Tonsillitis and Peritonsillar Abscess

Rate this Article

Last Updated: March 30, 2006 Email to a Colleague

Get CME/CE for article

Synonyms and related keywords: tonsillitis and peritonsillar abscess, quinsy, acute tonsillitis,
recurrent tonsillitis, chronic tonsillitis, pharyngitis, pharyngotonsillitis, adenotonsillitis, PTA,
inflammation of the pharyngeal tonsils, lingual tonsillitis, group A beta-hemolytic Streptococcus
pyogenes, GABHS, GABHS pharyngitis, adenoidectomy, trismus, quinsy tonsillectomy, abscessed
tonsil, bilateral tonsillectomy, sore throat, throat infection
AUTHOR INFORMATION Section 1 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up
Miscellaneous Pictures Bibliography
Author: Udayan K Shah, MD , Assistant Professor of Otorhinolaryngology-Head and Neck Surgery,
University of Pennsylvania School of Medicine; Director, Otolaryngology Innovative Technologies
Program, Associate Director, Trauma (Otolaryngology), The Children's Hospital of Philadelphia
Udayan K Shah, MD, is a member of the following medical societies: American Academy of
Otolaryngology-Head and Neck Surgery , American Academy of Pediatrics , American
Bronchoesophagological Association , American College of Surgeons , American Rhinologic Society
, American Society for Laser Medicine and Surgery , American Society of Pediatric Otolaryngology ,
Massachusetts Medical Society , Pennsylvania Medical Society , and Society for Ear, Nose and
Throat Advances in Children
Editor(s): Ari J Goldsmith, MD , Program Director, Associate Professor, Department of
Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate
Medical Center; Francisco Talavera, PharmD, PhD , Senior Pharmacy Editor, eMedicine; Gregory
C Allen, MD , Assistant Professor, Department of Otolaryngology-Head and Neck Surgery,
University of Colorado School of Medicine; Christopher L Slack, MD , Consulting Staff,
Otolaryngology-Facial Plastic Surgery, Lawnwood Regional Medical Center; and Arlen D Meyers,
MD, MBA , Professor, Department of Otolaryngology-Head and Neck Surgery, University of
Colorado School of Medicine
INTRODUCTION Section 2 of 11

Background: In the first century AD, Celsus described tonsillectomy performed with sharp tools and
followed by rinses with vinegar and other medicinals. Since that time, physicians have been
documenting management of tonsillitis. Tonsillitis gained additional attention as a medical concern in
the late 19th century. The consideration of quinsy in the differential diagnoses of George Washington's
death and the discussion of tonsillitis in Kean's Domestic Medical Lectures, a home medical
companion book published in the late 19th century, reflect the rise of tonsillitis as a medical concern.

Understanding the disease process and management of this common malady remain important today.
This article summarizes the current management of tonsillitis and highlights recent advances in the
pathophysiology and immunology of this condition and its variations: acute tonsillitis, recurrent
tonsillitis, and chronic tonsillitis and peritonsillar abscess (PTA).

Definitions

Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation usually extends to the
adenoids and the lingual tonsils; therefore, the term pharyngitis may be used interchangeably.
Pharyngotonsillitis and adenotonsillitis are considered equivalent for the purposes of this article.
Lingual tonsillitis refers to isolated inflammation of the lymphoid tissue at the base of the tongue.

Pathophysiology: Viral or bacterial infections and immunologic factors lead to tonsillitis and its
complications.

Frequency:

In the US: Tonsillitis is a common illness. Nearly all children in the United States experience
at least one episode of tonsillitis. Pharyngitis accompanies many upper respiratory tract
infections. The mean prevalence of carrier status of school children for group A
Streptococcus, a cause of tonsillitis, was 15.9% in one study.

Internationally: Recurrent tonsillitis was reported in 11.7% of Norwegian children in one study
and estimated in another study to affect 12.1% of Turkish children.

Mortality/Morbidity: Because of improvements in medical and surgical treatments, complications

associated with tonsillitis, including death, are rare. Historically, scarlet fever was a major killer at the
beginning of the 20th century, and rheumatic fever was a major cause of cardiac disease and
mortality. Although the incidence of rheumatic fever has declined significantly, the cases that occurred
in the 1980s and early 1990s support a resurgence of this condition.

Age: Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger
than 2 years. Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years,
while viral tonsillitis is more common in younger children. PTA usually occurs in young adults but can
occur occasionally in children.

CLINICAL Section 3 of 11

History: The patient's history determines the type of tonsillitis (ie, acute, recurrent, chronic) that is
present.

Acute tonsillitis

o Individuals with acute tonsillitis present with fever, sore throat, foul breath, dysphagia
(difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph
nodes.

o Airway obstruction may manifest as mouth breathing, snoring, nocturnal breathing

pauses, or sleep apnea.

o Lethargy and malaise are common.

o Symptoms usually resolve in 3-4 days but may last up to 2 weeks despite adequate
therapy.
 Recurrent tonsillitis is diagnosed when an individual has 7 episodes in 1 year, 5 infections in 2
consecutive years, or 3 infections each year for 3 years consecutively.

Individuals with chronic tonsillitis may present with chronic sore throat, halitosis, tonsillitis, and
persistent tender cervical nodes.

Individuals with PTA present with severe throat pain, fever, drooling, foul breath, trismus
(difficulty opening the mouth), and altered voice quality (the hot potato voice).

Physical:

Physical examination reveals fever and enlarged inflamed tonsils that may have exudates
(see Image 1 ).

Group A beta-hemolytic Streptococcus pyogenes and Epstein-Barr virus (EBV) can cause
tonsillitis that may be associated with the presence of palatal petechiae. Group A beta-
hemolytic Streptococcus (GABHS) pharyngitis usually occurs in children aged 5-15 years.

