Acute tonsillitis and pharyngitis

Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of the pharynx (tonsillopharyngitis). The terms tonsillitis and pharyngitis are often used interchangeably, but they refer to distinct sites of inflammation. Acute tonsillitis and pharyngitis are particularly common in children and young adults and are primarily caused by viruses or group A streptococci (GAS). They are characterized by the sudden onset of fever, sore throat, and painful swallowing. Patients may also have tender, swollen cervical lymph nodes and tonsillar exudates. The disease is normally self-limited. However, if GAS infection is confirmed via rapid antigen detection test and/or throat culture, treatment with antibiotics (most often penicillin) should be initiated to prevent rheumatic fever. Tonsillectomy is a treatment option for recurrent and chronic tonsillitis, especially in patients with tonsillar hypertrophy that causes obstructive sleep-disordered breathing. Peritonsillar abscess and parapharyngeal abscess are serious suppurative complications of acute bacterial tonsillitis and require immediate treatment.

• Peak incidence ^[1]
  • Acute viral tonsillopharyngitis: children < 5 years and young adults
  • Acute GAS tonsillopharyngitis: children aged 5–15 years; rare in children aged < 2 years
• Peak season: Acute GAS tonsillopharyngitis most commonly occurs in winter and spring. ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Acute tonsillopharyngitis
  • Viral (50–80% of cases): adenovirus, EBV, CMV, HSV, rhinovirus, coronavirus, influenza and parainfluenza viruses, HIV ^[2][3]
  • Bacterial (15–30% of cases)
    • Most common: acute GAS tonsillopharyngitis caused by Streptococcus pyogenes, also known as Group A Streptococcus (GAS) ^[2]
    • Others: Neisseria gonorrhoeae, Corynebacterium diphtheriae, Mycoplasma pneumonia, Fusobacterium necrophorum, Group C and Group G Streptococcus ^[2][4]
    • Necrotizing (or anaerobic) tonsillopharyngitis (sometimes referred to as Vincent angina): A rare anaerobic and/or mixed organism infection that may overlap with necrotizing periodontal disease. ^[5][6][7][8]
• Recurrent tonsillopharyngitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria

Acute bacterial tonsillopharyngitis ^[2]

• Sudden onset; of symptoms: fever, sore throat, dysphagia
• Significantly inflamed pharynx
  • Pharyngeal and/or tonsillar erythema and edema
  • Pharyngeal and/or tonsillar exudates (rare in children < 3 years of age)
  • Palatal petechiae
• Cervical lymphadenitis
• Absence of cough
• Acute GAS tonsillopharyngitis can also present as scarlet fever with:
  • Strawberry tongue
  • Scarlatiniform rash
• Rarely, features of necrotizing infection and/or dental disorders and/or periodontal disease may be present (see “Vincent angina”). ^[5][6][7][8]

Children < 3 years of age rarely develop GAS pharyngitis; GAS infection in this age group more typically manifests with fever, lymphadenopathy, mucopurulent rhinitis, and excoriated skin around the nostrils. ^[2]

Acute viral tonsillopharyngitis ^[2][3]

• Cough
• Coryza
• Rhinorrhea
• Oral ulcers, anterior stomatitis
• Conjunctivitis
• Diarrhea
• Absence of fever

Red flags for complications of tonsillopharyngitis ^[9]

The presence of any of the red flag features listed below may indicate suppurative and/or invasive complications of acute tonsillitis and/or pharyngitis, such as deep neck infections (e.g., peritonsillar abscess, retropharyngeal abscess), cervical lymphadenitis, mastoiditis, and rarely, sepsis. ^[2]

• Trismus
• Drooling
• Asymmetric tonsils
• Displaced uvula
• Unilateral facial swelling
• Muffled or “hot potato” voice
• Clinical features of sepsis
• Immunosuppression

Trismus and change in voice quality indicate the formation of potentially life-threatening peritonsillar abscess!

Recommendations in this section are consistent with the 2012 Infectious Disease Society of America (IDSA) and the 2009 American Heart Association (AHA)/American Academy of Pediatrics (AAP) guidelines on GAS pharyngitis. ^{[2][10][11][12]}

Approach ^[2][13]

The diagnosis of acute tonsillitis or acute pharyngitis is primarily clinical.

