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Tonsillitis - A full understanding for parents and patients

Infant and Children | November 20, 2014 | Author: The Super Pharmacist

Children, ENT

Tonsillitis - A full understanding for parents and patients

The immune system is the body’s defense against disease producing bacteria and viruses. It has many components. The tonsils are a part of the immune system. They are a pair of structures lying at the back of the throat, one on either side. They are quite strategically placed; at the entrance to the air and food passages. This emphasises their importance as guards, checking what is harmful for the body and what is not. Harmful viruses and bacteria are trapped and the immune system is alerted and activated against them. Sometimes during this fight against pathogens (disease producing agents) the tonsils themselves become infected and inflamed. The result is a condition known as tonsillitis. When it is of recent onset, it is termed acute tonsillitis. When it has been recurring or ongoing for some time, it is called chronic tonsillitis. Accumulation of pus next to the tonsil is known as peritonsillar abscess or quinsy.

Commonly affected Age-groups

The condition mostly affects children and young adults, as tonsils tend to regress with age.

Causes of tonsillitis

Tonsillitis is normally the result of either a viral or bacterial infection, the former being more common. It can also start as a viral condition and then develop into a superadded bacterial infection. Commonly implicated viruses are adenovirus, rhinovirus, influenza virus and Epstein-Barr virus. There can be an associated common cold or flu. Commonly implicated bacteria include Group A β-hemolytic Streptococcus (GABHS), Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and others. Of these the most frequent is Streptococcus pyogenes, an example of a Group A β-hemolytic Streptococcus (GABHS). It is the organism behind 'strep throat'.

​Signs and Symptoms of tonsillitisSigns and Symptoms of tonsillitis

  • Sore throat
  • Fever
  • Swollen neck lymph glands
  • Painful swallowing
  • Red, enlarged tonsils
  • Headache
  • Fatigue
  • Cough
  • Bad breath
  • Voice changes
  • Difficulty breathing

In young children, watch out for

  • Refusal to eat
  • Drooling
  • Irritability

Workup and Diagnosis

Your doctor will make the diagnosis after noting a relevant history and performing a physical examination including a throat exam. A swab is taken from the throat and tonsils for testing. The rapid strep test yields results within minutes and indicates the presence or absence of strep throat. A culture report can take one to two days and is more sensitive than the rapid test. A rise in ASO titres (antibodies to the strep antigen) shows previous infection. Negative tests for bacterial infection point to viral tonsillitis.

Treatment Options for tonsillitis

Supportive Care

Irrespective of the cause, the following measures will help in tonsillitis:

  • Adequate rest and sleep will aid the immune system in overcoming the infection.
  • Avoid dehydration. Especially in young children, who may avoid fluid intake due to the sore throat.
  • Saltwater gargles can have a soothing effect with mild antimicrobial activity.
  • Lozenges can help, though they are not recommended for young children as they represent a choking hazard.
  • Room humidifier/vapouriser. A dry throat will only increase the discomfort.
  • Over-the-counter pain relief such as paracetamol or ibuprofen. This is important not only for pain relief, it will alleviate the fever as well.

Antibiotics

Antibiotics by definition are effective against bacteria and have no role against viruses. Since many cases of tonsillitis have a viral cause, antibiotics are not always necessary. The decision to start an antibiotic lies with your doctor.

Treatment Options for tonsillitisA positive strep culture is a sure indication for an antibiotic such as penicillin or amoxycillin for approximately 10 days.

A narrow-spectrum oral cephalosporin such as cephalexin or a macrolide such as clarithromycin are penicillin alternatives for those sensitive or allergic to penicillins. Clindamycin is another effective choice. If your doctor prescribes an antibiotic, finish the full course to completely eradicate the organism.

Surgical Options

While an acute attack of tonsillitis is managed conservatively, recurrent or persistent tonsillitis, also known as chronic tonsillitis, interfering with school and work, is an indication for a tonsillectomy. Tonsillectomy is the name of the surgical procedure to remove the tonsils. The following criteria have been developed to indicate the recommendation of a tonsillectomy:

  • 7 attacks of tonsillitis over the last year
  • 5 attacks of tonsillitis each year for the last 2 years
  • 3 attacks of tonsillitis each year for the last 3 years

Any of these would suggest chronicity and an indication for surgery. Also if the tonsils interfere with breathing and/or swallowing, surgery should be considered. In children another infected structure nearby is the adenoid which is usually removed with the tonsils.

New Trends in Management

Lesser Antibiotics

The realisation that most cases are viral where antibiotics have no role, an overall decrease in unnecessary prescribing of antibiotics and a reduced incidence of strep throat and its complications, have all resulted in a continual decline in the use of antibiotics for tonsillitis.

Laser and Ultrasonic Surgery

Tonsillectomy is a very common surgical procedure. Traditionally done by blunt dissection and then use of ligatures or diathermy to stop the bleeding; new techniques utilise lasers and ultrasonic scalpels.

Outcomes in Tonsillitis

Outcomes in TonsillitisWithout Antibiotics

Most cases will resolve without antibiotics within a week or two. This is the time it takes for the body’s immune system to get rid of the infection on its own. However the supportive care measures outlined above including rest, rehydration and pain relief will improve patient comfort and hasten recovery.

With Antibiotics

Antibiotics do not markedly shorten the episode. Their main role is to prevent any complications and decrease the chances of transmission of infection. An untreated strep throat can give rise to complications including cardiovascular, joints or kidneys.

After Surgery

Most of the organisms that can infect the tonsils causing tonsillitis can infect the throat as well leading to pharyngitis. A tonsillectomy will eliminate future incidence of tonsillitis but pharyngitis can still occur. However there is a significant decrease in the frequency of recurrent throat infections. Also any breathing or swallowing difficulty due to the tonsils is taken care of for good. Generally speaking, people with repeated infections of the tonsils are better off without them.

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References

Sidell D, Shapiro NL (2012) Acute tonsillitis. Infect Disorder Drug Targets. 12(4): 271–6.

Lindbaek M, Hoiby E, Lermark G, Hjortdahl P, Steinsholt I. Predictors for spread of clinical group A streptococcal tonsillitis within the household. Scandanavian Journal of Primary Care. 2004;22:239–243.

Borschmann ME, Berkowitz RG. One-off streptococcal serologic testing in young children with recurrent tonsillitis. Ann Otol Rhinol Laryngol 2006; 115: 357–360.

Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. A scientific statement from American Heart Association. Circulation.2009;119:1541–1551.

Sheahan P, Miller I, Colreavy M, Sheahan JN, McShane D, Curran A. The ultrasonically activated scalpel versus bipolar diathermy for tonsillectomy: a prospective, randomized trial. Clin Otolaryngol Allied Sci. 2004;29:530–534.

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