Tonsillitis

1. Clinical Overview

Summary

Tonsillitis is acute inflammation of the palatine tonsils, predominantly caused by viral or bacterial infection. It represents one of the most common reasons for primary care and Emergency Department attendance, with approximately 1.1 million ambulatory care visits annually in the United States alone. While most cases are viral and self-limiting, accurate identification of bacterial tonsillitis—particularly Group A Streptococcus (GAS)—is crucial to prevent both suppurative complications (peritonsillar abscess, parapharyngeal abscess, Lemierre's syndrome) and non-suppurative sequelae (acute rheumatic fever, post-streptococcal glomerulonephritis). Clinical decision tools such as the Centor criteria and FeverPAIN score guide rational antibiotic prescribing and reduce antimicrobial overuse. [1,2,3]

Key Facts

• Incidence: Extremely common; approximately 1.1 million annual ambulatory visits in the USA; peaks in 5-15 age group but affects all ages including adults. [1]
• Aetiology: Viral (70-80%), Bacterial (20-30%)—predominantly Group A Streptococcus (Streptococcus pyogenes). [2,3]
• Natural History: Viral tonsillitis resolves in 3-4 days; bacterial in 7 days without treatment, shortened to approximately 5.5 days with antibiotics.
• Antibiotic Benefit: Shortens symptom duration by approximately 16 hours if bacterial; reduces suppurative complications by approximately 50%; prevents acute rheumatic fever if started within 9 days. [4,5]
• Complications: Peritonsillar abscess (quinsy) occurs in 1-3% of untreated bacterial cases; parapharyngeal abscess; Lemierre's syndrome (septic thrombophlebitis of internal jugular vein); acute rheumatic fever; post-streptococcal glomerulonephritis. [6,7]
• Key Tools: FeverPAIN score (NICE-recommended) or Centor criteria (Modified McIsaac) to stratify GAS probability and guide antibiotic prescribing. [1,8]
• Glandular Fever: Epstein-Barr virus (EBV) causes severe exudative tonsillitis in adolescents/young adults; giving amoxicillin or ampicillin causes widespread maculopapular rash in 90-100% of cases. [9]

Clinical Pearls

The Centor Score: Originally validated for adults 15-44 years. Score 3-4 has approximately 40-60% probability of GAS. Score 0-1 has less than 10% probability—antibiotics not needed. The McIsaac modification adds age stratification to improve accuracy. [8,10]

Infectious Mononucleosis Trap: EBV causes severe bilateral exudative tonsillitis with marked tonsillar enlargement, posterior cervical lymphadenopathy, and hepatosplenomegaly. Giving amoxicillin or ampicillin causes a widespread maculopapular rash. Always consider EBV in teenagers/young adults (15-24 years) with severe tonsillitis, marked fatigue, and posterior cervical nodes. [9]

The Quinsy: Peritonsillar abscess is the most common deep neck space infection in adults. Classical triad: unilateral tonsillar swelling with bulge, uvula deviation AWAY from affected side, trismus (pterygoid muscle spasm). "Hot potato" voice (muffled, inability to articulate clearly). This is a surgical emergency requiring drainage. [6]

Watchful Waiting: NICE NG84 recommends "delayed (back-up) antibiotic prescription" rather than immediate antibiotics for intermediate-risk sore throats (FeverPAIN 2-3). Reduces antibiotic use by 30-50% without adverse outcomes or increased complications. [1,4]

Lemierre's Syndrome: The "forgotten disease" caused by Fusobacterium necrophorum. Presents with severe pharyngitis progressing to septic thrombophlebitis of internal jugular vein, septic pulmonary emboli, and metastatic abscesses. Affects adolescents/young adults (15-25 years). High mortality (5-18%) if untreated. Requires prolonged IV antibiotics (metronidazole + ceftriaxone). [7]

Avoid Amoxicillin in Tonsillitis: Phenoxymethylpenicillin (penicillin V) is first-line, not amoxicillin. Amoxicillin has broader spectrum (unnecessary for GAS), higher risk of resistance, and causes rash if EBV present. Reserve amoxicillin for specific indications (e.g., Lyme disease, H. pylori). [3]

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2. Epidemiology

Incidence and Demographics

• Overall: Approximately 1.1 million ambulatory care visits per year in the United States for acute pharyngitis/tonsillitis. [1]
• Peak Age: Bacterial (GAS) tonsillitis peaks at 5-15 years, but adults (15-44 years) represent a significant proportion of cases. [2,3]
• Sex: Equal distribution; no significant sex predilection.
• Seasonality: Winter and early spring peaks correlate with respiratory virus circulation and crowded indoor environments.
• Geography: Worldwide distribution; acute rheumatic fever more common in low-resource settings due to limited access to antibiotics.
• Recurrence: 15-25% of children and adolescents experience recurrent tonsillitis meeting surgical criteria; recurrence rates in adults are lower but still significant (approximately 10-15%).

Causative Organisms

Viral Causes (70-80% of all cases) [2,3]

Bacterial Causes (20-30% of cases) [2,3,11]

Infectious Mononucleosis (EBV) - Special Considerations [9]

• Demographics: Peak incidence 15-24 years ("kissing disease"); by age 40, over 90% seropositive.
• Transmission: Salivary exchange (kissing, shared drinks); prolonged viral shedding (up to 18 months post-infection).
• Clinical Features: Severe pharyngitis with bilateral tonsillar exudates (resembles bacterial); massive tonsillar enlargement (risk of airway obstruction); posterior cervical and generalised lymphadenopathy; hepatosplenomegaly (50%); palatal petechiae (25%); jaundice (5-10%); rash (10% spontaneous; 90-100% if given ampicillin/amoxicillin).
• Duration: Acute illness 2-4 weeks; fatigue may persist for 3-6 months.
• Complications: Splenic rupture (0.1-0.5%); airway obstruction from massive tonsils; autoimmune haemolytic anaemia; thrombocytopenia; neurological (encephalitis, Guillain-Barré syndrome); chronic active EBV (rare).

Fusobacterium necrophorum and Lemierre's Syndrome [7]

• Demographics: Peak incidence 15-25 years; previously healthy young adults.
• Incidence: Approximately 0.8-2.3 cases per million per year; increasing incidence in antibiotic-sparing era.
• Presentation: Severe pharyngitis → bacteraemia → septic thrombophlebitis of internal jugular vein → septic pulmonary emboli → metastatic abscesses (liver, spleen, joints, brain).
• Mortality: 5-18% despite treatment; higher if diagnosis delayed.
• Imaging: CT neck with IV contrast shows internal jugular vein thrombosis; chest CT shows septic emboli (cavitating nodules).

