Describe acute and chronic tonsillitis with their complications.

Acute Tonsillitis

• Acute tonsillitis is acute inflammation of the palatine tonsils.
• It is predominantly a disease of children and young adults, and the central clinical task is to distinguish the viral majority from the bacterial minority.
• Organisms — the majority are viral (rhinovirus, adenovirus, influenza, epstein-BARR virus); the most important bacterial cause is group A beta-haemolytic streptococcus (Streptococcus pyogenes), which accounts for perhaps 15 to 30% in children and fewer in adults
• Types — acute catarrhal (part of a generalised pharyngitis); acute follicular, with yellowish exudate at the crypt openings, which is the classical appearance; acute parenchymatous, with a uniformly enlarged, congested tonsil; and acute membranous, in which the exudate coalesces into a membrane
• Features — sore throat and odynophagia; fever and malaise; referred otalgia via the glossopharyngeal nerve; halitosis; and, in children, abdominal pain and vomiting from mesenteric adenitis, which may dominate the presentation
• Signs — enlarged, congested tonsils with exudate; and tender, enlarged jugulodigastric nodes
• The CENTOR (or McISAAC) criteria estimate the probability of streptococcal infection, and are worth knowing precisely — tonsillar exudate; tender anterior cervical lymphadenopathy; fever (history of); and absence of cough — with a point added for age 3 to 14 and subtracted for age over 45 in the McIsaac modification
• The absence OF cough IS the point most often forgotten: a prominent cough, coryza, hoarseness or conjunctivitis points away from streptococcus and toward a virus
• Fewer criteria mean symptomatic treatment; more criteria justify a throat swab or empirical antibiotic, according to local policy
• Management — adequate analgesia, which is the most important and most neglected part of treatment; paracetamol and ibuprofen; fluids, with admission for dehydration or inability to swallow; rest; and salt-water gargles
• Antibiotic where streptococcal infection is likely — penicillin V or amoxicillin for 10 days, with a macrolide in penicillin allergy
• The full 10-day course matters, because the purpose is not merely symptom relief but eradication of the organism to prevent rheumatic fever — a point of real importance in India, where rheumatic heart disease remains common
• Avoid ampicillin and amoxicillin where infectious mononucleosis is possible.
• A short course of corticosteroid may be used for severe odynophagia or airway concern
• Complications:
• Suppurative (local) — peritonsillar abscess (quinsy); parapharyngeal and retropharyngeal abscess; acute otitis media; cervical adenitis and abscess; and lemierre’S syndrome — septic thrombophlebitis of the internal jugular vein with septic pulmonary emboli, caused by fusobacterium necrophorum, in a young adult with a sore throat who becomes systemically very unwell
• Non-suppurative (systemic, following streptococcal infection) — acute rheumatic fever.
• Also — scarlet fever, and PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection).

Chronic Tonsillitis and the Differential Diagnosis

• Chronic tonsillitis follows repeated acute attacks, or persistent low-grade infection within the crypts, with fibrosis and crypt obstruction
• Features — recurrent sore throat; persistent halitosis and a foul taste; tonsilloliths (crypt debris); chronic cervical lymphadenopathy; and irritable cough
• Signs — tonsils that may be large or small and fibrosed; persistent congestion of the anterior pillars.
• The size of the tonsils has NO relation to the frequency of infection — large tonsils in a healthy child are normal, and fibrosed, small tonsils may be the most infected. This point is consistently misunderstood by families
• The differential diagnosis of a membrane or exudate on the tonsil is the most examinable part of this topic:
• Infectious mononucleosis (glandular fever) — epstein-BARR virus in an adolescent or young adult, with marked malaise and fatigue, a thick grey-white membrane, generalised lymphadenopathy (especially posterior cervical), splenomegaly and hepatomegaly. Diagnosed by atypical lymphocytes on the film, a positive monospot or PAUL-bunnell test, and EBV serology
• Its management is supportive, with steroid for airway obstruction; NO ampicillin; and avoidance of contact sport for at least 4 to 6 weeks because of the risk of splenic rupture