Acta Otolaryngol 2000; Suppl 543: 206 – 208

Bacteriology of the Tonsil Core in Recurrent Tonsillitis and Tonsillar

Hyperplasia —a Short Review
ROBERT LINDROOS
From the Dextra Medical Center, Helsinki, Finland

Lindroos R. Bacteriology of the tonsil core in recurrent tonsillitis and tonsillar hyperplasia — a short re6iew. Acta
Otolaryngol 2000; Suppl 543: 206–208.
In recurrent tonsillitis, the tonsil core harbours numerous bacteria, some of which are pathogenic and may occur in great
numbers. The most frequent bacteria are Haemophilus influenzae, followed by Staphylococcus aureus and Streptococcus
pyogenes. A high tissue concentration of these bacteria correlates with clinical parameters of infection and hyperplasia of
the tonsils. The role of Streptococcus pyogenes, while undisputed in acute and epidemic tonsillitis, should perhaps be
re-evaluated in recurrent and/or hyperplastic tonsillitis. Key words: bacterial load, chronic tonsillitis, normal tonsils,
pathogenesis of tonsillitis.
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INTRODUCTION terium, with Staphylococcus aureus (SA) second and

Tonsillitis has generally been regarded as an infec-
tion caused by Streptococcus pyogenes (especially
group A b-haemolytic streptococci, GAS) or by
viruses (1, 2). Approximately 6 – 17% of tonsil
swabs in recurrent tonsillitis in the subclinical phase
have grown GAS (3 – 6). In addition, an abundance
of anaerobic bacteria and other aerobic bacteria
have been found, the importance of which has been
For personal use only.
GAS in third place. In addition, many other patho-
genic bacteria have been encountered, i.e. Moraxella
catarrhalis and S. pneumoniae, and numerous aero-
bic commensals, like alpha- and gamma-haemolytic
Streptococci, Neisseria, Lactobacillus, etc.
Bacteria of the tonsil surface and core
Most studies show that the tonsil surface patho-

debated; most of these are probably commensals (7,
8). In around 33 – 40% of cases, no pathogenic bac-
teria have been found on the surface of the tonsils
(1, 3, 5, 9).
The importance of finding GAS in the treatment
of tonsillitis has been stressed (9). However, prob-
lems arise if the focus is only on GAS. Why are
only about three out of four antibiotic courses for
GAS infections efficient (10)? What causes the dis-
ease if a mere virus is found? The answers may be
found in the tonsil core, investigations of which are
the subjects of this review.
genic bacteria in recurrent and hyperplastic tonsilli-
tis differ significantly from those of the core (5, 13,
17), especially with respect to HI (3–6, 17, 18).
Some investigations, however, do not show signifi-
cant differences between surface and core pathogens
(10, 20[CE1]). The correlation between surface and
core bacteria has varied between 27% and 61% (3,
5, 6, 17, 20). In this respect, GAS shows a some-
what better correlation (4). The predictability of a
tonsil swab seems to improve when the bacterial
load in the tonsil core increases (20). However,
many authors question the value of a tonsil surface
swab (3, 6, 13, 17, 19).

RECENT INVESTIGATIONS Bacteria of healthy and pathologic tonsils

During the last 20 years, many studies have been
made of the core bacteria of tonsils removed at
operation, as shown in Table I (2 – 8, 10 – 14). The
indications for operation have been recurrent tonsil-
litis (at least 3–5 episodes per year) and/or hyper-
plastic obstructing tonsils. This bacterial flora
apparently harbours in the deep crypts (4, 7, 11, 12,
15, 16). Most studies show 3.7 – 6.3 species of aero-
bic bacteria on average (6 – 8, 12, 16), and anaero-
bic bacteria in approximately the same amounts:
1.1–5.4 species per tonsil (6 – 8, 12, 16). Among the
latter, the Bacterioides and Fusobacterium species
have dominated (7, 8, 16). Haemophilus influenzae
(HI) has been the most common pathogenic bac-
The tonsil core has, as a rule, revealed a normal
bacterial flora in humans without anamnestical and
physical signs of tonsil infection, although patho-
gens have been encountered, usually in rather
minute amounts (10, 15, 21). In these cases, tonsil-
lar tissue has been obtained from patients with a
non-infectious tonsil disease or from patients under-
going a procedure under general anaesthesia for
some other reason, all of whom have had a nega-
tive history regarding tonsillitis. Normal flora has
been encountered in 3–18% in pathologic tonsils
(recurrent or hyperplastic tonsillitis) (5, 13, 18), al-
though sometimes the figure is as high as 38–45%
(4).