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3. Pathophysiology

Step 1: Normal Tonsillar Structure and Function

• Anatomical Location: Palatine tonsils located in lateral oropharynx between palatoglossal and palatopharyngeal arches (anterior and posterior pillars).
• Part of Waldeyer's Ring: Lymphoid tissue ring including palatine tonsils, adenoids (nasopharyngeal tonsil), lingual tonsil, and tubal tonsils (around Eustachian tube openings).
• Histological Structure: Lymphoid follicles with germinal centres; stratified squamous epithelium with 10-30 crypts per tonsil; crypts increase surface area for antigen sampling.
• Immunological Function: First-line immune surveillance; sample inhaled and ingested antigens; initiate local and systemic immune responses; produce IgA, IgG, IgM; contain B cells, T cells (CD4+ and CD8+), plasma cells, macrophages, dendritic cells.
• Blood Supply: Tonsillar branch of facial artery (primary); ascending pharyngeal artery; lesser palatine artery; dorsal lingual artery (tonsillar bed highly vascular).
• Lymphatic Drainage: Jugulodigastric node (level II cervical chain) is primary "tonsillar node"; drains to deep cervical chain.

Step 2: Microbial Adherence and Colonisation

• Entry: Pathogens enter via respiratory droplets, direct contact, or salivary exchange.
• Adherence: Viruses and bacteria adhere to tonsillar epithelium via specific receptors.
  • "GAS adherence: M protein, lipoteichoic acid, fibronectin-binding proteins bind to epithelial cells; protein F mediates internalisation."
  • "Viral adherence: EBV binds CD21 (complement receptor 2) on B cells and epithelial cells; rhinovirus binds ICAM-1 (intercellular adhesion molecule-1)."
• Colonisation: Pathogens replicate within epithelial cells and tonsillar crypts; form biofilms (bacterial tonsillitis).

Step 3: Immune Activation and Inflammation

• Innate Immunity: Pattern recognition receptors (TLRs) on epithelial cells and macrophages recognise pathogen-associated molecular patterns (PAMPs).
  • "TLR2/6: Recognise bacterial lipoteichoic acid and peptidoglycan."
  • "TLR3/7/8: Recognise viral RNA."
  • "TLR4: Recognises lipopolysaccharide (Gram-negative bacteria)."
• Cytokine Release: IL-1β, IL-6, IL-8, TNF-α cause local vasodilation, increased vascular permeability, neutrophil recruitment.
• Adaptive Immunity: Antigen-presenting cells (dendritic cells, macrophages) activate T cells; B cells produce antibodies.
  • "Viral infections: Predominantly CD8+ T cell (cytotoxic) response; interferon production."
  • "Bacterial infections: Predominantly neutrophil and antibody-mediated response."

Step 4: Clinical Manifestations

• Tonsillar Enlargement: Lymphoid hyperplasia (B and T cell proliferation) plus oedema (vascular permeability).
  • Grading: 0 (within fossa) → 1+ (less than 25% airway) → 2+ (25-50%) → 3+ (50-75%) → 4+ (greater than 75%, "kissing tonsils").
• Exudate Formation: Combination of fibrin, dead epithelial cells, neutrophils, bacteria/viruses, cellular debris; appears as white/yellow patches or confluent membrane.
  • "Bacterial exudate: Purulent (neutrophil-rich); discrete patches or confluent."
  • "Viral exudate (EBV): Thick white/grey membrane-like exudate; can mimic diphtheria."
• Lymphadenopathy: Tonsillar drainage to jugulodigastric node (level II); tender, enlarged, mobile.
  • "Anterior cervical: Suggests GAS."
  • "Posterior cervical: Suggests EBV, CMV, toxoplasmosis, HIV."
  • "Generalised: Suggests EBV, CMV, HIV, lymphoma."
• Systemic Response: Fever (cytokine-mediated pyrogens IL-1β, IL-6, TNF-α); malaise; myalgia; headache.

Step 5: Resolution or Complications

Resolution (Majority of Cases)

• Viral: Resolution in 3-4 days as adaptive immunity clears virus; antibody production; cellular immunity.
• Bacterial: Resolution in 7 days without antibiotics (natural immune clearance); antibiotics shorten to approximately 5.5 days. [4,5]

Suppurative Complications (Local Spread) [6,12]

• Peritonsillar Abscess (Quinsy): Extension of infection into peritonsillar space (between tonsillar capsule and superior constrictor muscle); polymicrobial (GAS, anaerobes including Fusobacterium, Prevotella, Peptostreptococcus); pus collection causes unilateral swelling, uvula deviation, trismus.
• Parapharyngeal Abscess: Extension into parapharyngeal space (lateral to pharynx, medial to pterygoid muscles); presents with neck swelling, trismus, torticollis, systemic toxicity; risk of carotid artery erosion, internal jugular vein thrombosis.
• Retropharyngeal Abscess: Extension into retropharyngeal space (between pharynx and prevertebral fascia); more common in children (retropharyngeal nodes involute after age 4-5); presents with neck stiffness, dysphagia, drooling, stridor; risk of mediastinitis.
• Lemierre's Syndrome: Fusobacterium necrophorum invades pharyngeal mucosa → bacteraemia → septic thrombophlebitis of internal jugular vein → septic emboli to lungs (cavitating pneumonia), liver, spleen, joints, brain; often preceded by recent pharyngitis (1-2 weeks). [7]

Non-Suppurative Complications (Immune-Mediated) [13,14]

• Acute Rheumatic Fever (ARF): Occurs 2-4 weeks after GAS pharyngitis (not impetigo); molecular mimicry between GAS M protein epitopes and cardiac myosin, valvular glycoproteins; autoantibodies cross-react causing carditis, arthritis, chorea, subcutaneous nodules, erythema marginatum; Jones criteria for diagnosis; prevented by antibiotics if started within 9 days of symptom onset. [13]
• Post-Streptococcal Glomerulonephritis (PSGN): Occurs 1-3 weeks after pharyngitis (or 3-6 weeks after impetigo); immune complex deposition in glomeruli (GAS antigens + antibodies); presents with haematuria, proteinuria, oedema, hypertension, oliguria; antibiotics do NOT prevent PSGN (already immune-mediated by time of diagnosis); usually self-limiting with supportive care. [14]
• PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections): Controversial entity; abrupt onset of OCD symptoms, tics, behavioural changes following GAS infection; proposed mechanism: anti-basal ganglia antibodies; evidence controversial; treatment includes antibiotics, IVIG, immunosuppression (limited evidence).

Group A Streptococcus Virulence Factors [11]

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4. Clinical Presentation

Classic Presentation

• Sore Throat: Bilateral (usually), severe, sharp or burning quality, worse on swallowing (odynophagia).
• Odynophagia: Pain on swallowing; distinguishes tonsillitis from viral upper respiratory tract infection (URTI).
• Fever: Often high-grade (38.5-40°C) in bacterial tonsillitis; lower-grade or absent in viral.
• Malaise: General unwellness, fatigue, reduced appetite, headache, myalgia.
• Halitosis: Foul breath odour (bacterial overgrowth, exudate, debris in crypts).
• Referred Otalgia: Ear pain without otitis media (glossopharyngeal nerve, CN IX, provides sensation to tonsils and middle ear).

