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TonsillitisandPeritonsillarAbscess

TonsillitisandPeritonsillarAbscess
Author:UdayanKShah,MD,FACS,FAAPChiefEditor:ArlenDMeyers,MD,MBAmore...
Updated:Oct6,2014

PracticeEssentials
Tonsillitisisinflammationofthepharyngealtonsils.Theinflammationusuallyextendstotheadenoidandthelingual
tonsilstherefore,thetermpharyngitismayalsobeused.MostcasesofbacterialtonsillitisarecausedbygroupA
betahemolyticStreptococcuspyogenes(GABHS).

Essentialupdate:Studysuggeststhatintravenoussteroidsincreaseposttonsillectomy
bleedingriskinchildren
Aretrospectivecohortstudyof61,430patientswhounderwenttonsillectomyindicatesthattheuseofintravenous
steroidsonthedayofsurgeryincreasestheincidenceofposttonsillectomybleedinginchildren,butnotinadults.In
thestudy,Suzukietalfoundthattherateofreoperationforbleedingwas1.2%forchildrenaged15yearsor
youngerwhoreceivedintravenoussteroids,versus0.5%forpatientsinthesameagegroupwhodidnot.Among
patientsolderthan15years,however,thereoperationratewasnotsignificantlyhigherinthesteroidpatientsthanin
thecontrols(1.7%vs.1.4%). [60,61]

Signsandsymptoms
Tonsillitis
Individualswithacutetonsillitispresentwiththefollowing:
Fever
Sorethroat
Foulbreath
Dysphagia(difficultyswallowing)
Odynophagia(painfulswallowing)
Tendercervicallymphnodes
Airwayobstructionmaymanifestasmouthbreathing,snoring,sleepdisorderedbreathing,nocturnalbreathing
pauses,orsleepapnea.
Peritonsillarabscess
Individualswithperitonsillarabscess(PTA)presentwiththefollowing:
Severethroatpain
Fever
Drooling
Foulbreath
Trismus(difficultyopeningthemouth)
Alteredvoicequality(thehotpotatovoice)
PhysicalexaminationofaPTAalmostalwaysrevealsunilateralbulgingaboveandlateraltooneofthetonsils.
SeeClinicalPresentationformoredetail.

Diagnosis
TonsillitisandPTAareclinicaldiagnoses.TestingisindicatedwhenGABHSinfectionissuspected.Throatcultures
arethecriterionstandardfordetectingGABHS.Forpatientsinwhomacutetonsillitisissuspectedtohavespreadto
deepneckstructures(ie,beyondthefascialplanesoftheoropharynx),radiologicimagingusingplainfilmsofthe
lateralneckorcomputedtomography(CT)scanningwithcontrastiswarranted.IncasesofPTA,CTscanningwith
contrastisindicated.
SeeWorkupformoredetail.

Management
Tonsillitis
Treatmentofacutetonsillitisislargelysupportiveandfocusesonmaintainingadequatehydrationandcaloricintake
andcontrollingpainandfever.
Corticosteroidsmayshortenthedurationoffeverandpharyngitisincasesofinfectiousmononucleosis(MN).In
severecasesofMN,corticosteroidsorgammaglobulinmaybehelpful.GABHSinfectionobligatesantibiotic
coverage.
Tonsillectomyisindicatedfortheindividualswhohaveexperiencedthefollowing:
Morethansixepisodesofstreptococcalpharyngitis(confirmedbypositiveculture)in1year
Fiveepisodesofstreptococcalpharyngitisin2consecutiveyears
Threeormoreinfectionsofthetonsilsand/oradenoidsperyearfor3yearsinarowdespiteadequate
medicaltherapy

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Chronicorrecurrenttonsillitisassociatedwiththestreptococcalcarrierstatethathasnotrespondedtobeta
lactamaseresistantantibiotics
Becauseadenoidtissuehassimilarbacteriologytothepharyngealtonsilsandbecauseminimaladditionalmorbidity
occurswithadenoidectomyiftonsillectomyisalreadybeingperformed,mostsurgeonsperformanadenoidectomyif
adenoidsarepresentandinflamedatthetimeoftonsillectomy.However,thispointremainscontroversial.
Peritonsillarabscess
TreatmentofPTAincludesaspirationandincisionanddrainage(I&D).Antibiotics,eitherorallyorintravenously,are
requiredtotreatPTAmedically,althoughtheconditionisusuallyrefractorytoantibiotictherapyalone.
SeeTreatmentandMedicationformoredetail.