Open-mouth breathing and voice change (ie, a thicker or deeper voice) result from obstructive
tonsillar enlargement.

o The voice change with acute tonsillitis is usually not as severe as that associated with
PTA.

o In PTA, the pharyngeal edema and trismus cause a hot potato voice.

Tender cervical lymph nodes and neck stiffness are observed in acute tonsillitis.

Examine skin and mucosa for signs of dehydration.

Consider infectious mononucleosis (MN) due to EBV in an adolescent or younger child with
acute tonsillitis, particularly when tender cervical, axillary, and/or inguinal nodes;
splenomegaly; severe lethargy and malaise; and low-grade fever accompany acute tonsillitis.

o A gray membrane may cover tonsils that are inflamed from an EBV infection (see
Image 2 ). This membrane can be removed without bleeding.

o Palatal mucosal erosions and mucosal petechiae of the hard palate may be observed.

An individual with herpes simplex virus (HSV) pharyngitis presents with red, swollen tonsils
that may have aphthous ulcers on their surfaces. Herpetic gingival stomatitis, herpes labialis,
and hypopharyngeal and epiglottic lesions may be observed.

Physical examination of a PTA almost always reveals unilateral bulging above and lateral to
one of the tonsils. Trismus is always present in varying severity. The abscess rarely is located
adjacent to the inferior pole of the tonsil.

o Inferior pole PTA is a difficult diagnosis to make, and radiologic imaging with a
contrast-enhanced CT scan is helpful.

o Tender cervical adenopathy and torticollis (neck turned in the cock-robin position) may
 be present.

o Ipsilateral otalgia may be observed.

Causes:

Most episodes of acute pharyngitis and acute tonsillitis are caused by viruses such as the
following:

o HSV
o EBV
o Cytomegalovirus
o Other herpes viruses
o Adenovirus
o Measles virus

One study showing that EBV may cause tonsillitis in the absence of systemic MN found EBV
to be responsible for 19% of exudative tonsillitis in children.
Bacteria cause 15-30% of pharyngotonsillitis cases. Anaerobic bacteria play an important role
in tonsillar disease.

o GABHS causes most bacterial tonsillitis.

o S pyogenes adheres to adhesin receptors that are located on the tonsillar epithelium.

o Immunoglobulin coating of pathogens may be important in the initial induction of

bacterial tonsillitis.

Organisms such as Mycoplasma pneumoniae and Chlamydia pneumoniae rarely cause acute
pharyngitis.

Arcanobacterium haemolyticum is an important cause of pharyngitis in Scandinavia and the

United Kingdom but is not recognized as such in the United States. A rash similar to that of
scarlet fever accompanies A haemolyticum pharyngitis.

Neisseria gonorrhea may cause pharyngitis in sexually active persons.

A polymicrobial flora consisting of both aerobic and anaerobic bacteria is observed in core
tonsillar cultures from cases of recurrent pharyngitis.

o Children with recurrent GABHS tonsillitis have different bacterial populations than do
children who have not had as many infections. Other competing bacteria are reduced,
offering less interference to GABHS infection.

o Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae are

the most common bacteria isolated in recurrent tonsillitis.

o Bacteroides fragilis is the most common anaerobic bacterium isolated in recurrent

tonsillitis.
o The microbiology of recurrent tonsillitis in children and adults is different: adults show
more bacterial isolates, with a higher recovery rate of Prevotella species,
Porphyromonas species, and B fragilis organisms, while children show more GABHS.
 Also, adults more often have bacteria that produce beta-lactamase.

A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha-
and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species
identified.

o One study, based on bacteriology of the tonsillar surface and core in 30 children
undergoing tonsillectomy, suggests that antibiotics prescribed 6 months before
surgery do not alter the tonsillar bacteriology at the time of tonsillectomy.

o A relationship between tonsillar size and chronic bacterial tonsillitis is believed to

exist. This relationship is based on both the aerobic bacterial load and the absolute
number of B and T lymphocytes.

o H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids.
o With regard to penicillin resistance or beta-lactamase production, the microbiology of
tonsils removed from patients with recurrent GABHS pharyngitis is not significantly
different from the microbiology of tonsils removed from patients with tonsillar
hypertrophy.

Local immunological mechanisms are important in chronic tonsillitis.

o The distribution of dendritic cells and antigen-presenting cells is altered during

disease, with fewer dendritic cells on the surface epithelium and more in the crypts
and extrafollicular areas.

o Study of immunologic markers may permit differentiation between recurrent and

chronic tonsillitis. Such markers in 1 study indicated that children more often
experience recurrent tonsillitis, while adults requiring tonsillectomy more often
experience chronic tonsillitis.

A polymicrobial flora is isolated from peritonsillar abscesses. Predominant organisms are the
anaerobes Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species;
major aerobic organisms are GABHS, S aureus, and H influenzae.
Radiation exposure may relate to the development of chronic tonsillitis. A high prevalence of
chronic tonsillitis was noted following the Chernobyl nuclear reactor accident in the former
Soviet Union.
Overcrowded conditions and malnourishment promote tonsillitis.