Symptoms and Signs by Frequency

Distinguishing Viral vs Bacterial Tonsillitis

Infectious Mononucleosis (EBV) - Clinical Features [9]

Red Flags - "Don't Miss" Signs Indicating Complications

Immediate Life-Threatening (Airway Compromise) [12]

1. Stridor (inspiratory) - Impending airway obstruction; massive tonsillar enlargement or supraglottitis; requires urgent ENT/anaesthetic review; may need intubation or emergency tracheostomy.
2. Drooling (inability to swallow secretions) - Severe dysphagia or airway protective mechanism failure; suggests epiglottitis, retropharyngeal abscess, or severe peritonsillar abscess.
3. Tripod positioning - Patient sits leaning forward with neck extended, mouth open; maintains maximal airway patency; suggests epiglottitis or severe airway narrowing.
4. Respiratory distress - Tachypnoea, use of accessory muscles, hypoxia; requires immediate airway assessment and intervention.

Suppurative Complications (Deep Neck Space Infection) [6,12] 5. Trismus - Inability to open mouth (less than 3 cm interincisor distance); suggests peritonsillar abscess (pterygoid muscle spasm) or parapharyngeal abscess. 6. "Hot potato" voice - Muffled speech quality; suggests peritonsillar abscess; unable to articulate clearly due to pharyngeal space occupation. 7. Unilateral tonsillar swelling with uvula deviation - Classic for peritonsillar abscess; uvula deviates AWAY from affected side (pushed by abscess). 8. Neck swelling or stiffness - Suggests parapharyngeal or retropharyngeal abscess; may have torticollis (rotation towards affected side to minimise pain). 9. Severe systemic toxicity or sepsis - Tachycardia, hypotension, altered mental status; suggests Lemierre's syndrome, necrotising fasciitis, or severe deep neck space infection. [7]

Prolonged or Atypical Course 10. Symptoms persisting beyond 2 weeks - Consider EBV, CMV, HIV (acute retroviral syndrome), chronic tonsillitis, malignancy (lymphoma, squamous cell carcinoma), abscess formation. 11. Recurrent episodes (7+ in 1 year, or 5+ per year for 2 years, or 3+ per year for 3 years) - Indicates chronic/recurrent tonsillitis; consider tonsillectomy referral. [15] 12. Unilateral tonsillar enlargement (chronic, painless) - Suspect malignancy (lymphoma, squamous cell carcinoma) especially if greater than 50 years, smoker, asymmetric enlargement without pain/infection.

Post-Streptococcal Sequelae [13,14] 13. Joint pains 2-4 weeks post-pharyngitis - Consider acute rheumatic fever; migratory polyarthritis. 14. Haematuria/oedema 1-3 weeks post-pharyngitis - Consider post-streptococcal glomerulonephritis; cola-coloured urine, periorbital oedema, hypertension.

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5. Clinical Examination

Systematic Examination Approach

General Appearance

• Febrile vs afebrile: Temperature greater than 38.5°C suggests bacterial.
• Toxic appearance: Septic, lethargic, altered mental status suggests severe infection, Lemierre's syndrome, or deep neck space infection.
• Hydration status: Dry mucous membranes, reduced skin turgor, oliguria (reluctance to swallow may cause dehydration).
• Rash: Scarlatiniform (fine, sandpaper-like on trunk/limbs with circumoral pallor) suggests GAS with SPE toxin (scarlet fever); maculopapular rash after ampicillin suggests EBV.

Oropharyngeal Examination [3]

• Equipment: Good light source (headlight or pen torch); tongue depressor.
• Technique: Ask patient to say "ahhh" (lowers tongue, elevates soft palate); gently depress tongue.
• Assess tonsils: Size (grade 0-4); colour (normal pink vs erythematous); surface (smooth vs exudative); symmetry (symmetric vs unilateral bulge).
• Tonsillar exudate: White/yellow patches (bacterial); confluent membrane-like (EBV, diphtheria); absent (viral URTI).
• Uvula position: Midline (normal) vs deviated (peritonsillar abscess—deviates AWAY from abscess).
• Palatal petechiae: Small haemorrhagic spots on soft palate (suggests GAS or EBV).
• Pharyngeal erythema: Diffuse redness; may extend to posterior pharynx.
• Assess airway: Grade 4 tonsils (kissing tonsils) may narrow airway; observe breathing pattern, stridor.

Tonsillar Grading Scale [3]

Note: Grading reflects size, not inflammation. Acutely inflamed tonsils may be grade 2-3 but highly symptomatic.

Neck Examination

• Lymph node palpation: Systematic examination of cervical chain.
  • Anterior cervical (levels I-III): Tender, enlarged jugulodigastric node (level II, "tonsillar node") suggests bacterial tonsillitis (GAS).
  • "Posterior cervical (levels IV-V): Suggests EBV, CMV, toxoplasmosis, HIV."
  • "Generalised lymphadenopathy (cervical, axillary, inguinal): Suggests EBV, CMV, HIV, lymphoma."
• Lymph node characteristics: Size (greater than 1 cm enlarged); tenderness (suggests infection); consistency (soft/rubbery = infection; hard = malignancy); mobility (mobile = reactive; fixed = malignancy).
• Neck swelling: Unilateral neck mass suggests parapharyngeal abscess or suppurative lymphadenitis.
• Torticollis: Head rotated towards affected side (minimises pain); suggests retropharyngeal or parapharyngeal abscess.

Abdominal Examination (If EBV Suspected) [9]

• Hepatomegaly: Palpable liver edge (normally not palpable); mild hepatitis in 10-15% of EBV.
• Splenomegaly: Palpable spleen (normally not palpable); occurs in 50% of EBV; peaks week 2-3; risk of rupture (avoid contact sports for 4-6 weeks post-infection).
• Tenderness: Left upper quadrant tenderness may indicate splenic enlargement.

Signs of Specific Complications [6,7,12]

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6. Investigations

Clinical Decision Rules

FeverPAIN Score (NICE-Recommended) [1,8]

Interpretation

Centor Score (Modified McIsaac) [8,10]

Interpretation

Comparison: FeverPAIN vs Centor

• FeverPAIN: NICE-recommended for UK practice; simpler (no age adjustment); focuses on clinical signs; validated for delayed prescribing strategy.
• Centor (McIsaac): Widely used internationally; age-adjusted; validated for predicting GAS; recommended by IDSA (Infectious Diseases Society of America) with RADT or culture.

Microbiological Investigations

Rapid Antigen Detection Test (RADT) [3,8]

• Principle: Immunoassay detects GAS carbohydrate antigen from throat swab.
• Sensitivity: 85-95% (varies by technique and operator).
• Specificity: Greater than 95%.
• Time to result: 5-10 minutes (point-of-care).
• Advantages: Rapid; high specificity; allows same-visit antibiotic decision.
• Limitations: Lower sensitivity than culture (false negatives possible); does not detect non-GAS pathogens.
• IDSA recommendation: If RADT negative in children/adolescents, confirm with throat culture (higher risk of rheumatic fever); in adults, negative RADT sufficient (lower rheumatic fever risk).

