Are tonsil ulcers worrisome?

Tonsil Ulcers: Evaluation and Management

Tonsil ulcers that persist beyond 2 weeks or do not respond to 1-2 weeks of treatment warrant further investigation as they may indicate serious underlying conditions requiring prompt medical attention. 1

Clinical Significance and Etiology

Tonsil ulcers can range from benign self-limiting conditions to manifestations of serious systemic diseases. The most common causes include:

• Viral infections (70-95% of tonsillitis cases) 2
• Bacterial infections (5-15% in adults, 15-30% in children) 2
• Recurrent aphthous ulcers (affecting approximately 20% of the general population) 3
• Traumatic injury
• Tuberculosis (rare but serious) 4
• Malignancy (particularly concerning in adults)

Evaluation Algorithm

Initial Assessment

1. Duration of symptoms:

   • Ulcers persisting >2 weeks are concerning 1
   • Non-healing ulcers after 1-2 weeks of treatment require further investigation

2. Associated symptoms to assess:

   • Fever, night sweats, weight loss (suggesting systemic disease)
   • Dysphagia, odynophagia (difficulty/pain with swallowing)
   • Voice changes ("hot potato" voice suggesting peritonsillar abscess) 5
   • Referred otalgia (ear pain without ear pathology) 1
   • Trismus (limited mouth opening) 5

3. Physical examination findings:

   • Ulcer characteristics (size, depth, borders, base)
   • Unilateral vs bilateral involvement
   • Presence of exudate or pseudomembrane
   • Cervical lymphadenopathy (size, tenderness, mobility)
   • Complete oropharyngeal examination including tongue mobility 1

Risk Stratification

High-Risk Features (Requiring Urgent Evaluation):

• Ulcers persisting >2 weeks 1
• Unilateral tonsil enlargement
• Neck mass (especially if nontender) 1
• Systemic symptoms (weight loss, night sweats)
• Age >40 years with new-onset ulceration
• Immunocompromised status
• History of tobacco or alcohol use

Diagnostic Approach

For persistent tonsil ulcers (>2 weeks), the following investigations should be considered:

1. Laboratory tests 1:

   • Complete blood count
   • Coagulation studies
   • Fasting blood glucose
   • HIV antibody testing
   • Syphilis serology

2. Biopsy for persistent ulcers to rule out malignancy or specific infections like tuberculosis 1, 4

3. Microbiological studies:

   • Throat culture or rapid strep test for Group A Streptococcus
   • Specific testing for tuberculosis if suspected 4

Management

Management depends on the underlying cause:

1. Infectious causes:

   • Viral tonsillitis: Supportive care (hydration, pain control)
   • Bacterial tonsillitis: Appropriate antibiotics (penicillin for Group A Streptococcus) 2
   • Tuberculosis: Anti-tuberculosis therapy 4

2. Recurrent aphthous ulcers:

   • Topical corticosteroids for minor ulcers
   • Systemic corticosteroids for major aphthous ulcers (>10mm) 3

3. Peritonsillar abscess:

   • Drainage of the abscess
   • Antibiotics effective against Group A Streptococcus and oral anaerobes
   • Corticosteroids may help reduce symptoms 5

4. Malignancy:

   • Referral to otolaryngology for definitive management

Complications and Prognosis

Potential complications of untreated tonsil ulcers include:

• Airway obstruction (rare but life-threatening)
• Spread of infection to deep neck spaces
• Aspiration
• Dehydration due to odynophagia
• Scarring (particularly with major aphthous ulcers) 3

When to Refer to a Specialist

Immediate referral to an otolaryngologist is warranted for:

• Ulcers persisting >2 weeks despite treatment 1
• Suspicion of malignancy
• Inability to adequately visualize the oropharynx 1
• Peritonsillar abscess requiring drainage 5
• Significant airway compromise

Prevention

For recurrent tonsil infections and ulcers:

• Maintain good oral hygiene
• Avoid known triggers (for aphthous ulcers)
• Consider tonsillectomy for patients meeting specific criteria:
  • ≥7 episodes of streptococcal tonsillitis in the preceding year
  • ≥5 episodes per year for 2 consecutive years
  • ≥3 episodes per year for 3 consecutive years 6

Remember that tonsillectomy carries risks including bleeding (0.1-3%), pain, dehydration, and rare but serious complications including mortality (estimated at 1 per 18,000 in ambulatory settings) 1.