50

The Author 2009. Published by Oxford University Press on behalf of the RCGP. All rights reserved.
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InnovAiT, Vol. 2, No. 1, pp. 50 55, 2009 doi:10.1093/innovait/inn139
Acute tonsillitis is a common condition often seen in
children aged 5 10 and young adults aged 15 25. It is
dened as inammation of the tonsils but may also
involve pharyngeal lymphoid tissue. The terms acute
tonsillitis and acute pharyngitis are often used
interchangeably. The latter is thought to be of viral
aetiology affecting the pharyngeal lymphoid tissue and
involving the tonsil. Acute tonsillitis may be either
bacterial or viral and is spread by respiratory droplets with
an incubation period of 2 4 days. It is most common in
children under 9 years of age.
A proportion of patients will have recurrent tonsillitis but the
natural history is for these attacks to become less frequent
with time; however, a subset of patients will have ongoing
problems that will need referral for operative intervention.
Recurrent tonsillitis is dened as ve or more episodes in
one year, episodes that impair daily living and ongoing
symptoms for more than a year.
Aetiology
Acute tonsillitis is most commonly viral in origin and can be
caused by adenovirus, inuenza virus, Epstein Barr virus
(EBV), herpes simplex virus and cytomegalovirus. Bacterial
acute tonsillitis is most frequently caused by group A
beta haemolytic streptococcus (GABHS ; Streptococcus
pyogenes ) but can also be caused by pneumococcus,
haemophilus inuenza and staphylococcus aureus . Rarer
causes of pharyngitis are Coryne diphtheriae , Mycoplasma
pneumoniae, Chlamydia pneumoniae and Neisseria
gonorrhea .
History and examination
Symptoms may vary between patients but most will present
with one or more localized symptoms such as sore throat,
pain on swallowing, enlarged painful cervical lymph glands
and earache. In addition, there may be generalized symptoms
of malaise, fever and lethargy ( Box 1 ). It is important that
the history should include duration of symptoms, use of
medications including over-the-counter preparations, past
medical history, risk factors and co-morbidities. A clinical
examination ( Box 2 ) of the oropharynx and direct
visualization of the tonsils is necessary, noting any swelling
or exudate. Temperature should be measured and the patient
should be examined for cervical lymphadenopathy (note if
tender).
Acute tonsillitis
S
ore throat is a common condition in primary care. As many as 1 in 10 people
suffer recurrent episodes of tonsillitis. The cost per year to the NHS for
primary care consultations, before investigation and treatment, for sore
throats is estimated at 60 million pounds. It is also estimated that 35 million work
and school days are lost in the UK per year because of sore throats.
The GP curriculum and tonsillitis
GP curriculum statement 15.4: ENT and facial problems
specically includes management of sore throat and tonsillitis
within the knowledge base. It requires GPs to: Use knowledge
of relative prevalence of ENT problems to assist diagnosis.
Understand the likely outcomes of tests.
Be able to manage tonsillitis with complications such
as quinsy.
Empower patents to adopt self-treatment and coping
strategies where possible.
Know when and how to use watchful waiting and
delayed prescription strategies.
Demonstrate an evidence-based approach to
antibiotic prescribing.
Understand and implement the key National
guidelines that inuence healthcare provision for ENT
problems
Box 1 . Symptoms
Malaise
Lethargy
Fever
Sore throat
Painful glands
Halitosis
Otalgia
Odynophagia
Headache
Signs of upper airway obstruction (mouth breathing,
snoring)
Loss of appetite
Chills
Rarely pyrexial convulsions