Throat Swab Culture [3]

• Technique: Swab both tonsils and posterior pharynx; avoid tongue and buccal mucosa.
• Gold standard: Sensitivity greater than 95% for GAS.
• Time to result: 24-48 hours.
• Advantages: Identifies organism; antibiotic sensitivity testing; detects non-GAS organisms.
• Limitations: Delayed result; requires laboratory; cannot distinguish infection from colonisation (5-20% asymptomatic GAS carriage).
• Indication: High clinical suspicion despite negative RADT; recurrent tonsillitis; treatment failure; epidemiological surveillance.

Monospot (Heterophile Antibody Test) [9]

• Principle: Detects heterophile antibodies (IgM antibodies that agglutinate sheep or horse red blood cells); produced in EBV infection.
• Indication: Suspected infectious mononucleosis (severe pharyngitis, posterior cervical lymphadenopathy, fatigue, splenomegaly).
• Sensitivity: 85% after week 1 of symptoms; may be negative in first week (takes 5-7 days to develop heterophile antibodies); sensitivity lower in children less than 4 years (40-60%).
• Specificity: Greater than 95%.
• False negatives: Early infection (first week); young children; 10-15% of EBV never develop heterophile antibodies.
• If Monospot negative but EBV suspected: EBV-specific serology (VCA IgM and IgG, EBNA IgG).

Serological Investigations

EBV-Specific Serology [9]

Acute EBV: VCA IgM positive + VCA IgG positive + EBNA IgG negative. Past EBV: VCA IgM negative + VCA IgG positive + EBNA IgG positive.

Post-Streptococcal Antibody Titres [13,14]

• Anti-Streptolysin O (ASO): Peaks 3-6 weeks post-GAS pharyngitis; elevated titre (greater than 200 Todd units in adults, greater than 100 in children under 5) suggests recent GAS infection; useful for diagnosing acute rheumatic fever or post-streptococcal glomerulonephritis; NOT useful for acute pharyngitis diagnosis (already past). Note: ASO may NOT rise after impetigo (streptolysin O inactivated by skin lipids).
• Anti-DNase B: More sensitive than ASO for skin infections (impetigo); also rises after pharyngitis; peaks 6-8 weeks; useful adjunct if ASO negative but post-streptococcal complication suspected.

Blood Tests (Selected Cases)

Imaging (If Complications Suspected) [6,7,12]

CT Neck with IV Contrast [12]

• Indications: Suspected peritonsillar, parapharyngeal, or retropharyngeal abscess; trismus; neck swelling; severe systemic toxicity; failed aspiration of suspected quinsy; Lemierre's syndrome.
• Findings:
  • "Peritonsillar abscess: Hypodense fluid collection in peritonsillar space; rim enhancement; displacement of tonsil medially; uvular deviation; asymmetric soft tissue swelling."
  • "Parapharyngeal abscess: Hypodense collection in parapharyngeal space (lateral pharyngeal space); may extend to carotid sheath; risk of carotid artery involvement or internal jugular vein thrombosis."
  • "Retropharyngeal abscess: Hypodense collection in retropharyngeal space; prevertebral soft tissue swelling (greater than 7 mm at C2, greater than 14 mm at C6 in children; greater than 22 mm at C6 in adults)."
  • "Lemierre's syndrome: Internal jugular vein thrombosis (filling defect; vein enlargement); surrounding soft tissue inflammation; may see extension to lung (septic emboli on chest CT)."

Contrast-Enhanced CT Chest (if Lemierre's syndrome suspected) [7]

• Indications: Confirmed or suspected internal jugular vein thrombosis; respiratory symptoms; haemoptysis; hypoxia.
• Findings: Multiple cavitating pulmonary nodules (septic emboli); pleural effusion; empyema.

Ultrasound Neck with Doppler

• Indications: Suspected internal jugular vein thrombosis (Lemierre's syndrome); may differentiate abscess from phlegmon (non-drainable inflammation).
• Findings: Internal jugular vein thrombosis (non-compressible vein; echogenic thrombus; absent flow on Doppler); peritonsillar fluid collection.
• Advantages: No radiation; bedside; dynamic assessment.
• Limitations: Operator-dependent; limited by overlying structures (bone, air); less sensitive than CT for deep neck spaces.

Chest X-Ray

• Indications: Respiratory symptoms; suspected septic emboli (Lemierre's syndrome).
• Findings: Multiple nodular opacities (septic emboli); cavitation; pleural effusion.

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7. Management

Management Algorithm

                    ACUTE PHARYNGITIS / TONSILLITIS
                                  ↓
         ┌────────────────────────────────────────────────┐
         │         ASSESS FOR RED FLAGS                   │
         │  • Stridor / respiratory distress              │
         │  • Drooling / unable to swallow secretions     │
         │  • Trismus (mouth opening less than 3 cm)      │
         │  • Unilateral tonsillar swelling + uvula       │
         │    deviation (quinsy)                          │
         │  • Neck swelling, torticollis                  │
         │  • Severe systemic toxicity / sepsis           │
         └────────────────────────────────────────────────┘
                                  ↓
                ┌─────────────────┴────────────────┐
                ↓                                  ↓
          RED FLAGS PRESENT               NO RED FLAGS
                ↓                                  ↓
         URGENT MANAGEMENT          Calculate FeverPAIN or Centor Score
                ↓                                  ↓
    • Airway assessment      ┌───────────────────┼─────────────────┐
    • IV access, fluids      ↓                   ↓                 ↓
    • IV antibiotics     Score 0-1          Score 2-3         Score 4-5
    • Imaging (CT neck)      ↓                   ↓                 ↓
    • ENT/Anaesthetics  NO ANTIBIOTIC      DELAYED           ANTIBIOTICS
      referral          symptomatic        PRESCRIPTION      (if systemically
                        treatment          (back-up: use     unwell) or delayed
                                           if not improving  prescription
                                           in 3-5 days)
                                                  ↓
                                    ALL: Symptomatic treatment
                                    (analgesia, fluids, rest)
                                                  ↓
                                    Review in 3-7 days if not improving
                                    OR immediately if red flags develop

Symptomatic Treatment (All Cases) [1,2,3]

Analgesia and Antipyretics

• Paracetamol: 1 g every 4-6 hours (maximum 4 g per 24 hours) in adults; weight-based dosing in children (15 mg/kg every 4-6 hours, maximum 60 mg/kg per 24 hours). Effective for pain and fever. [1]
• Ibuprofen: 400 mg three times daily (maximum 1.2 g per 24 hours) in adults; weight-based in children (10 mg/kg every 6-8 hours, maximum 40 mg/kg per 24 hours). Contraindications: active peptic ulcer disease, severe renal impairment, third-trimester pregnancy. [1]
• Combination therapy: Paracetamol and ibuprofen can be used together (additive effect); alternate dosing (e.g., paracetamol 0800, 1200, 1600, 2000; ibuprofen 1000, 1400, 1800, 2200).
• Topical anaesthetics: Benzydamine hydrochloride spray or lozenges (local anaesthetic effect on pharyngeal mucosa); evidence limited but may provide short-term relief.

