Tonsillitis isinflammation of thetonsils in the upper part of thethroat. It can be acute or chronic.^[8][9][2] Acute tonsillitis typically has a rapid onset.^[10] Symptoms may includesore throat,fever, enlargement of thetonsils, trouble swallowing, and enlargedlymph nodes around the neck.^[1][2] Complications includeperitonsillar abscess (quinsy).^[1][3]

Tonsillitis
A culture-positive case ofstreptococcal pharyngitis with typical tonsillarexudate in a 16-year-old
Pronunciation	/ˌtɒnsɪˈlaɪtɪs/
Specialty	Infectious disease
Symptoms	Sore throat,fever, enlargement of the tonsils, trouble swallowing,large lymph nodes around the neck[1][2]
Complications	Peritonsillar abscess[1][3]
Duration	~ 1 week[4]
Causes	Viral infection,bacterial infection[1][5][6]
Diagnostic method	Based on symptoms,throat swab,rapid strep test[1][5]
Medication	Paracetamol (acetaminophen),ibuprofen,penicillin[1][5]
Frequency	7.5% (in any given 3 months)[7]

Tonsillitis is most commonly caused by aviral infection and about 5% to 40% of cases are caused by abacterial infection.^[1][5][6] When caused by the bacteriumgroup A streptococcus, it is classed asstreptococcal tonsillitis^[11] also referred to asstrep throat.^[12] Rarely bacteria such asNeisseria gonorrhoeae,Corynebacterium diphtheriae, orHaemophilus influenzae may be the cause.^[5] Typically the infection is spread between people through the air.^[6] A scoring system, such as theCentor score, may help separate possible causes.^[1][5] Confirmation may be by athroat swab orrapid strep test.^[1][5]

Treatment efforts involve improving symptoms and decreasing complications.^[5]Paracetamol (acetaminophen) andibuprofen may be used to help with pain.^[1][5] If strep throat is present the antibioticpenicillin by mouth is generally recommended.^[1][5] In those who are allergic to penicillin,cephalosporins ormacrolides may be used.^[1][5] In children with frequent episodes of tonsillitis,tonsillectomy modestly decreases the risk of future episodes.^[13]

About 7.5% of people have a sore throat in any three-month period and 2% of people visit a doctor for tonsillitis each year.^[7] It is most common in school-aged children and typically occurs in the colder months of autumn and winter.^[5][6] The majority of people recover with or without medication.^[1][5] In 82% of people, symptoms resolve within one week, regardless if bacteria or viruses were present.^[4] Antibiotics probably reduce the number of people experiencing sore throat or headache, but the balance between modest symptom reduction and the potential hazards ofantimicrobial resistance must be recognised.^[4]

Those with tonsillitis usually experiencesore throat,painful swallowing,malaise, and fever.^[1][14][15] Their tonsils – and often the back of the throat – appearred and swollen, and sometimes give off a white discharge.^[1][15][16] Some also have tender swelling of thecervical lymph nodes.^[1][15]

Many viral infections that cause tonsillitis will also cause cough,runny nose,hoarse voice, or blistering in the mouth or throat.^[17]Infectious mononucleosis can cause the tonsils to swell with redspots or white discharge that may extend to the tongue.^[18] This can be accompanied by fever, sore throat, cervical lymph node swelling, and enlargement of the liver and spleen.^[18] Bacterial infections that cause tonsillitis can also cause a distinct"scarletiniform" rash, vomiting, and tonsillar spots or discharge.^[1][17]

Tonsilloliths occur in up to 10% of the population frequently due to episodes of tonsillitis.^{[clarification needed][19]}

Viral infections cause 40 to 60% of cases of tonsillitis.^[14] Many viruses can cause inflammation of the tonsils (and the rest of throat) includingadenovirus,rhinovirus,coronavirus,influenza virus,parainfluenza virus,coxsackievirus,measles virus,Epstein-Barr virus,cytomegalovirus,respiratory syncytial virus, andherpes simplex virus.^[17] Tonsillitis can also be part of theinitial reaction toHIV infection.^[17] An estimated 1 to 10% of the cases are caused by Epstein-Barr virus.^[15]