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I nnovAi T
Diagnosis
Tonsillitis is a clinical diagnosis. The differential diagnosis
includes non-bacterial tonsillitis and bacterial tonsillitis, with
viruses being the most common cause. Precise diagnosis has
been suggested in order to identify those patients with
bacterial GABHS infections who may benet from antibiotic
therapy. It is useful to note that GABHS account for only
15 30% of acute tonsillitis in children less than 15 years of
age and only 5 10% of adult cases.
In practice, the differentiation between viral and bacterial
tonsillitis is difcult with considerable overlap between signs
and symptoms. Several scoring systems have been developed.
One such system is the Centor criteria ( Box 3 ). Clinical
diagnosis, however, will miss 25 50% of GABHS tonsillitis
while 20 40% of those labelled by the scoring system as
positive will in fact be negative. Clinical scoring should
therefore not be relied upon to differentiate between viral
and bacterial tonsillitis.
A throat swab for microscopy, culture and sensitivity can be
used to further investigate sore throat. Throat swabs have a
wide range of sensitivity of 26 95% with variation thought
to be due predominantly to poor swab technique (the throat
swab should be taken from the surface of both tonsils and
the posterior pharyngeal wall). It should be noted that a
negative culture does not exclude streptococcal tonsillitis. In
addition, a proportion of people will be asymptomatic
carriers of GABHS suffering with a viral tonsillitis.
Rapid antigen detection tests are used commonly in the USA
to enable a quick diagnosis of beta haemolytic streptococcus.
These, however, may be unreliable and a negative result does
not exclude streptococcal tonsillitis, so further investigation
with a throat swab is necessary where there is clinical suspicion
of GABHS infection. The test may also produce a false-positive
result where asymptomatic carriers may be suffering from viral
tonsillitis. Consideration also has to be given to the additional
time and cost involved. In addition, the taking of a throat
swab or performing a rapid antigen test may over-medicalize
a self-limiting condition and actually alter few management
decisions as there is little evidence to suggest that the duration
or severity of illness is signicantly different between either
group. A routine throat swab or rapid antigen test in every
patient is therefore unnecessary.
A full blood count may be useful where there is a suspicion
of glandular fever, agranulocytosis or HIV ( Box 4 ). Testing
urea and electrolytes can also be helpful if there is a concern
about dehydration. Monospot may be considered if there is
clinical suspicion of infectious mononucleosis (EBV).
Red ag or alarm features that may suggest another
diagnosis are listed in Box 4. NICE recommends referral of
any adult with unexplained sore throat for greater than a
month for urgent (within 2 weeks) specialist ENT assessment
to exclude malignancy.
Treatment in primary care
The treatment consists of maintenance of hydration and
nutrition, antipyretics and antimicrobials if indicated. The
patient should be advised to rest and increase their oral uid
intake. They should use paracetamol ibuprofen for
temperature control and symptom relief (soluble if difculty
swallowing). Benzydamine hydrochloride (difam) spray can
also be used to relieve symptoms.
The decision on when to treat sore throats with antibiotics
is a controversial one. Antibiotics have been shown to
reduce the duration of symptoms by eight hours. There is no
evidence that used of antibiotics reduces complications
such as glomerulonephritis and rheumatic fever. Acute
tonsillitis resolves without antibiotics in 85% of patients
within 7 days.
It is commonly accepted that antibiotics should be prescribed
to patients if there are features of signicant systemic
upset, they are immunocompromised, those with previous
Box 3 . Centor criteria
Tonsillar exudates
Tender anterior cervical nodes
No cough
Fever
Three or more present gives a greater than 40% chance
of having GABHS.
If no more than one is present, this suggests an 80%
chance of not having the infection.
Box 2 . Examination
Pyrexia
Inamed and enlarged tonsils
Tonsillar white exudate
Halitosis
Tender cervical lymph nodes

Figure 1 . Acute tonsillitis.
Source: Wikimedia Commons, courtesy of Michael Bladon.