• Clinical evaluation
  • Assess for clinical features of acute bacterial tonsillopharyngitis, acute viral tonsillopharyngitis, and differential diagnoses of acute tonsillopharyngitis.
  • Proceed to immediate treatment if red flags of tonsillopharyngitis or clinical features of airway compromise are present.
• Suspected acute bacterial tonsillopharyngitis: Consider diagnostic testing to identify and treat GAS infection and minimize its transmission and complications (e.g., acute rheumatic fever). ^[4][12]
  • Consider deferring diagnostic testing based on a clinical scoring system, e.g., no testing if modified Centor score ≤ 1.
  • Obtain a rapid strep test if indicated, e.g., symptomatic patient ≥ 3 years old
    • Positive rapid strep test: GAS infection likely; proceed to treatment.
    • Negative rapid strep test: Obtain a throat culture in children (not routinely required in adults). ^[2]
• Suspected acute viral tonsillopharyngitis: Diagnostic testing is not routinely recommended.
  • Suspected infectious mononucleosis: Obtain either EBV serology or a heterophile antibody test. ^[13]
  • Suspected COVID-19: See “COVID-19 testing” for details.

Routine testing for GAS is not recommended for children < 3 years old, as their prevalence of GAS pharyngitis and risk of developing subsequent acute rheumatic fever are both low. Consider testing only if specific risk factors (e.g., close household contact) are present. ^[2][13]

Testing for GAS infection is not recommended in patients with clinical features that strongly suggest acute viral tonsillopharyngitis. ^[2]

Rapid strep test ^[2]

• Modality: rapid antigen detection test (RADT) specific for GAS antigens.
• Indications: first-line test in suspected acute bacterial tonsillopharyngitis
  • All symptomatic children ≥ 3 years of age and adults (unless symptoms are suggestive of acute viral tonsillopharyngitis)
  • Consider in symptomatic children < 3 years of age if there is a household or other close contact (e.g., daycare) with proven GAS infection.
  • Modified Centor score ≥ 2 (if scoring has been used)
• Procedure: Swab the patient's tonsils and the back of the throat.
• Findings ^[2]
  • Identifies the presence of GAS (positive RADT). ^[2][14]
  • Time to result: 5–10 minutes

Throat culture for GAS

• Indications
  • Confirmatory test to definitively rule out GAS infection in symptomatic children and adolescents with a negative RADT
  • Lack of clinical improvement after 3–4 days despite antibiotic treatment ^[9]
  • Recurrent or chronic tonsillitis ^[2][15]
  • Consider in adults with risk factors for invasive GAS infection. ^[16]
• Findings ^[2]
  • Causative bacteria and their antibiotic susceptibility (see “Etiology” for details)
  • Time to result: 24–48 hours

Clinical scoring systems ^[2][14]

• Rationale: Estimate the likelihood of acute bacterial pharyngitis based on clinical features alone.
• Example: the modified Centor score
• Clinical applications
  • Identifying patients with a low likelihood of GAS infection, thereby minimizing unnecessary diagnostic tests and antibiotic therapy.
  • The use of scoring systems to identify patients with a high likelihood of bacterial pharyngitis in order to treat empirically without testing is controversial. ^[2][11][12]

Think of M-CENTOR to remember the Modified Centor score criteria: M = Must be older than 3 years, C = Cough absent, E = Exudate on the tonsils, N = Node enlargement, T = Temperature elevation, OR = young OR old.

Empiric antibiotic therapy for patients with a modified Centor score ≥ 4 is not routinely recommended. ^[2]

Additional laboratory tests

Not routinely indicated; can be obtained as supportive diagnostic evidence

• CBC
• Inflammatory markers: CRP, ESR
• Antistreptolysin O (ASO) titer
  • Elevated levels suggest a previous GAS infection; not helpful to diagnose acute pharyngitis
  • Indicated in the workup of nonsuppurative complications of GAS tonsillopharyngitis (e.g., acute rheumatic fever, PSGN). ^[2]

Imaging ^[9]

• Not routinely indicated
• Consider CT of head and neck if there is clinical suspicion of suppurative complications

The differential diagnoses listed here are not exhaustive.