Tonsillitis can also stem from infection with bacteria, predominantly Group A β-hemolytic streptococci (GABHS), which causesstrep throat.^[1][14] Bacterial infection of the tonsils usually follows the initial viral infection.^[15] When tonsillitis recurs after antibiotic treatment for streptococcus bacteria, it is usually due to the same bacteria as the first time, which suggests that the antibiotic treatment was not fully effective.^[1][20] Less common bacterial causes include:Streptococcus pneumoniae,Mycoplasma pneumoniae,Chlamydia pneumoniae,Bordetella pertussis,Fusobacterium sp.,Corynebacterium diphtheriae,Treponema pallidum, andNeisseria gonorrhoeae.^{[21][22][23][24]}

Anaerobic bacteria have been implicated in tonsillitis, and a possible role in the acute inflammatory process is supported by several clinical and scientific observations.^[25]

Sometimes tonsillitis is caused by aninfection ofspirochaeta andtreponema, which is called Vincent's angina orPlaut-Vincent angina.^{[non-primary source needed][26]}

Within the tonsils,white blood cells of the immune system destroy the viruses or bacteria by producing inflammatorycytokines likephospholipase A2,^{[non-primary source needed][27]} which also lead to fever.^[28][29] The infection may also be present in thethroat and surrounding areas, causing inflammation of thepharynx.^[1][30]

There is no firm distinction between a sore throat that is specifically tonsillitis and a sore throat caused by inflammation in both the tonsils and also nearby tissues.^[1][31] Anacute sore throat may be diagnosed astonsillitis,pharyngitis, ortonsillopharyngitis (also called pharyngotonsillitis), depending upon the clinical findings.^[1]

Inprimary care settings, theCentor criteria are used to determine the likelihood of group A beta-hemolytic streptococcus (GABHS) infection in an acute tonsillitis and the need of antibiotics for tonsillitis treatment.^[1][15] However, the Centor criteria have their weaknesses in making precise diagnosis for adults. The Centor criteria are also ineffective in diagnosis for tonsillitis in children and insecondary care settings (hospitals).^[15] A modified version of the Centor criteria, which modified the original Centor criteria in 1998, is often used to aid in diagnosis. The original Centor criteria had four major criteria but the modified Centor criteria have five. The five major criteria of the modified Centor score are:

1. Presence of tonsillarexudate
2. Painful neck lymph nodes
3. History of fever
4. Age between five and fifteen years
5. Absence of cough

The possibility of GABHS infection increases with increasing score. The probability for getting GABHS is 2 to 23% for the score of 1, and 25 to 85% for the score of 4.^[15]The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing the throat and plating them onblood agar medium. This small percentage of false-negative results are part of the characteristics of the tests used but are also possible if the person has received antibiotics prior to testing. Identification requires 24 to 48 hours by culture but rapid screening tests (10–60 minutes), which have a sensitivity of 85–90%, are available. In 40% of the people without any symptoms, the throat culture can be positive. Therefore, throat culture is not routinely used in clinical practice for the detection of GABHS.^[15]

Centor and McIsaac scores are equally ineffective at identifying patients who need antibiotics presenting with pharyngitis at hospitals. Too many true positive cases are missed and too many false positives are treated, leading to the over prescription of antibiotics.^[32]

Bacterial culture may need to be performed in cases of a negative rapid streptococcal test.^[33] An increase in antistreptolysin O (ASO) streptococcal antibody titer following the acute infection can provide retrospective evidence of GABHS infection and is considered definitive proof of GABHS infection, but not necessarily of the tonsils.^[34]Epstein Barr virusserology can be tested for those who may haveinfectious mononucleosis with a typicallymphocyte count infull blood count result.^[15] Blood investigations are only required for those with hospital admission requiring intravenous antibiotics.^[15]

