What is Tonsillitis
Tonsillitis is inflammation of the palatine tonsils caused by viral or bacterial infection of the tonsillar tissue, presenting as sore throat with visible inflammation of the tonsils and pharynx. 1, 2
Definition and Pathophysiology
Tonsillitis is defined as sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be culture positive for group A streptococcus. 1
The condition encompasses terms including strep throat, acute tonsillitis, pharyngitis, adenotonsillitis, and tonsillopharyngitis. 1
Tonsillitis represents an inflammatory process of the tonsillar tissues that is usually infectious in nature, affecting the lymphoid tissue of the palatine tonsils. 3
Etiology and Epidemiology
Viral infections account for 70% to 95% of tonsillitis cases, making them the predominant cause. 4
Bacterial tonsillitis caused by group A beta-hemolytic streptococcus (Streptococcus pyogenes) accounts for 5% to 15% of cases in adults and 15% to 30% of cases in children aged 5 to 15 years. 4
The condition predominantly affects school-aged children but can occur in patients of any age. 3
Tonsillitis makes up approximately 0.4% of outpatient visits in the United States. 4
Clinical Presentation
Viral Tonsillitis
Typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy. 5
Presents with sore throat and difficulty swallowing, with visible inflammation of the tonsils on examination. 6
Bacterial Tonsillitis (Group A Streptococcus)
Characterized by sudden onset of sore throat, fever >38°C (100.9°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 5, 7
Physical examination reveals erythema of the uvula, pharynx, or tonsils, often with edema and potentially exudate. 1
Diagnostic Approach
Testing before treating is essential: use rapid antigen detection testing (RADT) and/or throat culture for group A Streptococcus before initiating antibiotic therapy. 7
At least 10 colonies of group A beta-hemolytic streptococci should be present on the culture plate for a positive diagnosis. 1
Throat specimens should be obtained from the posterior pharynx and uvula using a throat swab prior to initiating anti-infective therapy. 1
Impact on Quality of Life
Recurrent throat infections and tonsillitis can substantially affect child health status and quality of life. 1
Children with tonsillar disease show significantly lower scores on quality of life subscales including general health, physical functioning, behavior, bodily pain, and caregiver impact compared with healthy children. 1
The condition leads to increased healthcare usage, missed school days, and spread of infection within families. 1
Complications
Differentiating group A beta-hemolytic streptococcus from other causes is critical due to risk of progression to systemic complications including peritonsillar abscess, parapharyngeal abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever. 4, 2
Life-threatening complications can develop, highlighting the need for appropriate recognition and management. 2
Treatment Principles
Viral Tonsillitis
Bacterial Tonsillitis
Penicillin V for 10 days is the gold standard treatment for confirmed group A streptococcal tonsillitis, with amoxicillin as an acceptable alternative. 7
The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though shorter courses may resolve symptoms. 7
For penicillin-allergic patients with non-anaphylactic allergy, first-generation cephalosporins are recommended; for anaphylactic allergy, clindamycin, azithromycin, or clarithromycin should be used. 7
Recurrent Tonsillitis
Recurrent tonsillitis is defined by frequency: at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years. 1
Each documented episode must include temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A streptococcus. 1
Watchful waiting is strongly recommended if episodes are fewer than these thresholds before considering tonsillectomy. 4