Recommendations in this section are consistent with the 2012 IDSA and the 2009 AHA/AAP guidelines on GAS pharyngitis. ^{[2][10][11][12]}

Approach ^[2][13]

• All patients
  • Provide supportive care: e.g., analgesia, antipyretics.
  • If red flags of tonsillopharyngitis are present:
    • Consult ENT urgently.
    • Identify and treat deep neck infections.
    • Consider empiric IV antibiotics and steroids for patients with signs of airway compromise, and prepare for difficult airway management as needed. ^[13]
• GAS pharyngitis and/or tonsillitis: typically self-limited; prescribe antibiotics to prevent complications (e.g., peritonsillar abscess, rheumatic fever) and decrease transmission ^[2][23]
  • Positive rapid strep test or throat culture: Initiate antibiotic therapy for acute GAS pharyngitis.
  • Negative rapid strep test: Wait for throat culture results; treat if culture positive. ^[2][18]
  • Empiric treatment (e.g., for patients with modified Centor score ≥ 4) is controversial and not routinely recommended. ^{[2][10][11][12]}
  • Advise isolation and droplet precautions until patients are afebrile and have received ≥ 12 hours of antibiotic therapy. ^[24]
• Acute viral tonsillopharyngitis: self-limited; continue supportive care and provide patient education.
• Disposition: Outpatient treatment is possible for most patients.
  • Improvement can be expected within 3–4 days. ^[9]
  • Reasons to return to seek care: Persistent or worsening symptoms

Amoxicillin therapy in patients with infectious mononucleosis can trigger a maculopapular and/or morbilliform rash. Reserve antibiotics for patients with confirmed bacterial tonsillopharyngitis (e.g., positive rapid strep test or throat culture), whenever possible. ^[25]

Supportive care for sore throats ^[2]

• Ensure adequate hydration.
• Consider household remedies such as salt-water gargles.
• Consider oral topical local anesthetics: e.g., benzocaine lozenges, phenol throat sprays, compounded mouthwash. ^[2][26]
• Consider single low-dose corticosteroids to reduce symptom duration in patients > 3 years old. ^[27][28][29]
• Analgesics and antipyretics ^[2]
  • Acetaminophen
  • NSAIDS: e.g., ibuprofen

Avoid aspirin in children due to the risk of Reye syndrome.

Antibiotic therapy ^[2]

• Indication: patients with laboratory confirmation of GAS infection ^[2][10]
• Suspected anaerobic or necrotizing infection (e.g., features of infection with fusobacterium or mixed organisms): Consult a specialist (e.g., ENT or infectious disease) for targeted therapy. (see also “Deep neck infections”). ^[5]

Mistakenly treating an EBV infection (infectious mononucleosis) with amoxicillin can lead to a maculopapular rash.

Epidemiology

• Ambulatory tonsillectomy is one of the most frequently performed procedures in children < 15 years of age.
• In 2010, there were almost 300,000 cases in the US. ^[1][2]

Indications ^[1][2][31]

• Extreme hypertrophy of the tonsils (“kissing tonsils” ) causing obstructive sleep-disordered breathing. ^[32]
• Documented recurrent throat infections ^[33]
• Suspected tonsillar neoplasm
• Chronic tonsillitis
• Consider in patients with any of the following:
  • History of peritonsillar abscess
  • Allergy or intolerance to multiple antibiotics
  • PFAPA syndrome

Procedure ^[1][34][35]

• Total tonsillectomy
  • Tonsils are removed with their surrounding capsule.
  • Dissection is lateral to the tonsil in the plane between the tonsillar capsule and pharyngeal muscles.
• Subtotal tonsillectomy
  • Subtotal removal of tonsillar tissue, leaving a margin of tissue on the tonsillar capsule
  • Dissection is from medial to lateral in a stepwise approach to preserve the capsule.

Admit children < 3 years of age and those with severe obstructive sleep apnea, obesity, or complex medical histories (e.g., Down syndrome, congenital heart disease, neuromuscular disease) for overnight monitoring after tonsillectomy. ^[1]

Complications ^[1]

• Intraoperative: injury to adjacent structures, e.g., the carotid artery
• Postoperative
  • Pain, referred otalgia, nasopharyngeal stenosis
  • Dehydration from decreased oral intake
  • Respiratory compromise ^[36]
  • Bleeding: See “Posttonsillectomy hemorrhage.”