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52
rheumatic fever, unilateral peritonsillitis or they meet the
Centor criteria.
The National Institute for Health and Clinical Excellence
(NICE) has recently issued guidelines for antibiotic
prescribing in primary care for adults and children over 3
months old ( Box 6 ). They suggest a no antibiotic or delayed
antibiotic prescribing strategy for patients with acute sore
throat/pharyngitis/tonsillitis unless there are three or more
Centor criteria present. It is important to involve the patient,
parents or carers in the decision regarding antibiotic use.
Their concerns and expectations should be explored and the
prescribing strategy explained.
Source: National Institute for Health and Clinical Excellence
(NICE) (2008) Clinical Guideline: Prescribing of antibiotics
for self-limiting respiratory tract infections in adults and
children in primary care.
First-line antibiotic treatment should be Penicillin V
(phenoxymethylpenicillin) for 10 days. If allergic to penicillin,
erythromycin is an effective alternative. Ampicillin-based
Box 4 . Differential diagnosis
Scarlet fever
Streptococcal tonsillitis with a characteristic rash. The
rash is a punctate erythematous, non-pruritic rash which
blanches on pressure. It affects the trunk with Pastia
lines forming in the groin and axillary skin creases where
the rash becomes conuent. It generally appears 12 48
hours after onset of sore throat and fades after 2 3 days
with desquamation occurring which may last a further
week. The face is ushed with circumoral pallor and a
bright red strawberry tongue.
Glandular fever (infectious mononucleosis)
EBV causes a severe tonsillitis. There is cervical
lymphadenopathy, muscle ache and severe malaise.
There may be splenomegaly. Lymphocytosis may be
apparent on full blood count and a positive monospot
test is diagnostic. Ampicillin-based antibiotics may
precipitate a rash.
Diptheria
This is caused by the bacteria Corynebacterium
diphtheriae . It presents with a grey membrane on the
tonsils, fauces and uvula. It is rarely seen in the UK.
Leukaemia tonsillitis
This may present as tonsillitis due to impaired immune
status as a result of white cell abnormality.
Agranulocytosis
This has several causes including drugs, autoimmune
conditions and diseases resulting in impaired immunity.
There is neutropenia on blood testing. Clinical ndings
include ulceration and membrane formation on the
tonsils and oral mucosa.
HIV
Can cause ulcerative tonsillitis and pharyngitis.
Box 5 . Red ag features
Weight loss
Night sweats
Opportunistic infection
Raised white blood cell count with abnormal morphology
on blood lm
Box 6 . NICE guidance on antibiotic prescribing for
sore throat
The guideline offers advice on adults and children over 3
months.
Patients presenting with symptoms and history
suggestive of acute sore throat/pharyngitis/tonsillitis
should be offered clinical assessment consisting of a
history and examination
Patients or parents/carers concerns and expectations
should be determined and addressed when agreeing
use of the three antibiotic prescribing strategies (no,
delayed or immediate prescribing)
A no or delayed antibiotic prescribing strategy should
be agreed for acute sore throat/acute pharyngitis/
acute tonsillitis
Depending on clinical assessment of severity patients
can be considered for an immediate prescribing
strategy (in addition to a no antibiotic or delayed
antibiotic prescribing strategy) where three or more
Centor criteria are present
Patients should be given advice about the natural
history of the illness, including average total length
of the illness (before and after seeing the doctor)
1 week for acute sore throat/pharyngitis and
tonsillitis
Advice about managing symptoms, including fever
(antipyretics/analgesics)
When no antibiotic prescribing strategy is adopted,
patients should be offered reassurance that
antibiotics are not needed immediately as they may
make little difference to symptoms and may have side
effects. They should be offered clinical review if
condition is worse or prolonged
When a delayed prescription is issued, again patients
should be reassured that antibiotics are not needed
immediately and may have side effects . Advice about
using the delayed prescription if symptoms are not
settling or worsening. Advice on reconsulting if there
is a signicant worsening of symptoms
An immediate antibiotic prescription and/or
further appropriate investigation and management
should be offered to patients in the following
situations:
The patient is systemically very unwell
The patient has symptoms and signs of complica-
tions, for example peritonsillar abscess/cellulitis
The patient is at high risk of serious complications
because of pre-existing co-morbidity (includes
signicant heart, lung, renal, liver or neuromuscu-
lar disease. Immunosuppression, cystic brosis and
young children who were premature)

