrent severe tonsillitis is treated with Tonsillectomy, which carries a significant risk of delayed haemorrhage.

Key Facts

• Most Common Cause: Viral (70%).
• Most Common Bacterial: Streptococcus Pyogenes (Group A Strep).
• Antibiotic of Choice: Phenoxymethylpenicillin (Penicillin V).
• Contraindication: Amoxicillin/Ampicillin must be avoided if Glandular Fever (EBV) is suspected, as it causes a severe maculopapular rash.
• Quinsy: Collection of pus between the tonsil capsule and the superior constrictor muscle.

Clinical Pearls

"Hot Potato Voice": The muffled, thick speech of a patient with severe tonsillar swelling or Quinsy. It sounds like they are holding a hot potato in their mouth to avoid burning their tongue.

"Trismus is the tell": If a patient with sore throat CANNOT OPEN THEIR MOUTH (Trismus), it is a Quinsy until proven otherwise. Inflammation of the pterygoid muscles causes the spasm.

"Kissing Tonsils": When both tonsils are so huge they touch in the midline. In a child, checking O2 sats is vital – they can obstruct their airway when they sleep (OSA).

"The EBV Rash": If you give Amoxicillin to a teenager with a sore throat and they come back covered in a bright red rash, you have just diagnosed Glandular Fever (infectious mononucleosis).

          PATIENT WITH SORE THROAT
                     ↓
        ASSESS SEVERITY (Airway/Sepsis?)
         Assess TRISMUS (Quinsy?)
                     ↓
      ┌──────────────┼───────────────┐
    SEVERE         QUINSY          SIMPLE
  (Dehydrated/    (Abscess)       TONSILLITIS
   Airway risk)      |               ↓
      ↓              ↓          CENTOR SCORE?
    ADMIT         ADMIT +       ┌────┴────┐
   IV FLUIDS     DRAINAGE      0-2       3-4
   IV ABX        IV ABX         ↓         ↓
   STEROIDS                     NO ABX   CONSIDER
                             (Supportive) PEN V

1. Supportive Care (First Line)

• Analgesia: Paracetamol + Ibuprofen. (Crucial to enable swallowing).
• Hydration: Sips of water.
• Topical: Difflam (Benzydamine) spray/gargle.

2. Antibiotics

• Indication: Centor 3-4, Systemically unwell, Immunocompromised.
• First Line: Phenoxymethylpenicillin (Penicillin V) 500mg QDS for 10 days.
• Allergy: Clarithromycin or Erythromycin.
• Avoid: Amoxicillin (Risk of rash if EBV).

3. Steroids

• Dexamethasone: Single dose (e.g. 6.6mg or 8mg) reduces pain and swelling. Used in severe hospital cases (SIGN 117).

Indications (SIGN 117 / Paradise Criteria)

"The Rule of 7-5-3"

1. 7 episodes in the last 1 year.
2. 5 episodes/year for 2 years.
3. 3 episodes/year for 3 years.

• Episodes must be disabling preventing normal function.
• Other indications: Quinsy x2, Suspected Malignancy (Unilateral enlargement), Sleep Apnoea (OSA).

Technique (Dissection Tonsillectomy)

1. Position: "Rose position" (Neck extended, mouth gag).
2. Dissection: Tonsil grasped. Mucosa incised.
3. Plane: Dissected in the loose plane between tonsil capsule and muscular bed (Superior Constrictor).
4. Haemostasis: Bipolar diathermy or Ties. (Note: Diathermy increases pain but reduces intra-op blood. Cold steel reduces pain).
5. Poles: Superior and Inferior poles are vascular.

A Major ENT Emergency.

Infectious Mononucleosis

• Etiology: Epstein-Barr Virus.
• Adolescents: "Kissing Disease".
• Features:
  • Severe tonsillitis (thick creamy exudate).
  • Posterior Cervical Lymphadenopathy.
  • Hepatosplenomegaly (Risk of splenic rupture).
  • Fatigue (can last months).
• Diagnosis: Monospot +ve. Lymphocytosis.
• Advice: NO CONTACT SPORTS for 6-8 weeks (risk of splenic rupture). No alcohol (Liver).

Landmark Trials

1. Paradise Study: Established the 7/5/3 criteria compared to conservative management.
2. N-ICE Trial: Coblation vs Dissection tonsillectomy. Coblation has less pain but slightly higher bleed rate.

NICE NG84

• Do not prescribe antibiotics for typical viral sore throats.
• Use FeverPAIN or Centor to guide prescribing.
• Safety net: "Come back if not better in 1 week or unable to swallow".

What is Tonsillitis?

It is swelling of the tonsils (the two lumps at the back of your throat). It is usually caused by a virus (like a cold) but sometimes by bacteria (Strep).

Do I need antibiotics?

Usually, no. Most cases get better on their own in 3-4 days. Antibiotics only shorten the illness by about 12 hours and can cause side effects. We save them for severe cases (high fever, pus spots).

Why can't I play rugby? (Glandular Fever)

If you have Glandular Fever, your spleen (an organ under your left ribs) swells up. It becomes fragile. A tackle or fall could cause it to burst, which causes dangerous internal bleeding. You must avoid contact sports for a few weeks.

When should I have my tonsils out?

We don't take them out as often as we used to. We only do it if you are having severe tonsillitis again and again (e.g. 7 times in a year) and it is affecting your school or work.