© 2000 Taylor & Francis. ISSN 0365-5237

 Bacteriology of the tonsil core 207

Quantitati6e bacteriology Hyperplasia and recurrent tonsillitis

The dominant pathogenic aerobic bacteria in the
tonsil core has been present in large amounts in
recurrent tonsillitis, with a bacterial load of 100,000–
1,000,000 bacteria per gram of tonsil tissue (10, 12,
20, 21). HI and SA have shown the largest concentra-
tions in these studies, with GAS in third place. These
bacteria have been evenly distributed in the tonsil
(20). In addition to pathogenic bacteria, the tonsil
core of recurrently infected and hyperplastic tonsils
also harbours commensals and anaerobes in abun-
dance (15, 20).
A high bacterial load (colony-forming units per
gram= CFU/g) in the tonsil core has correlated with
the weight of the tonsil and with its concentration of
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The bacteriology of hyperplastic tonsils does not
differ much from that of recurrently infected ones,
although HI is somewhat more common in tonsil
hyperplasia (12, 13, 21), also quantitatively (11, 12,
21). These findings apply also in cases without a
history of infection (10, 11, 12, 21). SA and GAS
have been reported to correlate with hyperplasia as
well (10, 12, 15).
DISCUSSION
Table I gives a rather homogenous picture of
the qualitative bacteriology in the tonsil core, with
two exceptions (4, 14). The causes of these aberra-
tions are unclear. The message is rather unequivo-

B and T cells (21).

Table II shows the bacterial loads in pathological
and healthy tonsils (21 – 23).
Tonsil infections in children and adults
Hyperplasia of the tonsils is most frequent among
children; recurrent tonsillitis becomes more common
in the teens (24). Few pathogens have been found in
the tonsil core of healthy children or healthy adults
(10, 11). HI has been the most common finding in
For personal use only.
cal: in the tonsil core, the most common aerobic
pathogen is HI, with SA second and GAS in third
place.
Encountering potentially pathogenic microbes in
the tonsil core does not in itself prove that they are
pathogenic. However, the bacteria are found in
great concentrations, and these findings correlate
with patient history, clinical findings and weight of
the tonsils. Conversely, these findings are principally

recurrent tonsillitis in children, while SA is more
frequent in teenagers and older patients (5). GAS has
been found in equal amounts (6) or a little less in
children than in adults (5, 16). The tonsil core in
children and adults shows approximately the same
amounts of b-lactamase-producing bacteria (5).
absent in healthy tonsils. It is difficult to avoid the
thought that these microbes play a substantial role
in the pathogenesis of recurrent and hyperplastic
tonsillitis. However, one should remember that
many other microbes grow in the tonsil core, anaer-
obes not the least.

Table I. Bacteriology of the tonsil core. Aerobic pathogenic bacteria in recurrent tonsillitis (at least 3 episodes per
annum) and/or tonsil hyperplasia (with or without symptoms of infection)

Prevalence of core bacteria, % (n)

Patients Mean age
Authors (total n) (years) H. infl. S. aureus GAS M. catar. S. pneum.

%
Rosen et al. 1977 100 80%B18 40 (40) 15 (15) 9 (9) 5 (5)
Brook et al. 1981 50 6 24 (12) 48 (24) 22 (11)
Brook and Yocum 1984 22 23 23 (5) 36 (8) 9 (2) 68 (15)
Almadori et al. 1988 60 2–14 2 (1) 22 (13) 40 (24) 2 (1)
Brodsky et al. 1988 54 3–12 28 (15) 4 (2) 19 (10) 19 (10)
Surow et al. 1989 97 Children 34 (33) 42 (41) 20 (19)
Kielmovitch et al. 1989 51 6 49 (25) 35 (18) 18 (9)
Stjernquist et al. 1990 100 19 23 (23) 17 (17) 5 (5)
Gaffney et al. 1991 262 9 72 (188) 34 (88) 22 (57) 2 (4) 6 (15)
Mitchelmore et al. 1994 50 16 22 (11) 60 (30) 8 (4) 6 (3)
Kuhn et al. 1995 23 7 96 (22) 61 (140 26 (6) 9 (2) 9 (2)
Gaffney et al. 1998 119 6 79 (94) 33 (39) 20 (24) 0 (0) 8 (10)
Average prevalence (%) 41.0 35.5 19.2 14.3 8.8
Average prevalence of all 47.5 32.9 19.4 5.8 6.6
patients investigated (%)
 208 R. Lindroos
Table II. Relati6e load (×1,000 CFU/g) of pathogenic bacteria in the tonsil core in recurrent/hyperplastic
tonsillitis compared to healthy tonsils (controls)
Authors Recurrent/hyperplastic tonsillitis
Sasaki and Koss 1977 2,100
Brodsky et al. 1988a 239
Brook and Foote 1990 3,160
It can be assumed that hyperplasia of the tonsils is
physiological up to a point, but highly hyperplastic
tonsils probably harbour bacterial infection of a more
or less chronic nature in the core, even in cases without
a history of throat infection.
As to tonsillitis occurring sporadically, and espe-
cially epidemically, GAS are the dominating bacteria.
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When the disease recurs, there is probably reason to
re-evaluate the role of GAS.
In conclusion, the reported findings suggest that
recurrent tonsillitis and gross tonsillar hyperplasia are
diseases caused by a variety of common upper respira-
tory tract pathogenic bacterial species. However, defin-
ite conclusions cannot as yet be made.
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Address for correspondence:
Robert Lindroos
Kavallvägen 27 bA
FI-02700 Grankulla
Finland
Tel: + 358 9 505 2243
Fax: + 358 9 505 4859