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I nnovAi T
antibiotics should be avoided when there is suspicion of
glandular fever as it may cause an erythematous rash. Simple
advice may be given to avoid spread of infection such as
good hand washing and covering the mouth when coughing
to avoid spread to others.
If patient is acutely unwell and there is a concern about
dehydration, peritonsillar abscess or airway patency, then
the patient should be referred urgently to hospital.
When acute tonsillitis does not resolve with antibiotics, it is
usually due to the wrong antibiotic treatment being prescribed,
patient non-compliance or reinfection. Treatment with
cefuroxime or clindamycin is appropriate in this situation.
Complications of tonsillitis
Otitis media
The patient will present with acute onset ear pain. Otoscopy
will reveal otorrhea, bulging tympanic membrane or erythema
around the tympanic membrane.
Quinsy or peritonsillar abscess
A peritonsillar abscess ( Fig. 2 ) is the most frequent complication
of acute tonsillitis most commonly seen and is in the 20- to
40-year-old age group. It usually forms as a collection pus in
the superior pole between the tonsillar capsule, superior
constrictor and palatopharyngeus muscle ( Box 7 ).
Immediate management should focus on assessment of
airway compromise. Fluid rehydration should be considered
and use of antipyretics and analgesics are also necessary.
Treatment options then consist of needle aspiration and
incision and drainage. Untreated quinsy can lead to
respiratory obstruction, parapharyngeal abscess, jugular vein
thrombosis, fatal carotid artery haemorrhage or
mediastinitis.
Parapharyngeal abscess
Rarely, if left untreated, tonsillitis can spread through the
deep spaces in the neck causing infection of the mediastinum.
Further investigation may be necessary with ultrasound or
CT scan to assess the abscess cavity. Symptoms consist of
lethargy and malaise, high spiking temperatures,
breathlessness and trismus. Urgent admission to hospital
under an ENT surgeon is indicated.
Rheumatic fever
Patients most commonly present with a sore throat and a
migratory polyarthritis that affects the major joints,
overlapping as joints become inamed. Carditis may
present with breathlessness, chest pain and a new
murmur. Mitral regurgitation is the most common murmur
found. Other signs may include erythema marginatum
which presents as an erythematous, non-pruritic truncal
rash or Syndenhams Chorea which manifests with
involuntary purposeless movements. Subcutaneous
nodules may be present and seen as small painless lumps
normally close to tendons. Other features of rheumatic
fever include pyrexia, raised inammatory markers and
arthralgia (Box 8).
Streptococcal glomerulonephritis
This occurs 1 2 weeks post streptococcal throat infection.
It presents with general malaise, dark urine and facial
pufness. There may be haematuria, proteinuria, oliguria
and hypertension.
Septic arthritis
This can be a complication of streptococcal tonsillitis. It
presents after a recent episode of sore throat with an acutely
painful red, hot, swollen and tender joint. Urgent treatment
in hospital with intravenous antibiotics is required.
Airway obstruction
Airway obstruction may be caused by complicated severe
acute tonsillitis and require urgent transfer to hospital for
treatment. This may occur when the cause of tonsillitis is
glandular fever. Chronic problems with airway patency may
be due to enlarged tonsils/adenoids and present as
symptoms of snoring and sleep apnoea. The sleep pattern is
often disturbed and the patient may present with daytime
somnolence. Sleep disordered breathing in children is usually

Figure 2 . Close-up of throat with quinsy.
Dr P. Marazzi/Science Photo Library.
Box 7 . Features of peritonsillar abscess or quinsy
Malaise and lethargy
Painful throat
Pyrexia
Headache
Earache
Hot potato voice
Drooling
Trismus (difculty opening the mouth)
Cervical lymphadenopathy
Enlarged tonsil commonly unilateral
Displaced uvula to opposite side (maybe white
grapelike )
Oedema and hyperaemia of soft palate
Dehydration