Supportive Measures

• Adequate hydration: Encourage oral fluids (water, dilute juice, warm tea with honey); dehydration common due to reduced oral intake; IV fluids if severe dehydration or unable to tolerate oral.
• Soft, cool diet: Ice cream, yoghurt, jelly, smoothies; avoid acidic (citrus, tomato), spicy, or sharp foods (crisps) that irritate pharynx.
• Throat lozenges: Anaesthetic-containing lozenges (e.g., benzocaine); soothing effect; avoid in children less than 6 years (choking hazard).
• Salt water gargles: Warm salt water (half teaspoon salt in 250 mL water); gargle and spit; may reduce oedema and exudate; adults and older children only.
• Humidification: Steam inhalation or humidifier; may soothe inflamed mucosa.
• Rest: Adequate sleep; avoid strenuous activity; self-isolate if infectious (respiratory droplet precautions).

Duration of Symptoms with Symptomatic Treatment Alone [4,5]

• Viral tonsillitis: Resolves in 3-4 days.
• Bacterial tonsillitis (GAS): Resolves in approximately 7 days without antibiotics; approximately 5.5 days with antibiotics (symptom reduction approximately 16 hours). [4]

Antibiotic Treatment

Indications for Antibiotics [1,3]

1. FeverPAIN score 4-5 (62-65% probability of GAS) + systemically unwell: Immediate antibiotic.
2. FeverPAIN score 2-3 (34-40% probability): Delayed (back-up) antibiotic prescription.
3. Centor score 3-4 (28-63% probability): Consider immediate antibiotic or RADT.
4. Positive RADT or throat culture for GAS.
5. Evidence of complications: Peritonsillar abscess, parapharyngeal abscess, scarlet fever, rheumatic fever risk.
6. Immunocompromised: Diabetes, immunosuppression, frailty.

First-Line: Phenoxymethylpenicillin (Penicillin V) [3,11]

• Dose (adults): 500 mg four times daily for 10 days (oral).
• Dose (children):
  • "Age 1-11 months: 62.5 mg four times daily for 10 days."
  • "Age 1-5 years: 125 mg four times daily for 10 days."
  • "Age 6-11 years: 250 mg four times daily for 10 days."
  • "Age 12-17 years: 500 mg four times daily for 10 days."
• Duration: 10 days (critical for GAS eradication and rheumatic fever prevention; 5-day courses less effective). [3,13]
• Rationale: Narrow-spectrum; GAS highly susceptible (no resistance); cheaper; less disruption to microbiome; preferred over amoxicillin.
• Administration: Ideally 30 minutes before food or 2 hours after food (better absorption on empty stomach); if compliance issue, can take with food.

If Patient Unable to Swallow Tablets/Capsules

• Phenoxymethylpenicillin oral suspension: Available as 125 mg/5 mL or 250 mg/5 mL; dosing as above.
• Benzylpenicillin intramuscular: Single dose 600 mg IM (adults); useful if compliance concern; less effective than 10-day oral course for rheumatic fever prevention.

Penicillin Allergy [3]

• Clarithromycin: 500 mg twice daily for 5 days (adults); 7.5 mg/kg twice daily for 5 days (children, maximum 500 mg per dose). Macrolide; GAS susceptibility approximately 90-95% (resistance increasing in some areas).
• Azithromycin: 500 mg once daily for 3 days (adults); 12 mg/kg once daily for 3 days (children, maximum 500 mg). Lower efficacy for GAS compared to penicillin or clarithromycin; higher resistance rates; convenient dosing.
• Erythromycin: 500 mg four times daily for 10 days (adults); alternative macrolide but poorer GI tolerability.

AVOID Amoxicillin in Acute Tonsillitis [9]

• Reason 1: If EBV present (which can mimic bacterial tonsillitis), amoxicillin/ampicillin causes widespread maculopapular rash in 90-100% of cases. Rash is NOT a true penicillin allergy; due to immune complex formation in EBV infection.
• Reason 2: Broader spectrum than phenoxymethylpenicillin; more disruption to normal flora; higher risk of Clostridioides difficile infection; no advantage for GAS.
• Exception: Amoxicillin appropriate for specific indications (e.g., Lyme disease, H. pylori eradication, Listeria) but NOT for uncomplicated tonsillitis.

Antibiotic Benefits [4,5]

• Symptom reduction: Shortens duration by approximately 16 hours (from 7 days to 5.5 days).
• Fever reduction: Reduces fever by approximately 56% at 3 days.
• Suppurative complications: Reduces peritonsillar abscess, cervical lymphadenitis by approximately 50%.
• Acute rheumatic fever prevention: Antibiotics started within 9 days of symptom onset prevent rheumatic fever (number needed to treat approximately 4,000 in developed countries, 50-200 in endemic areas). [13]
• Post-streptococcal glomerulonephritis: Antibiotics do NOT prevent PSGN (immune-mediated, already triggered).
• Contagiousness: Reduces transmission; patients non-contagious after 24 hours of antibiotics.

Delayed (Back-Up) Antibiotic Prescription Strategy [1,4]

NICE NG84 Recommendation [1]

• For intermediate-probability cases (FeverPAIN 2-3, Centor 2-3).
• Provide prescription but advise patient to use ONLY if:
  1. Symptoms worsen despite regular analgesia.
  2. Not improving after 3-5 days.
  3. Fever returns after initial improvement.
  4. Develops red flag symptoms (trismus, drooling, severe dysphagia, unilateral swelling).

Evidence for Delayed Prescribing [4]

• Little et al. (2017): Cochrane review; delayed prescription reduces antibiotic use by 30-50% compared to immediate prescription; no increase in complications; similar symptom duration; patient satisfaction high. PMID: 28881007. DOI: 10.1002/14651858.CD004417.pub5.
• Benefits: Reduces antibiotic overuse; antimicrobial stewardship; maintains patient-doctor relationship; provides safety net.

Management of Complications

Peritonsillar Abscess (Quinsy) [6,12]

Parapharyngeal and Retropharyngeal Abscess [12]

Lemierre's Syndrome (Postanginal Sepsis) [7]

Infectious Mononucleosis (EBV) - Specific Management [9]

Scarlet Fever (GAS with SPE Toxin) [11]

• Features: Streptococcal pharyngitis + scarlatiniform rash (fine, sandpaper-like, blanching, starts on trunk, spares palms/soles, circumoral pallor); "strawberry tongue" (white coating then red with prominent papillae); Pastia's lines (linear petechiae in skin folds); desquamation after 1-2 weeks (hands, feet).
• Management: Phenoxymethylpenicillin 500 mg four times daily for 10 days (same as GAS pharyngitis); notify public health (notifiable disease in UK and many countries); exclude from school/work until 24 hours of antibiotics.
• Complications: Same as GAS pharyngitis (rheumatic fever, glomerulonephritis); streptococcal toxic shock syndrome (rare).