DIFFERENTIALS Section 4 of 11

Lymphomas of the Head and Neck

Malignant Nasopharyngeal Tumors
Malignant Tumors of the Tonsil

Other Problems to be Considered:

Sore throat
Gastroesophageal reflux disease (GERD)
Obstructive sleep apnea
Leukemia
Fungal infection

WORKUP Section 5 of 11

Lab Studies:

Tonsillitis and PTA are clinical diagnoses. Testing is indicated when GABHS infection is
suspected.

o Throat cultures are the criterion standard for detecting GABHS. GABHS is the principal
organism for which antibiotic therapy (sensitivity 90-95%) is definitely indicated. Growing
concerns over bacterial resistance make monitoring acute tonsillitis with throat swabs for
culture and sensitivity an important endeavor. Relying only on clinical criteria, such as
the presence of exudate, erythema, fever, and lymphadenopathy, is not an accurate
method for distinguishing GABHS from viral tonsillitis.
o Beta-lactamase resistance of streptococcal species may now be observed in up to a
third of community-based streptococcal infections. This resistance is probably due to the
presence of copathogens that are beta-lactamaseproducing organisms, such as H
influenzae and Moraxella catarrhalis . These organisms are able to degrade the beta-
lactam ring of penicillin and make an otherwise sensitive GABHS act resistant to beta-
lactam antibiotics. In one study, erythromycin did not inhibit nearly half of S pyogenes
isolates. The limited precision of many throat swabs may reduce the usefulness of these
samples.

o A rapid antigen detection test (RADT), also known as the rapid streptococcal test,
detects the presence of GABHS cell wall carbohydrate from swabbed material and is
considered less sensitive than throat cultures; however, the test has specificity of
greater than or equal to 95% and produces a result in significantly less time than that
required for throat cultures. A negative RADT requires that a throat culture be obtained
before excluding GABHS infection.

o A culture or RADT is not indicated in most cases following antibiotic therapy for acute
GABHS pharyngitis. Routine testing of asymptomatic household contacts is similarly not
usually warranted.

A Monospot serum test, CBC count, and serum electrolyte level test may be indicated.

Serum may be examined for antistreptococcal antibodies, including antistreptolysin-O antibodies

and antideoxyribonuclease (anti-DNAse) B antibodies. Titers are useful for documenting prior
infection in persons diagnosed with acute rheumatic fever, glomerulonephritis, or other
complications of GABHS pharyngitis.

Laboratory evaluation in chronic tonsillitis relies upon documentation of results of pharyngeal

swabs or cultures taken during prior episodes of tonsillitis. The usefulness and cost of throat
swabs for pharyngitis are debated.

Imaging Studies:
 Routine radiologic imaging is not useful in cases of acute tonsillitis.

For patients in whom acute tonsillitis is suspected to have spread to deep neck structures (ie,
beyond the fascial planes of the oropharynx), radiologic imaging using plain films of the lateral
neck or CT scans with contrast is warranted.

In cases of PTA, CT scanning with contrast is indicated only for the following situations:

o Unusual presentations (eg, an inferior pole abscess)

o For patients at high risk for drainage procedures (eg, patients with coagulopathy or
anesthetic risk)

CT scanning may be used to guide needle aspiration in the following situations:

o Draining PTAs after an unsuccessful surgical attempt

o Draining abscesses that are located in unusual locations and are anticipated to be
difficult to reach with standard surgical approaches

TREATMENT Section 6 of 11

Medical Care: Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate
hydration and caloric intake and controlling pain and fever. Inability to maintain adequate oral caloric and
fluid intake may require IV hydration, antibiotics, and pain control. IV corticosteroids may be
administered to reduce pharyngeal edema.

Corticosteroids may shorten the duration of fever and pharyngitis in cases of MN. In severe
cases of MN, corticosteroids or gammaglobulin may be helpful. Symptoms of MN may last for
several months. Corticosteroids are also indicated for patients with airway obstruction, hemolytic
anemia, and cardiac and neurologic disease. Inform patients of complications from steroid use.
Antibiotics are reserved for secondary bacterial pharyngitis. Because of the risk of a generalized
papular rash, avoid ampicillin and related compounds when MN is suspected. Similar reactions
from oral penicillin-based antibiotics (eg, cephalexin) have been reported. Therefore, initiate
therapy with another antistreptococcal antibiotic such as erythromycin.
Administer antibiotics if conditions support bacterial etiology, such as the presence of tonsillar
exudates, presence of a fever, leukocytosis, contacts who are ill, or contact with a person who
has a documented GABHS infection. In many cases, bacterial and viral pharyngitis are clinically
indistinguishable.

GABHS infection obligates antibiotic coverage. According to Bisno et al, the desired outcomes of
therapy for GABHS pharyngitis are (1) prevention of acute rheumatic fever, (2) prevention of
suppurative complications, (3) abatement of clinical symptoms and signs, (4) reduction in
transmission of GABHS to close contacts, and (5) minimization of potential adverse effects of
inappropriate antimicrobial therapy.
Administering oral penicillin for 10 days is the best treatment for acute GABHS pharyngitis.
Intramuscular penicillin (ie, benzathine penicillin G) is required for persons who may not be
compliant with a 10-day course of oral therapy. Penicillin is optimal for most patients (barring
allergic reactions) because of its proven safety, efficacy, narrow spectrum, and low cost. Other
antibiotics proven effective for GABHS pharyngitis are the penicillin congeners, many
 cephalosporins, macrolides, and clindamycin. Clindamycin may be of particular value because
its tissue penetration is considered equivalent for both oral and IV administration. Clindamycin is
effective even for organisms that are not rapidly dividing (Eagle effect), which explains its great
efficacy for GABHS infection. Vancomycin and rifampin have also been useful. Reduced-
frequency dosing is recommended to improve compliance with medication regimens. A
consensus on the efficacy of such dosing has not yet been formulated.

