Acute tonsillitis

Zhong Shixun Ph.D.

Department of Otolaryngology
The First Affiliated Hospital
Chongqing Medical University
 Definition
• An acute bacterial inflammation of the
palatine tonsils that is generally caused by
group A β-hemolytic streptococci
The bacteriology
– Beta-haemolytic streptococcus
– Staphylococcus
– Haemophilus influenzae
– Pneumococcus
The virus
– adenovirus
– rhinovirus
– Estein-Barr virus (EB virus)
– Influenza
– Coronavirus
– Respiratory syncytial virus
 Pathology
• The process of
inflammation originating
within the tonsil is
accompanied by
hyperemia and oedema
with conversion of lymphoid
follicles into small
abscesses which discharge
into crypts
 Pathology-1

follicular tonsillitis
When inflammatory exudate
collects in tonsillar crypts
these present as multiple
white spots on inflamed
tonsillar surface giving rise to
clinical picture of follicular
tonsillitis
 Pathology-2

Catarrhal tonsillitis
When tonsils are
inflamed as part
of the generalised
infection of the
oropharyngeal
mucosa it is
called catarrhal
tonsillitis.
 Pathology-3
Lacunar tonsillitis
Sometimes exudation
from crypts may coalesce
to form a membrane over
the surface of tonsil,
giving rise to clinical
picture of lacunar
tonsillitis
 Symptoms
• This infection most commonly presents in
children aged 5–6 and adolescents,
– High fever: may vary from 38 to 40℃ and may be
associated with chills and rigors
– Sore throat
– Severe pain on swallowing, which often radiates to
the ear.
– Others:
• swollen tonsillar lymph nodes
• muffling of speech due to oropharyngeal swelling
• dysphagia.
• An episode of acute tonsillitis may
progress to recurrent acute tonsillitis
– repeated episodes of acute tonsillitis followed
by periods in which the patient is
asymptomatic.
– During each acute episode, the patient may
develop symptoms of acute tonsillitis.
• In addition to the signs of acute tonsillitis,
patients experiencing recurrent acute
tonsillitis may develop enlarged tonsillar
crypts that accumulate debris, persistent
erythema of the tonsils, and dilated blood
vessels on the surface of the tonsils.
 Signs

 Swollen congested tonsils with

exudates
 Enlarged tender Jugulodiagastric
lymph nodes
 Laboratory test: WBC
 Signs
• Both tonsils are swollen, bright red
• Bright red, swollen, and coated tonsil
• hyperaemia of pillars, soft palate and uvula
• Acute tonsillitis. The appearance of the tonsils
in acute tonsillitis is either diffuse (a) or punctate
(b).
 Diagnosis
Readily to be diagnosed

 The tonsils are red and swollen

 Their surfaces are covered with
characteristics yellowish white spots of
purulent exudate
 The tongue is coated
 The breath is fetid
 Differential Diagnosis-1
Diphtheria
It is characterized by
sore throat, low fever,
and an adherent
membrane (a
pseudomembrane)
on the tonsils, Bull
neck
pharynx, and/or nasal
cavity
 Differential Diagnosis-2
 Scarlet fever
• It is characterized by:
– Sore throat
– Fever
– Bright red tongue with a
"strawberry" appearance
– Characteristic rash
– The rash begins to fade
three to four days after
onset and desquamation
(peeling) begins
 Differential Diagnosis-3
 Vincent's infection
(Acute necrotizing ulcerative
gingivitis)
 Unilateral sore throat
 necrosis and/or punched out
ulceration of the interdental
papillae
 pseudomembranous
formation
 painful, bright red marginal
gingiva that bleed upon
gentle manipulation
 Differential Diagnosis-4
 Infectious mononucleosis (‘kissing
disease’)
It is characterized by:
• Caused by EB virus, lasts for months
• tiredness
• fever
• headache
• muscle aches
• sore throat
• swollen lymph nodes in the neck
• blood test: atypical lymphocyte
 Treatment
• Patient is put to bed and encouraged to
take plenty of fluids.
• Isolation from family and friends
• Analgesics (aspirin or paracetamol) are
given to relieve local pain and bring down
the fever.
 Treatment
• Antimicrobial therapy
– may be started even in the absence of a
positive culture for group A beta-hemolytic
streptococcus.
– In most cases, penicillin and amoxicillin are
the initial drugs of choice.
– Macrolides or oral cephalosporins can be
used in patients allergic to penicillin.
• Surgery
– Children who continue to experience recurrent acute
tonsillitis, despite adequate antibiotic therapy, should
be considered for tonsillectomy and adenoidectomy.
– In over 70% of cases, core tonsil and core adenoid
tissue harbor the same pathogens, and both
tonsillectomy and adenoidectomy lead to their
eradication.
– Patients with three or more episodes of acute
tonsillitis within a year are candidates for
tonsillectomy and adenoidectomy.
 Complications
• Peritonsillar abscess
– Peritonsillar abscess is a
unilateral inflammatory
process that involves not only
the tonsillar parenchyma but
also the peritonsillar tissue—
i.e., the abscess spreads past
the tonsil to involve the
connective tissue between the
parenchyma and pharyngeal
musculature
 Complications
• Peritonsillar abscess
– The abscess usually lies in
the potential space between
the tonsillar capsule and the
surrounding pharyngeal
muscle bed
– Clinical features: pronounced
unilateral redness and
swelling of the soft palate,
muffled speech, and possible
trismus.
 Complications

