Summary

Tonsillitis is acute inflammation of the palatine tonsils, usually caused by viral or bacterial infection. It is one of the most common reasons for GP and Emergency Department attendance. While most cases are viral and self-limiting, identifying bacterial tonsillitis (particularly Group A Streptococcus) is important to prevent suppurative and non-suppurative complications. Clinical scoring systems guide the need for antibiotics. [1,2]

Key Facts

• Incidence: Very common; peaks in 5-15 age group but affects all ages.
• Aetiology: Viral (70-80%), Bacterial (20-30%) - predominantly Group A Streptococcus (GAS). [3]
• Natural History: Viral resolves in 3-4 days; bacterial in 7 days without treatment.
• Antibiotic Benefit: Shortens symptoms by approximately 16 hours if bacterial; prevents complications.
• Complications: Peritonsillar abscess (quinsy), rheumatic fever, post-streptococcal glomerulonephritis.
• Key Tool: FeverPAIN or Centor score to guide antibiotic prescribing.

Clinical Pearls

The Centor Score: Originally validated for adults 15-44 years. Score 3-4 has approximately 50% probability of GAS. Score 0-1 has less than 10% probability - antibiotics not needed.

Infectious Mononucleosis Trap: EBV causes severe exudative tonsillitis. Giving amoxicillin causes widespread maculopapular rash. Always consider EBV in teenagers/young adults with severe tonsillitis.

The Quinsy: Peritonsillar abscess is the most common deep neck infection. Look for: unilateral swelling, uvula deviation, trismus, "hot potato" voice. This is a surgical emergency.

Watchful Waiting: NICE recommends "back-up prescription" (delayed antibiotic) rather than immediate antibiotics for most sore throats where bacterial cause uncertain.

Systematic Examination

General Appearance

• Febrile, unwell appearance.
• Hydration status (lips, mucous membranes).
• Skin examination for rash (scarlet fever).

Oropharyngeal Examination

• Use good light source.
• Ask patient to say "ah" to visualise tonsils.
• Note size (grading 1-4), colour, exudate.
• Assess uvula position (midline vs deviated).
• Look for palatal petechiae (GAS indicator).

Tonsillar Grading Scale

Neck Examination

• Palpate anterior cervical chain (jugulodigastric node).
• Tender lymphadenopathy supports bacterial cause.
• Posterior cervical lymphadenopathy suggests EBV.
• Generalised lymphadenopathy - consider EBV, HIV, lymphoma.

Signs of Complications

Natural History

Prognosis for Complications

• Quinsy: Excellent with drainage; may recur.
• Rheumatic Fever: Prevented by antibiotics; if occurs, risk of valvular heart disease.
• PSGN: Usually complete recovery; rare progression to CKD.

Recurrence

• 15-25% of patients have recurrent episodes.
• Tonsillectomy significantly reduces recurrence (approximately 80% reduction).
• Quality of life improvement post-tonsillectomy well documented. [5]

Follow-Up

• Routine follow-up not required for uncomplicated cases.
• Review if symptoms persist beyond 7 days.
• Post-tonsillectomy: routine ENT follow-up.

Key Guidelines

Landmark Studies

1. Little et al. PRISM Trial (2013) [4]

• Question: Delayed vs immediate vs no antibiotics for sore throat?
• N: 12,677 patients (open RCT).
• Result: Delayed prescription reduces antibiotic use without worsening outcomes.
• Impact: Established delayed prescription as valid strategy.
• PMID: 24285052.

2. Spinks et al. Cochrane Review (2013) [6]

• Question: Do antibiotics help sore throat?
• N: 27 trials.
• Result: Antibiotics shorten duration by approximately 16 hours; reduce suppurative complications by 50%.
• Impact: Modest benefit supports selective prescribing.
• PMID: 24190439.

3. Burton et al. Cochrane Review (2014) [5]

• Question: Tonsillectomy for recurrent acute tonsillitis?
• N: 7 trials, 749 children.
• Result: Tonsillectomy reduces sore throat episodes (3.0 vs 0.5 per year).
• Impact: Supports tonsillectomy for recurrent disease.
• PMID: 25407135.

4. Fine et al. (2012) [7]

• Question: Accuracy of Centor and McIsaac scores?
• N: Meta-analysis.
• Result: Score 4 has approximately 50% probability of GAS.
• Impact: Informs antibiotic decision-making.
• PMID: 22586189.

What is Tonsillitis?

Tonsillitis is an infection of the tonsils - two round lumps of tissue at the back of your throat. It causes a sore throat, difficulty swallowing, and often a fever. Most cases are caused by viruses and get better on their own.

What Causes It?

• Viruses (most common): Like the common cold.
• Bacteria: Mainly "Strep throat" (Group A Streptococcus).
• It spreads through coughing, sneezing, and close contact.

What Are the Symptoms?

• Sore throat (may be severe).
• Painful swallowing.
• Fever.
• Swollen, red tonsils (sometimes with white spots).
• Swollen glands in the neck.
• Headache, tiredness.

Do I Need Antibiotics?

• Not always. Most sore throats are viral and won't respond to antibiotics.
• Your doctor may use a scoring system to decide if antibiotics will help.
• If prescribed, take the full course (usually 10 days).

What Can Help?

• Paracetamol or ibuprofen for pain and fever.
• Drink plenty of fluids.
• Eat soft, cool foods.
• Rest.
• Throat lozenges or saltwater gargles.
• Most sore throats improve within 7 days.

When to Seek Medical Help

• Symptoms not improving after a week.
• Difficulty opening your mouth.
• Unable to swallow liquids or drooling.
• Severe one-sided throat pain.
• Difficulty breathing.
• Swelling in the neck.
• Rash with sore throat.

What About Recurrent Tonsillitis?

If you have many episodes of tonsillitis (7 in a year, or 5 per year for 2 years), you may be offered surgery to remove your tonsils (tonsillectomy). This significantly reduces future episodes.