Airway obstruction may require management by placing a nasal airway device, using
intravenous corticosteroids, and administering humidified oxygen. Observe the patient in a
monitored setting until the airway obstruction is clearly resolving.
Most acute pharyngitis is self-limited with clinical improvement observed in 3-4 days. Recent
clinical practice guidelines state that avoiding antibiotic therapy for this time period is safe and
that a delay of up to 9 days from symptom onset to antimicrobial treatment should still prevent
the major complication of GABHS (ie, acute rheumatic fever).
Recurrent tonsillitis may be managed with the same antibiotics as acute GABHS pharyngitis. If
the infection recurs shortly after a course of an oral penicillin agent, then consider IM benzathine
penicillin G. Clindamycin and amoxicillin/clavulanate have been shown to be effective in
eradicating GABHS from the pharynx in persons suffering from repeated bouts of tonsillitis. A 3-
to 6-week course of an antibiotic against beta-lactamaseproducing organisms (eg,
amoxicillin/clavulanate) may allow tonsillectomy to be avoided.

Peritonsillar cellulitis may respond to oral antibiotics.

Antibiotics, either orally or intravenously, are required to treat PTA medically, although most
PTAs are refractory to antibiotic therapy alone. Penicillin, its congeners (eg,
amoxicillin/clavulanic acid, cephalosporins), and clindamycin are appropriate antibiotics.
Aetius of Amida, a sixth century Byzantine physician, managed spontaneously draining
abscesses with gargles of honey, milk and herbs, or rose extract. In rare cases of spontaneous
PTA rupture, mouthwashes are still recommended for hygienic reasons. A 10-day course of an
oral antibiotic is prescribed.

Surgical Care:

Recurrent tonsillitis

o Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of
streptococcal pharyngitis (confirmed by positive culture) in 1 year, 3 or more infections
of tonsils and/or adenoids per year despite adequate medical therapy, or chronic or
recurrent tonsillitis associated with the streptococcal carrier state that has not responded
to beta-lactamaseresistant antibiotics.
o Time missed from school or work and severity of illness (eg, whether hospitalization was
required) are important considerations in recommending tonsillectomy.

o Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and minimal
additional morbidity occurs with adenoidectomy if tonsillectomy is already being
performed, most surgeons perform adenoidectomy if adenoids are present and inflamed
at the time of tonsillectomy. However, this point remains controversial.
o Recurrent tonsillitis after tonsillectomy is extremely rare. Tonsillectomy reduces the
bacterial load of GABHS and may also allow an increase in alpha- Streptococcus, which
can be protective against GABHS infection. Recurrent tonsillitis is usually due to
regrowth of tonsillar tissue, which is treated by excision.

Chronic tonsillitis
 o Tonsillectomy with or without adenoidectomy is the treatment for chronic tonsillitis. The
details of the technique are reviewed in the article on Tonsillectomy .
o In cases of chronic tonsillitis, specific technical considerations for tonsillectomy include
awareness of a higher intraoperative and perioperative bleeding risk and awareness that
dissection may be more difficult because of fibrosis and scarring of the tonsillar capsule.
Such considerations may affect instrument selection and discharge decisions.

Lingual tonsillitis

o Surgery is rarely required for acute lingual tonsillitis.

o Surgery is indicated for frequent and disabling episodes of this uncommon malady.

Tonsillitis in cases of MN: Tonsillar hypertrophy that persists after resolution of MN and causes
obstructive airway symptoms may require tonsillectomy.

Peritonsillar abscess
o Treatment of PTAs includes aspiration and incision and drainage (I&D).
o Aetius recommended incision if an abscess did not spontaneously drain.
o When PTA is suspected, aspiration with a needle may be attempted to confirm the
diagnosis and to remove some of the purulence.
The area of the PTA is first anesthetized by infiltration with local anesthetic or by
spray or sponge application of topical anesthesia (eg, Americaine, benzocaine).
Sedation may be helpful; administer sedation only in a facility that is
appropriately staffed and equipped.
An 18-gauge needle on a 1 mL tuberculin syringe is placed into the pointing
area, taking care not to penetrate the pharyngeal mucosa more than 1 inch in
order to prevent injury to the vessels and nerves of the parapharyngeal space.
If attempt at aspiration from 3 different peritonsillar sites does not locate the
abscess, treat the patient with oral or IV antibiotics. If symptoms persist after 24-
48 hours of therapy, CT scanning with contrast may be performed.
o Once purulence is detected, complete aspiration may be attempted. In the author's
experience, limited aspiration is best, providing that sufficient material is available for
Gram stain and cultures with antibiotic sensitivities. Not all patients need microbiologic
evaluation. For those who are immunosuppressed or who have developed a PTA after
several days of appropriate antibiotic therapy, send aspirated material for Gram stain,
culture, and sensitivity tests.
o After needle aspiration, I&D may be performed using a knife.
The handle of a knife with an attached No 15 blade is taped 1 inch from the tip
to prevent deep penetration through the mucosa. A gentle curvilinear incision,
not more than half an inch deep, is fashioned along the perimeter of the tonsillar
capsule and through the point from which pus was evacuated. A widely tipped
blunt clamp (eg, Kelly clamp) is used to widely open the loculated pockets of
purulence. A sponge-covered finger to break loculations is ideal. Rinsing with
half-strength hydrogen peroxide solution aids hemostasis.
When the patient is dehydrated and uncomfortable, this well-intentioned
procedure is not greeted with enthusiasm from the patient. Sedation, hydration,
analgesia, and anesthesia (at the least, topical or local) are important.
Using the nondominant hand, the physician grasps the tongue with a sponge
and observes the posterior oropharynx. In patients with severe trismus, a
tongue blade may be used to depress the midportion of the tongue. Magnifying
and illuminating loupes, such as the LumiView, are the best sources of light. A
headlight or mirror is also effective. Arranging the instruments in order of use on
a tray adjacent to the physician's dominant hand facilitates rapid
accomplishment of this procedure. In experienced hands, this procedure should
 take fewer than 3 minutes from aspiration to rinsing with peroxide.
Some adults and most children require deeper levels of sedation or general
anesthesia for safe and adequate aspiration or drainage. An institution with a
carefully designed policy for I&D of PTA with conscious sedation, including
appropriate indications, staff, and criteria, may offer sedation to children.
After the procedure, the patient is observed in accordance with sedation and
anesthetic protocols. Hospitalization for adults and for older children is rarely
required. The patient is discharged with a prescription for an oral antibiotic (10-d
course of therapy), a prescription for an oral narcotic for pain control (taking
care to avoid antiplatelet agents), and instructions to maintain hydration and
control fever. Antibiotic therapy may be altered after cultures return. A follow-up
office visit or telephone call is made in 2-4 weeks after the procedure to confirm
symptomatic resolution.