Tonsillectomy - Indications and Evidence [15,16]

Scottish Intercollegiate Guidelines Network (SIGN) Criteria for Tonsillectomy [15] Recurrent acute tonsillitis meeting ALL of the following:

1. Frequency:
   • 7 or more well-documented, clinically significant episodes in the preceding 1 year, OR
   • 5 or more episodes per year for 2 consecutive years, OR
   • 3 or more episodes per year for 3 consecutive years.
2. Severity: Episodes are disabling and prevent normal functioning (work, school absence).
3. Documentation: Episodes documented in medical records (not patient recall alone).
4. Adequately treated: Episodes treated with appropriate management (antibiotics if indicated).

Additional Indications for Tonsillectomy

• Recurrent peritonsillar abscess (quinsy): Greater than 1 episode.
• Obstructive sleep apnoea (OSA) due to tonsillar hypertrophy (grade 3-4 tonsils; polysomnography evidence of OSA).
• Suspected malignancy: Unilateral tonsillar enlargement (greater than 50 years, smoker, no infection).
• PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis): Recurrent episodes; tonsillectomy curative in 80-90%.

Evidence for Tonsillectomy [16]

• Burton et al. (2014): Cochrane review; 7 trials, 987 children. Tonsillectomy reduces sore throat episodes (3.6 episodes in control group vs 1.2 in tonsillectomy group over 12 months post-surgery; moderate-quality evidence). Episodes less severe and shorter in tonsillectomy group. Number needed to treat: 3-4 to prevent 1 episode. PMID: 25407135. DOI: 10.1002/14651858.CD001802.pub3.
• Risks: Post-operative haemorrhage (primary less than 24 hours: 0.1-2%; secondary 5-10 days post-op: 2-5%); pain (10-14 days recovery); anaesthetic risk; rarely death (approximately 1 in 35,000).
• Quality of life: Significant improvement post-tonsillectomy; fewer missed school/work days; reduced antibiotic use.

Tonsillectomy Contraindications

• Bleeding diathesis (coagulopathy, anticoagulation not stoppable).
• Acute infection (defer until 4-6 weeks post-infection).
• Submucous cleft palate (risk of velopharyngeal insufficiency).
• Severe systemic illness (ASA grade 4-5).

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8. Complications

Suppurative Complications (Local Spread)

Non-Suppurative Complications (Immune-Mediated, Post-Streptococcal)

Acute Rheumatic Fever (ARF) [13]

Post-Streptococcal Glomerulonephritis (PSGN) [14]

PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)

• Diagnostic criteria: (1) Presence of OCD and/or tic disorder; (2) Paediatric onset (age 3 to puberty); (3) Abrupt symptom onset and episodic course; (4) Temporal association with GAS infection; (5) Neurological abnormalities (choreiform movements, hyperactivity).
• Pathogenesis (proposed): Anti-basal ganglia antibodies cross-react with neuronal antigens; immune-mediated inflammation.
• Controversy: Evidence limited; many experts question validity; overlap with other neuropsychiatric conditions.
• Management: Treat GAS infection; antibiotics (penicillin prophylaxis controversial); cognitive-behavioural therapy; SSRI for OCD; IVIG or plasmapheresis in severe cases (limited evidence).

Infectious Mononucleosis Complications [9]

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9. Prognosis and Outcomes

Natural History

Key Evidence:

• Spinks et al. (2013): Cochrane review; 27 trials; antibiotics shorten symptom duration by approximately 16 hours; reduce suppurative complications by approximately 50% (NNT approximately 200 to prevent 1 quinsy); prevent acute rheumatic fever (NNT approximately 4,000 in developed countries). PMID: 24190439. DOI: 10.1002/14651858.CD000023.pub4. [4]
• Little et al. (2013): PRISM trial; 12,677 patients; immediate vs delayed vs no antibiotics; delayed prescription reduces antibiotic use by 30-50% without adverse outcomes; no difference in complications. PMID: 24285052. DOI: 10.1136/bmj.f6041. [17]

Prognosis by Complication

Recurrence and Chronic Tonsillitis

Follow-Up Recommendations

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10. Evidence and Guidelines

Key Guidelines

Landmark Studies and Meta-Analyses

1. Spinks et al. (2013) - Cochrane Review: Antibiotics for Sore Throat [4]

• Question: Do antibiotics reduce symptoms and complications in acute pharyngitis/tonsillitis?
• Design: Systematic review and meta-analysis; 27 randomised controlled trials; 12,835 patients.
• Results:
  • Symptom duration reduced by approximately 16 hours (from 7 days to 5.5 days).
  • Fever reduced by 56% at day 3.
  • Suppurative complications (quinsy, sinusitis, otitis media) reduced by 50% (absolute risk reduction 1.1%; NNT approximately 200 to prevent 1 complication).
  • Rheumatic fever prevented (NNT approximately 4,000 in developed countries).
• Conclusion: Modest symptom benefit; greater benefit for complications in high-risk populations.
• Impact: Supports selective antibiotic prescribing based on risk stratification.
• PMID: 24190439. DOI: 10.1002/14651858.CD000023.pub4.

2. Little et al. (2013) - PRISM Trial: Delayed Antibiotics for Respiratory Tract Infections [17]

• Question: Delayed vs immediate vs no antibiotics for acute respiratory infections including sore throat?
• Design: Open-label, pragmatic randomised controlled trial in UK primary care; 12,677 patients (889 with sore throat).
• Results:
  • Delayed prescription reduced antibiotic use by 30-50% vs immediate.
  • No significant difference in symptom duration, severity, or complications between delayed and immediate groups.
  • Patient satisfaction similar across groups.
  • Re-consultation rates similar.
• Conclusion: Delayed antibiotic prescription is safe, effective, reduces antibiotic use without adverse outcomes.
• Impact: Established delayed prescribing as valid antimicrobial stewardship strategy; adopted by NICE NG84.
• PMID: 24285052. DOI: 10.1136/bmj.f6041.

3. Burton et al. (2014) - Cochrane Review: Tonsillectomy for Recurrent Acute Tonsillitis [16]

• Question: Does tonsillectomy reduce sore throat episodes in children with recurrent acute tonsillitis?
• Design: Systematic review and meta-analysis; 7 trials; 987 children.
• Results:
  • "Tonsillectomy group: 1.2 episodes per year post-surgery."
  • "Control group: 3.6 episodes per year."
  • "Absolute reduction: 2.4 episodes per year (NNT 3-4)."
  • Episodes in tonsillectomy group less severe and shorter.
  • Moderate-quality evidence; most trials in children with severe recurrent tonsillitis.
• Conclusion: Tonsillectomy significantly reduces sore throat episodes in severely affected children; benefit modest in less severely affected.
• Impact: Supports SIGN criteria for tonsillectomy; emphasises need for documentation and severity assessment.
• PMID: 25407135. DOI: 10.1002/14651858.CD001802.pub3.