Nasoendoscopy can be used for those with severe neck pain and inability to swallow any fluids to rule out maskedepiglotitis and supraglotitis. Routine nasoendscopy is not recommended for children.^[15]

Treatments to reduce the discomfort from tonsillitis include:^{[1][22][23][24][30]}

• pain and fever reducing medications such asparacetamol (acetaminophen) andibuprofen
• warm saltwater gargle,lozenges,honey, or warm liquids

There are no antiviral medical treatments for virally caused tonsillitis.^[35]

If the tonsillitis is caused bygroup A streptococcus, thenantibiotics are useful, withpenicillin oramoxicillin being primary choices.^[1][15]Cephalosporins andmacrolides are considered good alternatives to penicillin in the acute care setting.^[1][36] A macrolide, such asazithromycin orerythromycin, is used for people allergic to penicillin.^[1] If penicillin therapy fails, bacterial tonsillitis may respond to treatment effective against beta-lactamase producing bacteria such asclindamycin oramoxicillin-clavulanate.^[37] Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins.^[38] There is no significant difference in efficacy of various groups of antibiotics for treating tonsillitis.^[15] Intravenous antibiotics can be for those who are hospitalized with inability to swallow and presented with complications.^{[citation needed]} Oral antibiotics can be resumed immediately if the person is clinically improved and able to swallow orally.^[15] Antibiotic treatment is usually taken for seven to ten days.^[1][5]

Paracetamol andnonsteroidal anti-inflammatory drugs (NSAIDs) can be used to treat throat pain in children and adults.^[1][15]Codeine is avoided in children under 12 years of age to treat throat pain or following tonsilectomy.^[39][40] NSAIDs (such asibuprofen) andopioids (such as codeine andtramadol) are equally effective at relieving pain, however, precautions should be taken with these pain medications. NSAIDs can causepeptic ulcer disease and kidney damage.^{[citation needed]} Opioids can causerespiratory depression in those who are vulnerable.^[15] Anaestheticmouthwash can also be used for symptomatic relief.^[15]

Corticosteroids reduce tonsillitis pain and improve symptoms in 24 to 48 hours. Oral corticosteroids are recommended unless the person is unable to swallow medications.^[15]

When tonsillitis recurs frequently, often arbitrarily defined as at least five episodes of tonsillitis in a year,^[41] or when the palatine tonsils become so swollen that swallowing is difficult as well as painful, atonsillectomy can be performed to surgically remove the tonsils. A randomised controlled trial of tonsillectomy versus medical treatment (antibiotics and pain killers) in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat.^[42][43]

Children have had only a modest benefit from tonsillectomy for repeated cases of tonsillitis.^[44]

Since the advent of penicillin in the 1940s, a major preoccupation in the treatment of streptococcal tonsillitis has been the prevention ofrheumatic fever, and its major effects on thenervous system andheart.

Complications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, andpharyngitis due to the spread of infection.^{[22][23][24][30]}

Anabscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis.^{[citation needed]} This is termed aperitonsillar abscess (or quinsy).

Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of theinternal jugular vein giving rise to a spreading infectiousthrombophlebitis (Lemierre's syndrome).^{[citation needed]}

Instrep throat, diseases likepost-streptococcal glomerulonephritis^{[non-primary source needed][45]} can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations.^[46][47]

Tonsillitis occurs throughout the world, without racial or ethnic differences.^[48] Most children have tonsillitis at least once during their childhood,^[49] although it rarely occurs before the age of two.^[48] It most typically occurs between the ages of four and five; bacterial infections most typically occur at a later age.^[48]

Tonsillitis is described in the ancient GreekHippocratic Corpus.^[50]

Recurrent tonsillitis can interfere with vocal function and the ability to perform among people who use their voices professionally.^[51][52]

• Tonsillitt Velbehagklinikk 26 July 2022

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