o Tonsillectomy is indicated for PTA associated with chronic or recurrent tonsillitis or for
exposure of the abscess in unusual cases. Acute tonsillectomy is generally regarded as
a safe and effective treatment for PTA. Some physicians advocate immediate
tonsillectomy for younger patients with PTA. Removing hot tonsils (ie, those that are
acutely infected) carries the expectation of higher intraoperative blood loss and a higher
risk of immediate and delayed posttonsillectomy hemorrhage.
o The term quinsy tonsillectomy refers to tonsillectomy performed to treat PTA. Bilateral
tonsillectomy is usually performed in these cases, and the abscessed tonsil is usually
easier to remove during surgery than the inflamed contralateral tonsil. The abscessed
tonsil is easier to remove because the abscess partially dissects the tonsil from the
pharyngeal musculature.
o During surgery, if the abscess cannot be located in the usual superior lateral region of
the tonsillar fossa, then careful exploration with needle aspiration may locate the
collection, allowing for wide exposure and drainage. Tonsillectomy may be required for
exposure in such cases. A CT scan with contrast may be indicated.

Consultations: Consultations with infectious-disease, hematologic, and pediatric subspecialists are

valuable in selected cases.

Diet:

Hydration is important, and the oral route is usually adequate.

Intravenous fluids may be required for severe dehydration.

Hyperalimentation is rarely necessary.

Activity:

Adequate rest for adults and children with tonsillitis accelerates recovery.

In order to reduce risk of splenic rupture in persons diagnosed with systemic MN, patients must
be cautioned against activities that may cause abdominal injury.

MEDICATION Section 7 of 11
Medications used to manage tonsillitis include antibiotics, anti-inflammatory agents (eg, corticosteroids),
antipyretics and analgesics (eg, acetaminophen, ibuprofen), and immunologic agents (eg,
gammaglobulin).

Drug Category: Corticosteroids -- Agents that reduce inflammation, which may impair swallowing
and breathing.

Dexamethasone (Decadron, AK-Dex) -- Short-acting,

Drug Name
rapid-onset glucocorticoid.
Adult Dose Not established
0.5-1 mg/kg IV q8h; not to exceed 10 mg q8h;
Pediatric Dose
discontinue by tapering if prolonged use
Documented hypersensitivity; sulfite sensitivity,
Contraindications though rare, is more common in individuals with
asthma; systemic fungal infections
Enhanced effect of steroids in hypothyroidism and
cirrhosis; use aspirin with caution in conjunction with
corticosteroids and hypoprothrombinemia;
Interactions
phenytoin, phenobarbital, ephedrine, and rifampin
may enhance metabolic clearance of corticosteroids;
check PT when using corticosteroids and coumarin
C - Safety for use during pregnancy has not been
Pregnancy
established.
Growth suppression in infants breastfed by mother
using dexamethasone; injection contains sodium
bisulfite; salt and water retention, therefore,
hypertension risk; electrolyte imbalance; live-virus
vaccination risk; tuberculosis risk with active and
Precautions
latent tuberculosis; risk of relative adrenocortical
insufficiency after rapid withdrawal; masking signs of
infection; ocular complications; behavioral changes;
wound-healing problems; aggravation of peptic ulcer
disease; male infertility

Drug Category: Antibiotics -- Therapy must be comprehensive and cover all likely pathogens in the
context of this clinical setting.