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54
caused by enlarged tonsils/adenoids and requires further
assessment by a specialist.
Management of recurrent
tonsillitis
In all, 12% of the population have recurrent tonsillitis during
their lifetime. Tonsillectomy is indicated in frequent
conrmed attacks of acute tonsillitis and in those who
require numerous days off work/school. If tonsillectomy is
contraindicated, then long-term penicillin prophylaxis may
reduce the frequency and severity of attacks.
Tonsillectomy is one of the most commonly performed
surgical procedures. It is performed under general anaesthetic
and may involve an overnight stay. The patient will have
simple analgesia post-operatively and they should be advised
that referred pain to the ear is common. Pain should usually
resolve within 7 10 days.
There may be a whitish layer of brinous exudates coating
the tonsillar fossa post-operatively, which is normal
but may be confused for infection. Post-operatively, the
patient should be advised to drink plenty of uid and to eat
normal (non-spicy) food as chewing and swallowing has
been shown to be important for recovery and infection
prevention.
The main complication of tonsillectomy is bleeding which
can occur up to 2 weeks after the procedure. Approximately
2 in 100 children and 5 in 100 adults will need to return to
hospital for post-tonsillectomy bleeding and in each of
these groups one patient will require a second surgical
procedure. Signs of this may be tachycardia, pallor and
vomiting of blood and require urgent referral to secondary
care for assessment and treatment. Rarer complications
include infection of the tonsillar fossae (presenting as
pyrexia, worsening pain post-operatively or bleeding),
subacute bacterial endocarditis in those with valvular heart
disease or a septal defect and pneumonia due to inhalation
of blood or fragments of tissue.
When to refer for
tonsillectomy
The number of tonsillectomies performed from 2003 04 in
England was 50 531. Of these, 57% were done on individuals
under 15 years of age, 42% on those between 15 and 59
and 1% in the 60 74 year age group.
Guidance exists ( www.sign.ac.uk/guidelines/fulltext/34/
references.html # 9 ) as to which patients with sore throats
should be referred for consideration of tonsillectomy.
Patients should meet all the following criteria:
sore throats are due to tonsillitis
ve or more episodes of sore throat per year
symptoms for at least a year
the episodes of sore throat are disabling and prevent
normal functioning
Asymptomatic enlarged tonsils require no treatment.
However, if enlarged tonsils are accompanied by
obstructive sleep apnoea, then referral for tonsillectomy
is indicated. Contraindications to tonsillectomy are
recent acute tonsillitis and recent upper respiratory
tract infection. Bleeding tendency may be a relative
contraindication.
Box 8 . Revised Jones criteria for diagnosis of rheumatic fever
Requirements for diagnosis of rheumatic fever
Evidence of previous streptococcal infection (scarlet fever, positive throat swab and/or increased antistreptolysin-O
(ASO) titre above 200/ml)
and
2 major criteria
or
1 major + 2 minor criteria
Major criteria
Carditis (4570%) - arrhythmia, new murmur,
pericardial rub, heart failure, conduction defects.
Migratory polyarthritis ( itting - 75%) red, tender
joints.
Sydenhams chorea (St. Vitus dance - 10%)
Subcutaneous nodules (2-20%)
Erythema marginatum (2-10%)
Minor criteria
Prolonged P-R interval on ECG (but not if carditis is
one of the major criteria)
Arthralgia (but not if arthritis is one of the major criteria)
Fever
Increased Erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP)
History of rheumatic heart disease or rheumatic fever
Reproduced with permission from the Oxford Handbook of General Practice (3 rd edition) .

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I nnovAi T
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Key points
Acute tonsillitis is a common condition particularly in
those aged less than nine
It is most commonly caused by a virus, though
differentiating between a viral and bacterial cause is
difcult
The benets of antibiotics for all patients are not
proven but should be prescribed if clinically concerned
Patients with recurrent tonsillitis should be referred for
tonsillectomy if they have ve or more episodes per
year, symptoms for at least a year and the episodes
are disabling and prevent normal functioning.
REFERENCES AND FURTHER INFORMATION
Bull , P. Lecture notes on diseases of the ear, nose and
throat, 9th edition ( 2002 ) Oxford : Blackwell
Publishing
Corbridge , R. , Steventon , N. Oxford Handbook of ENT
and Head and Neck Surgery ( 2006 ) Oxford : Oxford
University Press ISBN 9780198564928
ENT UK . The British Association of Otorhino-
laryngologists Head and Neck Surgeons . www.entuk.
org
Guidelines for the diagnosis of rheumatic fever. Jones
Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and
Kawasaki Disease of the Council on Cardiovascular
Disease in the Young of the American Heart
Association . The Journal of the American Medical
Association ( 1992 ) 268 : p. 2069 73
Herzon , F.S. , Harris, P. Mosher Award thesis.
Peritonsillar abscess: incidence, current management
practices, and a proposal for treatment guidelines .
Laryngoscope ( 1995 ) 105 ( 8 ) Suppl 1 17
Kerr , A.G. Scott-Browns otorhinolaryngology: head
and neck Surgery ( 1996 ) London : Hodder Arnold
ISBN 978 0750619356
Kvestad , E. , Kvaerner , K.J. , Roysamb , E. et al. Heritability
of recurrent tonsillitis: archives of recurrent tonsillitis .
Archives of Otolaryngology: Head and Neck Surgery
( 2005 ) 131 : p. 383 387 Accessed via archotol.ama-
Mr B.M. Stubbs
SpR General Surgery, North East Thames
E-mail: benstubbs@hotmail.com
Dr A.L. Isaacs
SHO, Medical Assessment Unit, Basildon Hospital

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