Background
InthefirstcenturyAD,Celsusdescribedtonsillectomyperformedwithsharptoolsandfollowedbyrinseswith
vinegarandothermedicinals.Sincethattime,physicianshavebeendocumentingmanagementoftonsillitis.
Tonsillitisgainedadditionalattentionasamedicalconcerninthelate19thcentury.Theconsiderationofquinsyin
thedifferentialdiagnosisofGeorgeWashington'sdeathandthediscussionoftonsillitisinKean'sDomesticMedical
Lectures,ahomemedicalcompanionbookpublishedinthelate19thcentury,reflecttheriseoftonsillitisasa
medicalconcern. [1,2]
Understandingthediseaseprocessandmanagementofthiscommonmaladyremainimportanttoday.Thisarticle
summarizesthecurrentmanagementoftonsillitisandhighlightsrecentadvancesinthepathophysiologyand
immunologyofthisconditionanditsvariations:acutetonsillitis(seetheimagebelow),recurrenttonsillitis,and
chronictonsillitisandperitonsillarabscess(PTA).

Acutebacterialtonsillitisisshown.Thetonsilsareenlargedandinflamedwithexudates.Theuvulaismidline.

Definitions
Tonsillitisisinflammationofthepharyngealtonsils.Theinflammationusuallyextendstotheadenoidandthelingual
tonsilstherefore,thetermpharyngitismayalsobeused.Pharyngotonsillitisandadenotonsillitisareconsidered
equivalentforthepurposesofthisarticle.Lingualtonsillitisreferstoisolatedinflammationofthelymphoidtissueat
thetonguebase.
A"carrierstate"isdefinedbyapositivepharyngealcultureofgroupAbetahemolyticStreptococcuspyogenes
(GABHS),withoutevidenceofanantistreptococcalimmunologicresponse.

PathophysiologyandEtiology
Viralorbacterialinfectionsandimmunologicfactorsleadtotonsillitisanditscomplications.Overcrowdedconditions
andmalnourishmentpromotetonsillitis.Mostepisodesofacutepharyngitisandacutetonsillitisarecausedby
virusessuchasthefollowing:
Herpessimplexvirus
EpsteinBarrvirus(EBV)
Cytomegalovirus
Otherherpesviruses
Adenovirus
Measlesvirus
InonestudyshowingthatEBVmaycausetonsillitisintheabsenceofsystemicmononucleosis,EBVwasfoundto
beresponsiblefor19%ofexudativetonsillitisinchildren.
Bacteriacause1530%ofcasesofpharyngotonsillitis.Anaerobicbacteriaplayanimportantroleintonsillardisease.
MostcasesofbacterialtonsillitisarecausedbygroupAbetahemolyticStreptococcuspyogenes(GABHS).S
pyogenesadherestoadhesinreceptorsthatarelocatedonthetonsillarepithelium.Immunoglobulincoatingof
pathogensmaybeimportantintheinitialinductionofbacterialtonsillitis.
Mycoplasmapneumoniae,Corynebacteriumdiphtheriae,andChlamydiapneumoniaerarelycauseacutepharyngitis.
Neisseriagonorrheamaycausepharyngitisinsexuallyactivepersons.Arcanobacteriumhaemolyticumisan
importantcauseofpharyngitisinScandinaviaandtheUnitedKingdombutisnotrecognizedassuchintheUnited
States.ArashsimilartothatofscarletfeveraccompaniesAhaemolyticumpharyngitis.