Penicillin (Benzathine, Permapen) -- Interferes with

Drug Name synthesis of cell wall mucopeptides during active
multiplication, which results in bactericidal activity.
1.2 million U IM, preferably into upper outer quadrant
Adult Dose
of buttock
<60 lb: 300,000-600,000 U IM; not to exceed
900,000 U IM; consulting hospital formulary at
Pediatric Dose
physician's institution recommended
>60 lb: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Probenecid can increase penicillin effectiveness by
 decreasing clearance; coadministration with
tetracyclines can decrease effectiveness
Pregnancy B - Usually safe but benefits must outweigh the risks.
Not for injection into or near artery or nerve; caution
with cephalosporin and procaine sensitivities; may
cause pseudomembranous colitis; with
neurovascular injection, may observe severe
neurovascular damage with myelitis resulting in
paralysis or gangrene resulting in amputation; with
Precautions
intravascular injection, pallor, mottling, cyanosis, and
edema requiring fasciotomies may occur; caution
when using in mothers who are breastfeeding;
hemolytic anemia, leukopenia, and
thrombocytopenia; overdose may cause
neuromuscular hyperirritability or convulsive seizures
Clarithromycin (Biaxin) -- Inhibits bacterial growth,
possibly by blocking dissociation of peptidyl tRNA
Drug Name from ribosomes causing RNA-dependent protein
synthesis to arrest. Semisynthetic macrolide with bid
dosing.
Adult Dose 250 mg PO q12h for 10 d
Pediatric Dose 7.5 mg/kg PO q12h; not to exceed 250 mg/dose
Documented hypersensitivity; coadministration of
Contraindications
pimozide
Toxicity increases with coadministration of
fluconazole and pimozide; clarithromycin effects
decrease and GI adverse effects may increase with
coadministration of rifabutin or rifampin; may
increase toxicity of anticoagulants, cyclosporine,
tacrolimus, digoxin, carbamazepine, ergot alkaloids,
Interactions
triazolam, HMG CoA-reductase inhibitors; plasma
levels of certain benzodiazepines may increase,
prolonging CNS depression; arrhythmias and
increase in QTc intervals occur with disopyramide;
coadministration with omeprazole may increase
plasma levels of both agents
C - Safety for use during pregnancy has not been
Pregnancy
established.
Coadministration with ranitidine or bismuth citrate is
not recommended with CrCl <25 mL/min; administer
half dose or increase dosing interval if CrCl <30
Precautions
mL/min; diarrhea may be sign of
pseudomembranous colitis; superinfections may
occur with prolonged or repeated antibiotic therapies
Clindamycin (Cleocin) -- Oral or parenteral antibiotic
for anaerobic or susceptible streptococcal,
Drug Name pneumococcal, or staphylococcal species.
Considered to have good absorption into
bloodstream in both oral and parental forms.
Adult Dose 150-450 mg PO q8h
 1.2-2.7 g IV/IM q8h
Neonates: Consult hospital pharmacy
Pediatric Dose Infants and children: 15-25 mg/kg/d PO q8h; 25-40
mg/kg/d IV/IM q8h
Contraindications Documented hypersensitivity
Increases duration of neuromuscular blockade,
induced by tubocurarine and pancuronium;
Interactions
erythromycin may antagonize effects of clindamycin;
antidiarrheals may delay absorption
Pregnancy B - Usually safe but benefits must outweigh the risks.
Adjust dose in severe hepatic dysfunction; no
adjustment necessary in renal insufficiency;
Precautions
associated with severe and possibly fatal colitis by
allowing overgrowth of Clostridium difficile
Vancomycin (Vancocin, Lyphocin) -- Indicated for
patients who cannot receive or have failed to
respond to penicillins and cephalosporins, or who
have infections with resistant staphylococci. To avoid
toxicity, current recommendation is to assay
vancomycin trough levels after third dose drawn 0.5
Drug Name h prior to next dosing. Use creatinine clearance to
adjust dose in patients diagnosed with renal
impairment. Use CrCl to adjust dose in patients
diagnosed with renal impairment. Used in
conjunction with gentamicin for prophylaxis in
penicillin allergic patients undergoing gastrointestinal
or genitourinary procedures.
Adult Dose 500 mg IV q6h or 1000 mg IV q12h
10 mg/kg IV q6h in neonates and infants; in first wk
Pediatric Dose of life, 15 mg/kg IV first dose, followed by 10 mg/kg
IV q12h, then q8h up to age 1 mo
Contraindications Documented hypersensitivity
Potent antibiotic directed against gram-positive
organisms and active against Enterococcus species;
useful in the treatment of septicemia and skin
structure infections; indicated for patients who
cannot receive or have failed to respond to
penicillins and cephalosporins, or who have
infections with resistant staphylococci; for abdominal
penetrating injuries, it is combined with an agent
Interactions
active against enteric flora and/or anaerobes; to
avoid toxicity, current recommendation is to assay
vancomycin trough levels after third dose drawn 0.5
h prior to next dosing; use CrCl to adjust dose in
patients diagnosed with renal impairment; used in
conjunction with gentamicin for prophylaxis in
penicillin allergic patients undergoing gastrointestinal
or genitourinary procedures
C - Safety for use during pregnancy has not been
Pregnancy
established.
 Rapid infusion associated with hypotension and,
rarely, cardiac arrest; ototoxicity, especially with
other ototoxins (eg, aminoglycoside); caution with
Precautions renal insufficiency; reversible neutropenia may
occur; avoid extravasation; caution when
administering other neurotoxic drugs or nephrotoxins
(eg, amphotericin B, aminoglycosides, bacitracin)
Rifampin (Rifadin, Rimactane) -- Inhibitor of bacterial
Drug Name
DNA-dependent RNA polymerase activity.
Adult Dose Not used for this indication
<1 month: 5 mg/kg PO q12h for 2 d
Pediatric Dose >1 month: 10 mg/kg PO q12h for 2 d; not to exceed
600 mg/dose
Contraindications Documented hypersensitivity
Induces microsomal enzymes, which may decrease
effects of acetaminophen, oral anticoagulants,
barbiturates, benzodiazepines, beta-blockers,
chloramphenicol, oral contraceptives,
corticosteroids, mexiletine, cyclosporine, digitoxin,
disopyramide, estrogens, hydantoins, methadone,
Interactions clofibrate, quinidine, dapsone, tazobactam,
sulfonylureas, theophyllines, tocainide, and digoxin
Blood pressure may increase with coadministration
of enalapril; coadministration with isoniazid may
result in higher rate of hepatotoxicity than with either
agent alone (discontinue 1 or both agents if
alterations in LFTs occur)
C - Safety for use during pregnancy has not been
Pregnancy
established.
Obtain CBC counts and baseline clinical chemistries
prior to and throughout therapy; in liver disease,
weigh benefits against risk of further liver damage;
interruption of therapy and high-dose intermittent
Precautions therapy are associated with thrombocytopenia that is
reversible if therapy is discontinued as soon as
purpura occurs; if treatment is continued or resumed
after appearance of purpura, cerebral hemorrhage or
death may occur
Amoxicillin (Trimox, Amoxil, Biomox) -- Interferes
with synthesis of cell wall mucopeptides during
Drug Name
active multiplication, resulting in bactericidal activity
against susceptible bacteria.
Adult Dose 500-875 mg PO q12h or 250-500 PO q8h
<12 weeks: 30 mg/kg q12h for 10 d; recommended
for prevention of poststreptococcal rheumatic fever
Pediatric Dose >3 months: 25 mg/kg/d q12h in 2 divided doses, 20
mg/kg/d q8h in 3 divided doses, or 45 mg/kg/d q12h
in 2 divided doses
Contraindications Documented hypersensitivity
Interactions Probenecid increases levels; reduces the efficacy of
 oral contraceptives
Pregnancy B - Usually safe but benefits must outweigh the risks.
Documented hypersensitivity; GI adverse effects;
reversible anemia; thrombocytopenia; eosinophilia;
Precautions leukopenia; behavioral changes; chewable tabs
contain phenylalanine and, therefore, are a risk for
those with phenylketonuria
Amoxicillin-clavulanate (Augmentin) -- Oral antibiotic
with specific activity against penicillin-resistant
Drug Name
organisms, due to beta-lactamase inhibitor,
clavulanate potassium.
Adult Dose 500 mg tab PO q12h or one 250 mg tab PO q8h
<12 weeks: 30 mg/kg/d PO q12h in 2 divided doses,
based on reduced renal elimination of the amoxicillin
Pediatric Dose component
>3 months: 45 mg/kg/d PO q12h or 40 mg/kg/d q8h
>40 kg: Administer as in adults
Documented hypersensitivity to any penicillin; history
Contraindications of Augmentin-associated cholestatic jaundice and/or
hepatic dysfunction
Rash with ampicillin-related antibiotics in infectious
mononucleosis; when used with probenecid,
Interactions reduced renal tubular secretion, therefore, increased
and prolonged blood levels with probenecid; PKU
caution as with amoxicillin
Pregnancy B - Usually safe but benefits must outweigh the risks.
Diarrhea, loose stools, nausea, skin rashes,
vomiting, and anemia and other heme effects
Precautions
reversible upon discontinuation of drug; reported
behavioral changes