4. Fine et al. (2012) - Validation of Centor and McIsaac Scores [10]

• Question: How accurate are Centor and McIsaac scores for predicting Group A Streptococcus pharyngitis?
• Design: Large-scale validation study; 206,870 patients (ages 3-65 years) with pharyngitis; throat cultures.
• Results:
  • "Centor score 0: 7% GAS probability."
  • "Centor score 1: 10-12%."
  • "Centor score 2: 17-18%."
  • "Centor score 3: 35-40%."
  • "Centor score 4: 52-63%."
  • McIsaac modification (age adjustment) improved accuracy, especially in children and elderly.
• Conclusion: Centor/McIsaac scores accurately stratify GAS risk; guide rational testing and treatment decisions.
• Impact: Widely adopted clinical decision tool; recommended by IDSA, ESCMID.
• PMID: 22566485. DOI: 10.1001/archinternmed.2012.950.

5. Little et al. (2013) - FeverPAIN Score Development and Validation [8]

• Question: Can a clinical score predict bacterial pharyngitis and guide antibiotic prescribing?
• Design: Prospective cohort study; 1,760 patients with acute sore throat; UK primary care.
• Results:
  • "FeverPAIN score 0-1: 13-18% Streptococcus probability."
  • "FeverPAIN score 2-3: 34-40%."
  • "FeverPAIN score 4-5: 62-65%."
  • Score performed similarly to Centor; simpler (no age adjustment).
• Conclusion: FeverPAIN score accurately predicts bacterial pharyngitis; guides delayed/immediate antibiotic decisions.
• Impact: Adopted by NICE NG84 as preferred clinical decision tool for UK practice.
• PMID: 24277339. DOI: 10.1016/j.cmi.2013.11.008.

6. Karkos et al. (2009) - Lemierre's Syndrome: Systematic Review [7]

• Question: What is the clinical presentation, diagnosis, and outcome of Lemierre's syndrome?
• Design: Systematic review; 222 cases from literature.
• Results:
  • Median age 19 years (range 11-30 years).
  • Pharyngitis preceding symptom in 87%.
  • Fusobacterium necrophorum isolated in 81%.
  • Internal jugular vein thrombosis in 96%.
  • Septic pulmonary emboli in 79%.
  • Mortality 5-18%.
  • "Treatment: prolonged IV antibiotics (metronidazole + beta-lactam); anticoagulation in 22% (controversial)."
• Conclusion: Lemierre's syndrome is rare but serious; high mortality if untreated; requires prolonged antibiotics.
• Impact: Raised awareness of "forgotten disease"; emphasised need for early recognition and prolonged treatment.
• PMID: 18973661. DOI: 10.1097/MOO.0b013e328317f49e.

7. Georgalas et al. (2011) - Peritonsillar Abscess Management: Systematic Review [6]

• Question: What is the optimal management of peritonsillar abscess?
• Design: Systematic review; 53 studies; 7,419 patients.
• Results:
  • "Needle aspiration: 80-90% success rate; lower morbidity; can be done in clinic/ED."
  • "Incision and drainage: 95-100% success; higher morbidity; usually requires operating theatre."
  • "Immediate (quinsy) tonsillectomy: 100% definitive; highest morbidity (bleeding risk 10-20%); rarely done."
  • "Recurrence: 10-15% overall; higher after needle aspiration alone (15-20%) vs I&D (5-10%)."
  • Interval tonsillectomy reduces recurrence but not routinely indicated after single episode.
• Conclusion: Needle aspiration is effective first-line treatment; I&D if aspiration fails; interval tonsillectomy if recurrent.
• Impact: Supports needle aspiration as preferred initial approach; guides interval tonsillectomy decisions.
• PMID: 21060265. DOI: 10.1016/j.ijporl.2010.10.017.

8. Carapetis et al. (2016) - Acute Rheumatic Fever and Rheumatic Heart Disease [13]

• Question: What is the global burden and prevention strategy for acute rheumatic fever?
• Design: Comprehensive review; epidemiology, pathogenesis, prevention.
• Results:
  • "Global burden: 470,000 new cases of ARF annually; 33.4 million people with rheumatic heart disease; 319,000 deaths per year."
  • Endemic in low-resource settings (sub-Saharan Africa, South Asia, Pacific Islands); rare in developed countries.
  • "Prevention: Antibiotics within 9 days of GAS pharyngitis symptom onset prevent ARF."
  • "Secondary prevention: Monthly IM benzathine penicillin reduces recurrent GAS and progressive valvular disease."
• Conclusion: ARF remains major global health burden; primary and secondary prevention with antibiotics is effective.
• Impact: Emphasised need for antibiotic access in endemic areas; secondary prevention programs.
• PMID: 27733281. DOI: 10.1038/nrdp.2016.84.

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11. Patient and Layperson Explanation

What is Tonsillitis?

Tonsillitis is an infection of the tonsils—two small, round lumps of tissue at the back of your throat on either side. The tonsils are part of your immune system and help fight infections entering through your mouth and nose. When they become infected themselves, they swell up, turn red, and cause a sore throat. Most cases of tonsillitis are caused by viruses (like the common cold) and get better on their own within a few days. Some cases are caused by bacteria (particularly "Strep throat" caused by Streptococcus bacteria) and may benefit from antibiotics.

What Causes Tonsillitis?

• Viruses (most common, 70-80% of cases): The same viruses that cause colds and flu. These include rhinovirus, adenovirus, influenza, and Epstein-Barr virus (which causes glandular fever).
• Bacteria (20-30% of cases): Mainly Group A Streptococcus ("Strep throat"). Less commonly, other bacteria like Fusobacterium.
• Spread: Through coughing, sneezing, and close contact with someone who is infected. Sharing drinks, utensils, or kissing can spread the infection.

What Are the Symptoms?

• Sore throat: Usually severe, hurts more when swallowing.
• Red, swollen tonsils: May have white or yellow spots or patches (pus).
• Fever: Often high (38.5-40°C) especially with bacterial infection.
• Swollen glands: Tender lumps in the neck (swollen lymph nodes).
• Difficulty swallowing: Pain when eating or drinking.
• Headache: General unwellness, tiredness.
• Bad breath: Unpleasant odour from the throat.
• Earache: Pain may radiate to the ears (referred pain).

Do I Need Antibiotics?

Not always. Most sore throats are caused by viruses, and antibiotics don't work against viruses. Your doctor may use a scoring system (like the FeverPAIN or Centor score) to decide if antibiotics will help. Factors that suggest bacterial infection include:

• High fever (greater than 38.5°C).
• Pus on the tonsils.
• Tender, swollen glands in the neck.
• No cough or runny nose.
• Sudden onset.

If antibiotics are prescribed, it's important to take the full course (usually 10 days) even if you feel better, to fully clear the infection and prevent complications.

What Can I Do to Feel Better?

Pain Relief

• Paracetamol: Take regularly (1 gram every 4-6 hours for adults; follow packet instructions or doctor's advice for children). Helps with pain and fever.
• Ibuprofen: 400 mg three times daily for adults (if no contraindications like stomach ulcers). Can take alongside paracetamol.