• Peritonsillar abscess
– This is frequently
accompanied by uvular
edema, but the swelling
may also spread to the
tongue base and lateral
pharyngeal wall, causing
respiratory complications
In a patient with peritonsillar abscess
which is really a peritonsillar cellulitis

puncture incision and drainage

• Sequelae of streptococcal tonsillitis
– Rarely, a delayed-type antigen-antibody
reaction can give rise to poststreptococcal
diseases involving the kidneys (acute
glomerulonephritis), major joints (acute
rheumatic fever), or heart (rheumatic
endocarditis).
– Besides appropriate medical therapy, the
treatment of choice is tonsillectomy under
antibiotic coverage.
 Complications
Septicemia
Untreated acute tonsillitis can result in
septicemia with septic abscesses, septic
arthritis and meningitis
 Conclusions
 Acute tonsillitis is a generalized inflammation of
the mass of the tonsil
 Acute tonsillitis is characterized by sore throat,
fever, malaise, and often, cervical adenitis.
 The onset of acute tonsillitis is often abrupt
 Maybe initiated by a chill and a swiftly rising fever.
 Therapy must be directed against both the local
and the systemic features of the disease.
 The most important therapeutic agent is an
effective antibiotic
 Chronic Tonsillitis
• Recurrent infections of the tonsils and the
peritonsillar tissue lead to permanent
inflammation in the tonsillar crypts and
scarring of the tonsillar tissue.
• Mostly affects children and young adults.
Rarely occurs after 50 years.
• Aetiology
– It may be a complication of acute tonsillitis.
Pathologically, microabscesses walled off by
fibrous tissue have been seen in the lymphoid
follicles of the tonsils.
– Subclinical infections of tonsils without an
acute attack.
– Chronic infection in sinuses or teeth may be a
predisposing factor.
• The organisms responsible for chronic
tonsillitis are similar to those which cause
acute infection, with a predominance of β-
haemolytic streptococci.
• Chronic infected tonsils are considered as
a “focus” which may activate other chronic
inflammatory diseases in the body by
spreading bacteria and mediators
• Symptoms
– Recurrent attacks of sore throat or acute
tonsillitis.
– Chronic irritation in throat with cough.
– Bad taste in mouth and foul breath (halitosis)
due to pus in crypts.
– Thick speech, difficulty in swallowing and
choking spells at night (when tonsils are large
and obstructive).
• Examination
– Tonsils may be covered with debris or there
may be purulent material in the tonsillar crypts.
– Tonsils appear atrophic and scared, often with
surrounding peritonsillar erythematous tissue.
• Examination
– Enlargement of Jugulodigastric lymph nodes
is a reliable sign of chronic tonsillitis. During
acute attacks, the nodes enlarge further and
become tender
– Tonsillar smears are found to contain group A
β-hemolytic streptococci
• Chronic tonsillitis. Deep tonsillar crypts, white debris in these crypts,
and the vascularization of the anterior pillars are seen. This white
debris consisting of stagnated food remnants in the crypts may
cause halitosis
• Tonsils removed with their capsules after
tonsillectomy
• Treatment
– Conservative treatment consists of attention
to general health, diet, treatment of coexistent
infection of teeth, nose and sinuses.
– Tonsillectomy: indicated when tonsils
interfere with speech, deglutition and
respiration or cause recurrent attacks
 Tonsillectomy
• Indication
 Tonsillectomy
• Contraindication