Drug Category: Immune globulins -- Used to improve clinical aspects of the disease.

Immune globulin intravenous (Gamimune N,

Gammagard, Sandoglobulin) -- Pooled human Ig.
Because of shortage of supply, reserved for use for
Drug Name
severe infections. Use in accordance with
institutional policies. Use in past was more common
for various indications.
Consult hospital pharmacy and medical consultants
Adult Dose
if necessary
Consult hospital pharmacy and medical consultants
Pediatric Dose
if necessary
Documented hypersensitivity; IgA deficiency; anti-
Contraindications
IgE/IgG antibodies
Increases toxicity of live virus vaccine (MMR); do not
Interactions
administer within 3 mo of vaccine
Pregnancy C - Safety for use during pregnancy has not been
 established.
Check serum IgA before IVIG (use an IgA-depleted
product, eg, Gammagard S/D); infusions may
increase serum viscosity and thromboembolic
events; infusions may increase risk of migraine
attacks, aseptic meningitis (10%), urticaria, pruritus,
or petechiae (2-5 d postinfusion to 30 d); increases
Precautions risk of renal tubular necrosis in elderly, and in those
with diabetes, volume depletion, and preexisting
kidney disease
Lab result changes associated with infusions include
elevated antiviral or antibacterial antibody titers for 1
mo, 6-fold increase in ESR for 2-3 wk, and apparent
hyponatremia
Metronidazole (Flagyl) -- Effective in patients with
tonsillitis and MN, shortening fever duration and
Drug Name
reducing tonsillar size, and in management of acute
episodes of nonstreptococcal tonsillitis.
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV
over 1 h
Adult Dose Maintenance dose: 6 h following loading dose, infuse
7.5 mg/kg or 500 mg for 70-kg adult over 1 h q6-8h;
not to exceed 4 g/d
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
May increase toxicity of anticoagulants, lithium, and
phenytoin; cimetidine may increase toxicity of
Interactions
metronidazole; disulfiramlike reaction may occur with
orally ingested ethanol
Adjust dose in hepatic disease; monitor for seizures
Precautions
and development of peripheral neuropathy
FOLLOW-UP Section 8 of 11

Further Inpatient Care:

Discharge of patient from the hospital occurs after the physician determines that oral use of pain
medication and antibiotics is possible.

Home intravenous therapy under the supervision of qualified home health providers or the
independent oral intake ability of patients ensures hydration.

Further Outpatient Care:

To confirm clinical improvement, follow-up care by telephone contact or physical examination

may be useful in 2-4 weeks after the acute episode.

Follow-up throat swabs and cultures are usually not necessary, unless family or personal history
of rheumatic fever exists, significant recurrent tonsillitis is evident, or family members continue to
 reinfect each other.

In/Out Patient Meds:

Order pain control, hydration, and antibiotics as discussed above for specific types of tonsillitis
and associated complications.

Transfer:

Consider transfer of patient care when tonsillitis or its complications cannot be managed safely
and expediently.

o Ensure airway protection for transfer.

o Ensure that appropriately trained personnel accompany the patient during transfer.

Children younger than 3 years may require transfer because of the special care needed during
tonsillitis or its complications.

Patients with syndromic diagnoses (eg, trisomy 21) and patients with hematologic problems may
benefit from transfer to facilities that have the availability of subspecialist care.

