Tonsillitis and Peritonsillar Abscess

Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Arlen D Meyers, MD, MBA more...

Overview
Presentation
DDx
Workup
Treatment
Medication
Updated: Jul 09, 2015

Practice Essentials

Background
Pathophysiology and Etiology
Epidemiology
Prognosis
Show All
Multimedia Library
References

Practice Essentials
Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the
lingual tonsils; therefore, the term pharyngitis may also be used. Most cases of bacterial tonsillitis are caused
by group A beta-hemolytic Streptococcus pyogenes (GABHS).

Signs and symptoms

Tonsillitis
Individuals with acute tonsillitis present with the following:

Fever
Sore throat
Foul breath
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Tender cervical lymph nodes
Airway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing
pauses, or sleep apnea.
Peritonsillar abscess
Individuals with peritonsillar abscess (PTA) present with the following:

Severe throat pain

Fever
Drooling
Foul breath
Trismus (difficulty opening the mouth)
Altered voice quality (the hot-potato voice)
Physical examination of a PTA almost always reveals unilateral bulging above and lateral to one of the tonsils.
See Clinical Presentation for more detail.

Diagnosis
Tonsillitis and PTA are clinical diagnoses. Testing is indicated when GABHS infection is suspected. Throat
cultures are the criterion standard for detecting GABHS. 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 computed tomography (CT) scanning with contrast is warranted. In cases of
PTA, CT scanning with contrast is indicated.
See Workup for more detail.

Management
Tonsillitis
Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric
intake and controlling pain and fever.
Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In
severe cases of MN, corticosteroids or gamma globulin may be helpful. GABHS infection obligates antibiotic
coverage.
Tonsillectomy is indicated for the individuals who have experienced the following:

More than six episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year
Five episodes of streptococcal pharyngitis in 2 consecutive years
Three or more infections of the tonsils and/or adenoids per year for 3 years in a row despite adequate
medical therapy

Chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to
beta-lactamaseresistant antibiotics
Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and because minimal additional
morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform an
adenoidectomy if adenoids are present and inflamed at the time of tonsillectomy. However, this point remains
controversial.
Peritonsillar abscess
Treatment of PTA includes aspiration and incision and drainage (I&D). Antibiotics, either orally or intravenously,
are required to treat PTA medically, although the condition is usually refractory to antibiotic therapy alone.
See Treatment and Medication for more detail.
Next Section: Background

Pathophysiology and Etiology

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Overcrowded
conditions and malnourishment promote tonsillitis. Most episodes of acute pharyngitis and acute tonsillitis are
caused by viruses such as the following:

Herpes simplex virus

Epstein-Barr virus (EBV)
Cytomegalovirus
Other herpes viruses
Adenovirus
Measles virus

In one study showing that EBV may cause tonsillitis in the absence of systemic mononucleosis, EBV was found
to be responsible for 19% of exudative tonsillitis in children.
Bacteria cause 15-30% of cases of pharyngotonsillitis. Anaerobic bacteria play an important role in tonsillar
disease. Most cases of bacterial tonsillitis are caused by group A beta-hemolytic Streptococcus
pyogenes (GABHS). S pyogenes adheres to adhesin receptors that are located on the tonsillar epithelium.
Immunoglobulin coating of pathogens may be important in the initial induction of bacterial tonsillitis.
Mycoplasma pneumoniae, Corynebacterium diphtheriae, and Chlamydia pneumoniae rarely cause acute
pharyngitis. Neisseria gonorrhea may cause pharyngitis in sexually active persons. 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.

Recurrent tonsillitis
A polymicrobial flora consisting of both aerobic and anaerobic bacteria has been observed in core tonsillar
cultures in cases of recurrent pharyngitis, and children with recurrent GABHS tonsillitis have different bacterial
populations than children who have not had as many infections. Other competing bacteria are reduced, offering
less interference to GABHS infection. Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus
influenzae are the most common bacteria isolated in recurrent tonsillitis, and Bacteroides fragilis is the most
common anaerobic bacterium isolated in recurrent tonsillitis.
The microbiologies of recurrent tonsillitis in children and adults are different; adults show more bacterial
isolates, with a higher recovery rate of Prevotella species,Porphyromonas species, and B
fragilis organisms , whereas children show more GABHS. Also, adults more often have bacteria that produce
beta-lactamase.

Chronic tonsillitis
A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and betahemolytic streptococcal species, S aureus, H influenzae, andBacteroides species having been identified. A
study that was based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy
suggested that antibiotics prescribed 6 months before surgery did not alter the tonsillar bacteriology at the time
of tonsillectomy.[3] 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. H
influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids. With regard to penicillin
resistance or beta-lactamase production, the microbiology of tonsils removed from patients with recurrent
GABHS pharyngitis has not been shown to be significantly different from the microbiology
oftonsilsremovedfrom patients with tonsillar hypertrophy.
Local immunologic mechanisms are important in chronic tonsillitis. 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. Study of immunologic markers may permit differentiation between
recurrent and chronic tonsillitis. Such markers in one study indicated that children more often experience
recurrent tonsillitis, whereas adults requiring tonsillectomy more often experience chronic tonsillitis. [4]
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.

Peritonsillar abscess
A polymicrobial flora is isolated from peritonsillar abscesses (PTAs). Predominant organisms are the
anaerobes Prevotella, Porphyromonas, Fusobacterium, andPeptostreptococcus species. Major aerobic
organisms are GABHS, S aureus, andH influenzae.
Uhler et al, in an analysis of data from 460 patients with PTA, found a higher incidence of the condition in
smokers than in nonsmokers.[5]

Epidemiology

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. Peritonsillar abscess (PTA) usually occurs in teens or young adults but may
present earlier.
Pharyngitis accompanies many upper respiratory tract infections. Between 2.5% and 10.9% of children may be
defined as carriers. In one study, the mean prevalence of carrier status of schoolchildren for group
A Streptococcus, a cause of tonsillitis, was 15.9%.[6, 7]
According to Herzon et al, children account for approximately one third of peritonsillar abscess episodes in the
United States.[8] 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.[9]
Klug found seasonal and/or age-based variations in the incidence and cause of PTA. Among his conclusions,
he reported that the incidence of PTA increased during childhood, peaking in teenagers and then gradually
falling until old age. He also found that until age 14 years, girls were more affected than boys, but that the
condition subsequently was more frequent in males than in females.[10]
Klug also found a significantly higher incidence of Fusobacterium necrophorumthan of group
A Streptococcus in patients aged 15-24 years with PTA. However, the incidence of group A Streptococcus was
significantly higher than F necrophorum in children aged 0-9 years and in adults aged 30-39 years. [10]
Although Klug determined that the incidence of PTA did not significantly vary by season, the presence of group
A Streptococcus was significantly more frequent in winter and spring than in summer, while F
necrophorum tended to be found more often in summer than in winter.[10]

Prognosis
Because of improvements in medical and surgical treatments, complications associated with tonsillitis,
including death, are rare.[11] 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, cases that occurred in the 1980s and early 1990s support concern over a resurgence
of this condition.