Recurrenttonsillitis
Apolymicrobialfloraconsistingofbothaerobicandanaerobicbacteriahasbeenobservedincoretonsillarcultures
incasesofrecurrentpharyngitis,andchildrenwithrecurrentGABHStonsillitishavedifferentbacterialpopulations
thanchildrenwhohavenothadasmanyinfections.Othercompetingbacteriaarereduced,offeringlessinterference
toGABHSinfection.Streptococcuspneumoniae,Staphylococcusaureus,andHaemophilusinfluenzaearethemost
commonbacteriaisolatedinrecurrenttonsillitis,andBacteroidesfragilisisthemostcommonanaerobicbacterium
isolatedinrecurrenttonsillitis.
Themicrobiologiesofrecurrenttonsillitisinchildrenandadultsaredifferentadultsshowmorebacterialisolates,

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withahigherrecoveryrateofPrevotellaspecies,Porphyromonasspecies,andBfragilisorganisms,whereas
childrenshowmoreGABHS.Also,adultsmoreoftenhavebacteriathatproducebetalactamase.

Chronictonsillitis
Apolymicrobialbacterialpopulationisobservedinmostcasesofchronictonsillitis,withalphaandbetahemolytic
streptococcalspecies,Saureus,Hinfluenzae,andBacteroidesspecieshavingbeenidentified.Astudythatwas
basedonbacteriologyofthetonsillarsurfaceandcorein30childrenundergoingtonsillectomysuggestedthat
antibioticsprescribed6monthsbeforesurgerydidnotalterthetonsillarbacteriologyatthetimeoftonsillectomy. [3]
Arelationshipbetweentonsillarsizeandchronicbacterialtonsillitisisbelievedtoexist.Thisrelationshipisbasedon
boththeaerobicbacterialloadandtheabsolutenumberofBandTlymphocytes.Hinfluenzaeisthebacterium
mostoftenisolatedinhypertrophictonsilsandadenoids.Withregardtopenicillinresistanceorbetalactamase
production,themicrobiologyoftonsilsremovedfrompatientswithrecurrentGABHSpharyngitishasnotbeen
showntobesignificantlydifferentfromthemicrobiologyoftonsilsremovedfrompatientswithtonsillarhypertrophy.
Localimmunologicmechanismsareimportantinchronictonsillitis.Thedistributionofdendriticcellsandantigen
presentingcellsisalteredduringdisease,withfewerdendriticcellsonthesurfaceepitheliumandmoreinthecrypts
andextrafollicularareas.Studyofimmunologicmarkersmaypermitdifferentiationbetweenrecurrentandchronic
tonsillitis.Suchmarkersinonestudyindicatedthatchildrenmoreoftenexperiencerecurrenttonsillitis,whereas
adultsrequiringtonsillectomymoreoftenexperiencechronictonsillitis. [4]
Radiationexposuremayrelatetothedevelopmentofchronictonsillitis.Ahighprevalenceofchronictonsillitiswas
notedfollowingtheChernobylnuclearreactoraccidentintheformerSovietUnion.

Peritonsillarabscess
Apolymicrobialfloraisisolatedfromperitonsillarabscesses(PTAs).Predominantorganismsaretheanaerobes
Prevotella,Porphyromonas,Fusobacterium,andPeptostreptococcusspecies.MajoraerobicorganismsareGABHS,
Saureus,andHinfluenzae.
Uhleretal,inananalysisofdatafrom460patientswithPTA,foundahigherincidenceoftheconditioninsmokers
thaninnonsmokers. [5]