Deterrence/Prevention:

Avoidance of contact with individuals who are ill or patients who are immunocompromised is
useful.

The use of the antipneumococcal vaccine may help to prevent acute tonsillitis; however, to date,
experience is insufficient to determine whether prevention is likely to occur.

Complications:

Acute tonsillitis: Untreated or incompletely treated tonsillitis can lead to potentially life-
threatening complications.

o Acute oropharyngeal infections can spread distally to the deep neck spaces and then
into the mediastinum. Such complications may require thoracotomy and cervical
exposure for drainage. Spread beyond the pharynx is suspected in persons with
symptoms of tonsillitis who also have high or spiking fevers, lethargy, torticollis, trismus,
or shortness of breath. Radiologic imaging using plain films of the lateral neck or CT
scans with contrast is warranted for patients in whom deep neck spread of acute
tonsillitis (beyond the fascial planes of the oropharynx) is suspected.
o The most common complication is adjacent spread just beyond the tonsillar capsule.
Peritonsillar cellulitis develops when inflammation spreads beyond the lymphoid tissue
of the tonsil to involve the oropharyngeal mucosa. PTA, historically referred to as quinsy,
is caused by purulence trapped between the tonsillar capsule and the lateral pharyngeal
wall; the superior constrictor muscle primarily comprises the lateral pharyngal wall in this
area.
o Rarely, acute pharyngotonsillitis may lead to thrombophlebitis of the internal jugular vein
(Lemierre syndrome). The usual cause of this condition is Fusobacterium necrophorum .
A patient who appears toxic following tonsillitis presents with spiking fevers and
unilateral neck fullness and tenderness. CT scanning with contrast is necessary to help
 make the diagnosis. A prolonged course of IV antibiotics and treatment of the source of
infection (eg, an abscess) are required. Anticoagulation is controversial. Ligation or
excision of the internal jugular vein is required after multiple septic emboli become
evident.

Peritonsillar abscess

o PTA may spread to the deep neck tissues; most often, PTA spreads into the
retropharyngeal space or into the parapharyngeal space. Spread may result in
necrotizing fasciitis.

o Treatment includes IV antibiotics, surgical debridement, and, in cases of associated

toxic shock syndrome, possibly IV immunoglobulins. Distal abscess spread can be life
threatening.

Complications specific to GABHS pharyngitis are scarlet fever, rheumatic fever, septic arthritis,
and glomerulonephritis.

o Scarlet fever manifests as a generalized, nonpruritic, macular erythematous rash that is

worse on the extremities and spares the face. The classic strawberry tongue is bright
red and tender because of papillary desquamation. The rash lasts up to 1 week and is
accompanied by fever and arthralgias.
o Individuals at risk for this rash are those who do not have antitoxin antibodies to the
exotoxin produced by GABHS.

o Acute poststreptococcal glomerulonephritis (AGN) occurs in 10-15% of pharyngitis

cases that are caused by the type-12 serotype. AGN follows GABHS by 1-2 weeks.
Urinalysis to detect excreted protein may allow detection of subclinical renal injury for
persons with recurrent tonsillitis.

o Rheumatic fever follows acute pharyngitis by 2-4 weeks and was observed in up to 3%
of streptococcal pharyngitides in the mid-20th century. Today, far fewer persons
experience this complication, largely because of appropriate antibiotic therapy. Cardiac
valvular vegetations affect the mitral and tricuspid valves, leading to murmurs, persistent
relapsing fevers, and valvular stenosis or incompetence. A throat swab does not identify
the causative organism because a positive result may reflect colonization rather than
pathogenicity. Elevated or rising titers of antistreptolysin (ASO) antibodies, anti-DNAse
beta, or antihyaluronidase are required to make the diagnosis.

o Septic arthritis results in a painful hot joint that contains fluid with bacteria.
Arthrocentesis is diagnostic and partially therapeutic. Treatment with IV antibiotics for 6
weeks is required to prevent long-term joint complications.

Patient Education:

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center . Also,
see eMedicine's patient education articles Peritonsillar Abscess , Tonsillitis , and Antibiotics .

MISCELLANEOUS Section 9 of 11
Medical/Legal Pitfalls:

Failure to be vigilant for signs of impending complications from tonsillitis (eg, mental status
changes, severe trismus, high fevers) may lead to litigation.

Failure to obtain further tests or perform other diagnostic evaluations (eg, CBC counts, CT
scanning) in patients with signs of impending complications from tonsillitis may have
medicolegal implications if a suppurative complication is missed initially.

Failure to test patient's family members for the presence of streptococcal antibodies to detect
carrier of group A Streptococcus (especially a family member who is immunocompromised) may
lead to legal implications.

Failure to treat suspected streptococcal pharyngitis with appropriate antibiotics may lead to
complications (eg, acute rheumatic fever, glomerulonephritis) and may have legal implications.

Special Concerns:

Tonsillitis and its complications are frequently encountered. Antibiotics cure most patients with
bacterial tonsillitis, and surgery usually cures patients with infections and complications that are
refractory to medical management. Better understanding of the immunology of tonsillitis, actively
tracking patterns of bacterial and viral pathogenicity and resistance, and exploring novel
technologies for tonsillectomy allow physicians to continue to build on their long experience with
these conditions.

PICTURES Section 10 of 11

Caption: Picture 1. Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with
exudates. The uvula is midline.

View Full Size Image

eMedicine Zoom View (Interactive!)

Picture Type: Photo
Caption: Picture 2. Tonsillitis caused by Epstein-Barr infection (infectious mononucleosis). The
enlarged inflamed tonsils are covered with grey-white patches.

View Full Size Image

eMedicine Zoom View (Interactive!)