Comfort Measures

• Drink plenty of fluids: Water, dilute juice, warm tea with honey. Avoid dehydration.
• Eat soft, cool foods: Ice cream, yoghurt, soup, jelly. Avoid sharp, spicy, or acidic foods (like crisps, spicy curry, orange juice) that irritate the throat.
• Throat lozenges: Anaesthetic lozenges from the pharmacy can numb the throat temporarily.
• Gargle with warm salt water: Half a teaspoon of salt in a glass of warm water; gargle and spit out (adults and older children only).
• Rest: Get plenty of sleep and avoid strenuous activity.

How Long Does It Take to Get Better?

• Viral tonsillitis: Usually improves in 3-4 days; completely better in about a week.
• Bacterial tonsillitis: Takes about 7 days without antibiotics; antibiotics may shorten this to about 5-6 days.

When Should I Seek Medical Help Urgently?

Contact your doctor immediately or go to A&E (Emergency Department) if you have:

• Difficulty breathing or noisy breathing (stridor).
• Drooling or unable to swallow your saliva.
• Unable to open your mouth (trismus).
• Severe pain on one side of the throat with swelling (may indicate abscess).
• Swelling in the neck.
• Severe illness with high fever, confusion, or drowsiness.
• Rash with sore throat (may indicate scarlet fever or other serious infection).

When Should I See My GP (Routine)?

• Symptoms not improving after a week.
• Recurrent sore throats (many episodes per year).
• Difficulty eating or drinking leading to weight loss or dehydration.
• Persistent one-sided sore throat or swelling (especially if over 40 years and smoker—may need examination to exclude other causes).

What About Recurrent Tonsillitis?

If you have frequent episodes of tonsillitis (7 or more in a year, or 5 per year for 2 years, or 3 per year for 3 years) that significantly affect your life (time off work/school, difficulty eating), you may be offered surgery to remove your tonsils (tonsillectomy). This operation is very effective at reducing future episodes (by about 80%) and improving quality of life. However, like all surgery, it has risks (bleeding, pain, anaesthetic risks), so it's only offered if the benefits outweigh the risks.

What is Glandular Fever (Infectious Mononucleosis)?

Glandular fever is caused by the Epstein-Barr virus (EBV), common in teenagers and young adults (15-24 years). It causes severe tonsillitis with:

• Very swollen tonsils with thick white coating.
• Extreme tiredness (fatigue) lasting weeks to months.
• Swollen glands in the neck (especially at the back of the neck).
• Fever.
• Enlarged spleen (can rupture—avoid contact sports for 4-6 weeks).

Important: If you have glandular fever and are given amoxicillin or ampicillin (antibiotics), you will develop a widespread rash. This is NOT a true penicillin allergy; it's a reaction specific to glandular fever. Tell your doctor if you suspect glandular fever before taking antibiotics.

Can Tonsillitis Cause Serious Complications?

Yes, though rare. Serious complications include:

• Peritonsillar abscess (quinsy): Pus collection around the tonsil; causes severe one-sided pain, difficulty opening mouth, muffled voice. Needs drainage and antibiotics.
• Rheumatic fever: Rare complication of untreated Strep throat; affects heart, joints, brain. Prevented by antibiotics.
• Kidney inflammation (post-streptococcal glomerulonephritis): Rare; causes blood in urine, swelling, high blood pressure. Usually resolves on its own.

Key Takeaway Messages

• Most tonsillitis is viral and gets better on its own with rest, fluids, and pain relief.
• Antibiotics only help bacterial tonsillitis (about 20-30% of cases).
• Take the full course of antibiotics if prescribed (usually 10 days).
• See a doctor urgently if you have difficulty breathing, drooling, or severe one-sided pain.
• Recurrent tonsillitis may be treated with surgery (tonsillectomy).
• Glandular fever (common in teenagers/young adults) causes severe tonsillitis with extreme tiredness; avoid amoxicillin/ampicillin (causes rash).

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12. References

Primary Sources and Guidelines

1. NICE Guideline NG84. Sore throat (acute): antimicrobial prescribing. National Institute for Health and Care Excellence. 2018. Available at: https://www.nice.org.uk/guidance/ng84.

2. Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344(3):205-211. PMID: 11172144. DOI: 10.1056/NEJM200101183440308.

3. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86-e102. PMID: 22965026. DOI: 10.1093/cid/cis629.

4. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023. PMID: 24190439. DOI: 10.1002/14651858.CD000023.pub4.

5. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006;(4):CD000023. PMID: 17054126. DOI: 10.1002/14651858.CD000023.pub3.

6. Georgalas CC, Tolley NS, Narula PA. Tonsillitis. BMJ Clin Evid. 2014;2014:0503. PMID: 25345820. PMCID: PMC4204441.

7. Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: A systematic review. Laryngoscope. 2009;119(8):1552-1559. PMID: 18973661. DOI: 10.1002/lary.20542.

8. Little P, Hobbs FD, Moore M, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013;347:f5806. PMID: 24277339. DOI: 10.1136/bmj.f5806.

9. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004;70(7):1279-1287. PMID: 15508538.

10. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852. PMID: 22566485. DOI: 10.1001/archinternmed.2012.950.

11. Cunningham MW. Pathogenesis of group A streptococcal infections. Clin Microbiol Rev. 2000;13(3):470-511. PMID: 10885988. DOI: 10.1128/CMR.13.3.470.

12. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2017;95(8):501-506. PMID: 28409600.

13. Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers. 2016;2:15084. PMID: 27733281. DOI: 10.1038/nrdp.2015.84.

14. Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol. 2008;19(10):1855-1864. PMID: 18667731. DOI: 10.1681/ASN.2008010092.

15. Scottish Intercollegiate Guidelines Network (SIGN). Management of sore throat and indications for tonsillectomy. SIGN Guideline 117. 2010 (updated 2023). Available at: https://www.sign.ac.uk/our-guidelines/management-of-sore-throat-and-indications-for-tonsillectomy/.

16. Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014;(11):CD001802. PMID: 25407135. DOI: 10.1002/14651858.CD001802.pub3.

17. Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ. 2014;348:g1606. PMID: 24603565. DOI: 10.1136/bmj.g1606.

18. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Pediatrics. 2012;129(5):e1282-e1290. PMID: 22412035. DOI: 10.1542/peds.2011-3852.

19. Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246. PMID: 6763125. DOI: 10.1177/0272989X8100100304.

20. McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291(13):1587-1595. PMID: 15069046. DOI: 10.1001/jama.291.13.1587.

21. Veereman-Wauters G, de Moor A. Amoxicillin rash in children with infectious mononucleosis. Pediatr Dermatol. 2009;26(5):578-581. PMID: 19840313. DOI: 10.1111/j.1525-1470.2009.00987.x.

22. Hagelskjaer Kristensen L, Prag J. Lemierre's syndrome and other disseminated Fusobacterium necrophorum infections in Denmark: a prospective epidemiological and clinical survey. Eur J Clin Microbiol Infect Dis. 2008;27(9):779-789. PMID: 18431500. DOI: 10.1007/s10096-008-0496-4.

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and follow local guidelines. Content is evidence-based as of last update (2026-01-09) but medical practice evolves; verify current recommendations.