Tonsillitis

Tonsil Basics - Ring of Fire

• Waldeyer's Tonsillar Ring: A strategic collection of lymphoid tissue encircling the naso- and oropharynx.
• Acts as the first line of immune defense; its inflammation is common, hence "Ring of Fire".
• Key Components:
  • Pharyngeal tonsil (Adenoids): Located on the roof of the nasopharynx.
  • Palatine tonsils (Faucial): Situated in the oropharynx between palatal arches.
  • Lingual tonsil: Found at the base of the tongue.
  • Tubal tonsils (of Gerlach): Surround Eustachian tube openings.

⭐ Palatine tonsils are the largest lymphoid masses in Waldeyer's ring, especially prominent in children, and are the most frequently infected part (acute tonsillitis).

Bugs & Battles - The Infection Story

• Common Culprits:
  • Viral (most frequent): Adenovirus, Rhinovirus, Influenza, EBV, Coxsackie A.
  • Bacterial: Streptococcus pyogenes (GAS) is the leading bacterial cause.
    • Others: Staph. aureus, H. influenzae, anaerobes.
• Less Common:
  • Corynebacterium diphtheriae (greyish pseudomembrane).
  • Fungal (Candida in immunocompromised).
• Spread & Attack:
  • Transmission: Droplet, direct contact.
  • Mechanism: Pathogens invade tonsillar crypts → inflammation, exudate.

⭐ Group A Streptococcus (GAS) accounts for 15-30% of acute pharyngitis in children and 5-15% in adults.

Symptoms & Signs - Spotting the Soreness

• Key Complaints:
  • Sudden sore throat (odynophagia), painful swallowing (dysphagia)
  • Fever (often >38°C), headache, general malaise
• On Examination:
  • Tonsils: Enlarged, erythematous; may show whitish/yellowish exudates (follicular spots or confluent membrane)
  • Pharynx: Inflamed pillars, soft palate, uvula
  • Halitosis (bad breath)
• Associated Findings:
  • Tender, swollen jugulodigastric (tonsillar) lymph nodes
  • Referred ear pain (otalgia)
  • Children may present with abdominal pain, vomiting

⭐ Scarlet fever rash (sandpaper-like) with strawberry tongue indicates associated GABHS toxin production.

Diagnosis & Dangers - Tests & Troubles

• Diagnosis:
  • Clinical: Acute sore throat, fever, odynophagia, tonsillar erythema/exudates, cervical lymphadenopathy.
  • Scoring: Centor/McIsaac criteria assess Group A Strep (GAS) probability.
  • Tests:
    • Throat Swab Culture: Gold standard for GAS.
    • Rapid Antigen Detection Test (RADT): Quick GAS detection.
    • Monospot test: For Infectious Mononucleosis.
• Dangers (Complications):
  • Suppurative:
    • Peritonsillar Abscess (Quinsy): Most common. Hot potato voice.
    • Parapharyngeal/Retropharyngeal abscess.
    • Lemierre's Syndrome: IJV thrombophlebitis.
  • Non-Suppurative (Post-Strep):
    • Acute Rheumatic Fever (ARF).
    • Post-Streptococcal Glomerulonephritis (PSGN).
  • Severe tonsillar swelling → Airway obstruction.

⭐ Lemierre's syndrome ("forgotten disease"): IJV thrombophlebitis, post-anginal sepsis, often Fusobacterium necrophorum.

Treatment Time - Fixing the Pharynx

• Medical Management:

  • Analgesics, hydration, rest.
  • Antibiotics (bacterial): Penicillin V/Amoxicillin (7-10 days). Macrolides (allergy).
  • Saline gargles.

• Surgical Management (Tonsillectomy Indications):

  • Recurrent acute tonsillitis (e.g., ≥7 episodes/year).
  • Complications: Peritonsillar abscess (Quinsy), airway obstruction (e.g., OSA).
  • Suspicion of malignancy.

⭐ One absolute indication for tonsillectomy is suspicion of malignancy in an enlarged tonsil, especially if unilateral.

High‑Yield Points - ⚡ Biggest Takeaways

• Group A Streptococcus (GAS) is the most common bacterial cause; viral overall.
• Centor criteria (Fever, Exudates, Tender Anterior Cervical Nodes, Absence of Cough) help diagnose GAS pharyngitis.
• Key GAS complications: Rheumatic fever, PSGN, and Peritonsillar abscess (Quinsy).
• Quinsy features unilateral swelling, uvular deviation, trismus, and "hot potato voice".
• Penicillin (or Amoxicillin) is the drug of choice for GAS tonsillitis.
• Tonsillectomy indications include recurrent infections (e.g., Paradise criteria), airway obstruction, or suspicion of malignancy.
• Infectious Mononucleosis (EBV): exudative tonsillitis, posterior cervical lymphadenopathy, splenomegaly; avoid ampicillin (rash).