Epidemiology
Tonsillitismostoftenoccursinchildrenhowever,theconditionrarelyoccursinchildrenyoungerthan2years.
TonsillitiscausedbyStreptococcusspeciestypicallyoccursinchildrenaged515years,whileviraltonsillitisismore
commoninyoungerchildren.Peritonsillarabscess(PTA)usuallyoccursinteensoryoungadultsbutmaypresent
earlier.
Pharyngitisaccompaniesmanyupperrespiratorytractinfections.Between2.5%and10.9%ofchildrenmaybe
definedascarriers.Inonestudy,themeanprevalenceofcarrierstatusofschoolchildrenforgroupAStreptococcus,
acauseoftonsillitis,was15.9%. [6,7]
AccordingtoHerzonetal,childrenaccountforapproximatelyonethirdofperitonsillarabscessepisodesinthe
UnitedStates. [8]Recurrenttonsillitiswasreportedin11.7%ofNorwegianchildreninonestudyandestimatedin
anotherstudytoaffect12.1%ofTurkishchildren. [9]
Klugfoundseasonaland/oragebasedvariationsintheincidenceandcauseofPTA.Amonghisconclusions,he
reportedthattheincidenceofPTAincreasedduringchildhood,peakinginteenagersandthengraduallyfallinguntil
oldage.Healsofoundthatuntilage14years,girlsweremoreaffectedthanboys,butthatthecondition
subsequentlywasmorefrequentinmalesthaninfemales. [10]
KlugalsofoundasignificantlyhigherincidenceofFusobacteriumnecrophorumthanofgroupAStreptococcusin
patientsaged1524yearswithPTA.However,theincidenceofgroupAStreptococcuswassignificantlyhigherthan
Fnecrophoruminchildrenaged09yearsandinadultsaged3039years. [10]
AlthoughKlugdeterminedthattheincidenceofPTAdidnotsignificantlyvarybyseason,thepresenceofgroupA
Streptococcuswassignificantlymorefrequentinwinterandspringthaninsummer,whileFnecrophorumtendedto
befoundmoreofteninsummerthaninwinter. [10]

Prognosis
Becauseofimprovementsinmedicalandsurgicaltreatments,complicationsassociatedwithtonsillitis,including
death,arerare. [11]Historically,scarletfeverwasamajorkilleratthebeginningofthe20thcentury,andrheumatic
feverwasamajorcauseofcardiacdiseaseandmortality.Althoughtheincidenceofrheumaticfeverhasdeclined
significantly,casesthatoccurredinthe1980sandearly1990ssupportconcernoveraresurgenceofthiscondition.

ContributorInformationandDisclosures
Author
UdayanKShah,MD,FACS,FAAPProfessorofOtolaryngologyHeadandNeckSurgeryandPediatrics,
JeffersonMedicalCollege,ThomasJeffersonUniversityDirector,FellowandResidentEducationinPediatric
Otolaryngology,DivisionofOtolaryngology,NemoursAIduPontHospitalforChildren
UdayanKShah,MD,FACS,FAAPisamemberofthefollowingmedicalsocieties:AmericanAcademyof
OtolaryngologyHeadandNeckSurgery,AmericanAcademyofPediatrics,AmericanCollegeofSurgeons,
AmericanSocietyofPediatricOtolaryngology,PhiBetaKappa,andSocietyforEar,NoseandThroatAdvances
inChildren
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
TedLTewfik,MDProfessor,DepartmentofOtolaryngologyHeadandNeckSurgery,DirectorofContinuing
MedicalEducationofOtolaryngologyandProfessorofPediatricSurgery,McGillFacultyofMedicine,Senior

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StaffMontrealChildren'sHospital,MontrealGeneralHospitalandRoyalVictoriaHospital
TedLTewfik,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyofPediatricOtolaryngology
andCanadianSocietyofOtolaryngologyHead&NeckSurgery
Disclosure:Nothingtodisclose.
ChiefEditor
ArlenDMeyers,MD,MBAProfessorofOtolaryngology,Dentistry,andEngineering,UniversityofColorado
SchoolofMedicine
ArlenDMeyers,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofFacialPlastic
andReconstructiveSurgery,AmericanAcademyofOtolaryngologyHeadandNeckSurgery,andAmericanHead
andNeckSociety
Disclosure:MedvoyOwnershipinterestManagementpositionCerescanImagingHonorariaConsulting
AdditionalContributors
AriJGoldsmith,MDChiefofPediatricOtolaryngology,LongIslandCollegeHospitalAssociateProfessor,
DepartmentofOtolaryngology,DivisionofPediatricOtolaryngology,StateUniversityofNewYorkDownstate
MedicalCenter
AriJGoldsmith,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngologyHead
andNeckSurgery,AmericanMedicalAssociation,andMedicalSocietyoftheStateofNewYork
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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