Acute tonsillitis Acute tonsillitis can occur at any age but is most frequent in children under 9 years. Spread is by droplet infection. In infants under 3 years of age with acute tonsillitis, 15% of cases were found to be streptococcal; the remainder were probably viral. In older children, up to 50% of cases are due to streptococcus pyogenes. It is commonest in winter and spring. SYMPTOMS 1 Sore throat and dysphagia. Young children may not complain of sore throat but will refuse to eat. 2 Earache—as a result of referred otalgia. 3 Headache and malaise. SIGNS 1 Pyrexia is always present and may be high. It may lead to febrile convulsions in susceptible infants. 2 The tonsils are enlarged and hyperaemic and may exude pus from the crypts in follicular tonsillitis. 3 The pharyngeal mucosa is inflamed. 4 Foetor is present. 5 The cervical lymph nodes are enlarged and tender. DIFFERENTIAL DIAGNOSIS Infectious mononucleosis Infectious mononucleosis (glandular fever) usually presents as severe membranous tonsillitis. The node enlargement is marked and malaise is more severe than expected from tonsillitis (Fig. 28.1). Diagnosis is confirmed by lymphocytosis and within a week the monospot test becomes positive. Scarlet fever Scarlet fever, now rare, is a streptococcal tonsillitis with added features caused by a specific toxin. It is characterized by a punctate erythematous rash, circumoral pallor and a ‘strawberry and cream’ tongue. Diphtheria Diphtheria still occurs on rare occasions in the UK and should be considered in recent travellers to India or the former USSR. It is of insidious onset and characterized by a grey membrane (difficult to remove) on the tonsils, fauces and uvula. Pyrexia is usually low and diagnosis is confirmed by examination and culture of a swab. Agranulocytosis Agranulocytosis is manifested by ulceration and membrane formation on the tonsils and oral mucosa.The neutropenia is diagnostic. HIV Patients with impaired immunity from HIV infection are particularly at risk of pharyngitis and ulcerative tonsillitis. TREATMENT OF ACUTE TONSILLITIS 1 Rest—the patient will usually prefer to be in bed. 2 Soluble aspirin or paracetamol held in the mouth and then swallowed eases the discomfort. Remember that aspirin should not be given to children under the age of 12 years because of the risk of Reye’s syndrome. 3 Encourage the patient to drink or she/he will easily become dehydrated. 4 Antibiotics in severe cases. Penicillin by injection followed by oral treatment remains the treatment of choice. It is recommended that treatment be continued for 10 days to reduce the risk of reactivation. COMPLICATIONS 1 Acute otitis media (the most common complication). 2 Peritonsillar abscess (quinsy). 3 Pulmonary infections (pneumonia, etc.). 4 Acute nephritis IgA nephropathy. 5 Acute rheumatism. Peritonsillar abscess (quinsy) CLINICAL FEATURES A quinsy is a collection of pus forming outside the capsule of the tonsil in close relationship to its upper pole.The abscess occurs as a complication of acute tonsillitis, but is more common in adults than in children. The patient, already suffering from acute tonsillitis, becomes more ill, has a peak of temperature and develops severe dysphagia with referred otalgia. On examination, a most striking and constant feature is trismus; the buccal mucosa is dirty and foetor is present. The anatomy of the buccopharyngeal isthmus is distorted by the quinsy, which pushes the adjacent tonsil downwards and medially.The uvula may be so oedematous as to resemble a white grape. TREATMENT Systemic penicillin must be given without delay, and in very early cases with ‘peritonsillitis’ only, abscess formation may be aborted. If much trismus is present and the presence of pus strongly suspected, incision is indicated, for without this, spontaneous rupture may be long-delayed. If the diagnosis is correct, the patient will spit out pus and some blood, and the relief from former misery is immediate and dramatic. In children, the drainage of a quinsy should be performed under general anaesthesia; great skill and care are called for to avoid premature rupture of the quinsy before the airway is safeguarded. Following quinsy, it is conventional to carry out tonsillectomy 6 weeks later. If there has been no previous history of tonsillitis this may not be necessary. Recurrent acute tonsillitis Most people will at some time experience acute tonsillitis, but some indi-viduals are subject to recurrent attacks, especially in childhood. Between attacks the patient is usually symptom-free and the tonsils appear healthy. If such attacks are frequent and severe, tonsillectomy is advisable. It is important before arriving at such a decision to be sure that the attacks are truly acute tonsillitis, with the features listed earlier. If there is doubt, it is helpful to ask the patient (or the parents) to document the attacks over a period of several months. If there are contraindications to operation, e.g. a bleeding disorder, long-term prophylaxis with oral penicillin may reduce the frequency and severity of attacks. Tonsillar enlargement As a general rule, the size of the tonsils is immaterial. Many parents are concerned about the size of their offspring’s tonsils but can be reassured that no treatment is necessary unless the child is subject to recurring attacks of acute tonsillitis. There is, however, a small number of children in whom the tonsils and adenoids are enlarged to a degree that makes eating difficult and endangers the airway. Such children are dyspnoeic even at rest, mouth breathe, snore and are prone to episodes of sleep apnoea. Right heart failure may ensue. A timely operation to remove the tonsils and adenoids from such a child will result in a dramatic improvement in health. Acute pharyngitis Acute pharyngitis is exceedingly common, and probably starts as a virus infection. It is often associated with acute nasal infections. The symptoms consist of dysphagia and malaise and, on examination, the mucosa is found to be hyperaemic. As a general rule the treatment of acute pharyngitis should consist of regular analgesics, such as aspirin 4–6-hourly. Unhappily, this complaint is frequently treated by course after course of oral antibiotics, often aided and abetted by antibiotic or antiseptic lozenges. As a result, the flora of the mouth and pharynx may be disturbed completely and moniliasis ensues, with the net result that after 6 weeks of treatment little or no progress has been achieved. Chronic pharyngitis Chronic pharyngitis produces a persistent though mild soreness of the throat, usually with a complaint of dryness. Examination shows the pharynx to be reddened and there may be enlargement of the lymphoid nodules on the posterior pharyngeal wall—granular pharyngitis.There may also be present lateral bands of lymphoid tissue alongside the posterior faucial pillars. Predisposing factors that should be looked for are: 1 smoking or excessive indulgence in spirit drinking; 2 mouth breathing as a result of nasal obstruction; 3 chronic sinusitis; 4 chronic periodontal disease; 5 exposure to harmful fumes, usually industrial; 6 use of antiseptic throat lozenges. TREATMENT If any of the causes listed are present, appropriate action will be beneficial. If the lymphoid aggregates on the posterior wall are prominent, treatment by diathermy or cryosurgery may help. Malignant disease of the tonsil and pharynx Carcinoma Carcinoma will present as painful ulceration with induration of the tonsil, fauces or pharyngeal wall. It is often accompanied by referred otalgia and slight bleeding. Lymphatic spread to the upper deep cervical nodes is early. Diagnosis is confirmed by biopsy of the tonsil. Lymphoma Lymphoma of the tonsil tends not to ulcerate, but produces painless hypertrophy of the affected tonsil. Tonsillectomy as an excision biopsy is indicated without delay in such a case. TREATMENT Treatment of carcinoma is by radical excision usually followed by external irradiation, and of lymphoma by chemotherapy and/or radiotherapy. The prognosis of carcinoma is poor but for lymphoma will depend on its cellular nature, some types having a very good prognosis.