Do not use acetylsalicylic acid for postoperative pain relief after tonsillectomy because of the increased risk of bleeding. Recommended analgesics after tonsillectomy are ibuprofen and acetaminophen. ^[1][37]

Posttonsillectomy hemorrhage ^[38][39]

• Background: The risk of bleeding increases with age, reaching up to 20% in adults. ^[40][41]
  • Primary bleeding: occurs ≤ 24 hours after surgery
  • Secondary bleeding: occurs > 24 hours after surgery
• Clinical features
  • Bleeding can range from clot formation and oozing to active profuse hemorrhage.
  • Clinical features of airway compromise may be present.
• Initial management
  • Move patients to a monitored setting with airway and resuscitation equipment available.
  • Examine the posterior pharynx for signs of recent and/or active bleeding.
  • If any bleeding is visible (e.g., clots, oozing, or active hemorrhage), establish large-bore IV access and obtain CBC, coagulation panel, and type and screen.
  • Consult ENT surgery early.
  • Establish NPO status (at least until evaluated by ENT surgeon).
• Minor bleeding
  • Small bleed that has self-resolved: Consider observation under ENT for 12–24 hours. ^[38]
  • History of recurrent bleeding or visualization of oozing or clot
    • Keep for observation with frequent clinical reassessment.
    • Definitive management as guided by ENT (e.g., cauterization at the bedside or in the operating room).
• Active hemorrhage or history of severe hemorrhage: Evaluate and manage patients simultaneously using the ABCDE approach while urgently contacting the operating room and ENT for high-priority surgical intervention.
  • Airway management
    • Have the patient lean forward to keep blood out of the airway.
    • Use gentle suction to remove blood.
    • Prepare for intubation; anticipate a difficult airway. ^[36]
  • If clinical features of shock are present, initiate immediate hemodynamic support followed by emergency blood transfusion.
  • Hemostatic measures
    • Apply ice to the neck
    • Consider intravenous tranexamic acid ^[42]
    • Consider lateral pressure to the affected tonsillar bed with gauze
    • Once intubated, pack the tonsillar fossa.

Secondary posttonsillectomy hemorrhage typically presents ∼ 1 week after surgery, around the time the eschar (fibrin clot) detaches. ^[43]

Suspected acute viral tonsillopharyngitis

• Diagnostic tests are not routinely required.
• Consider testing for COVID-19 or infectious mononucleosis as needed.
• Supportive care

Suspected acute bacterial tonsillopharyngitis

• Provide symptomatic treatment, e.g., analgesia, antipyretics.
• Use a clinical scoring system (e.g., modified Centor score) to identify patients at low risk of GAS infection.
• Suspected acute GAS tonsillopharyngitis: Perform RADT.
• If RADT is negative: Obtain a throat culture in children and adolescents to reliably rule out GAS infection.
• If RADT and/or throat culture is positive: Initiate antibiotic therapy for GAS tonsillopharyngitis.

Suppurative complications of acute tonsillopharyngitis ^[44]

• Deep neck infections
  • Peritonsillar abscess
  • Parapharyngeal abscess
  • Retropharyngeal abscess
• Otitis media
• Sinusitis
• Cervical lymphadenitis
• Mastoiditis
• Infectious thrombophlebitis of the internal jugular vein (Lemierre syndrome)
  • Definition: a severe, potentially fatal condition usually resulting from oropharyngeal infections characterized by infection of the carotid sheath vessels and bacteremia
  • Etiology: most commonly caused by oropharyngeal flora (e.g., Fusobacterium necrophorum)
  • Clinical features: fever, respiratory distress, neck pain, throat pain

Nonsuppurative complications of GAS infection

• Acute rheumatic fever
• Scarlet fever
• Poststreptococcal glomerulonephritis (PSGN)
• Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) ^[45]
  • Definition: a rare disorder that is characterized by sudden onset or exacerbation of obsessive-compulsive disorder (OCD) and/or a tic disorder following infection with S. pyogenes
  • Pathophysiology
    • Not fully understood
    • Preceding GAS infection results in an abnormal immune response with development of cross-reactive, anti-neuronal antibodies ^[46]
  • Clinical features
    • Abrupt onset or exacerbation of symptoms of OCD and/or a tic disorder
    • Possible additional behavioral changes: enuresis, separation anxiety disorder, regression in learning and handwriting ability
  • Diagnostic criteria ^[47]
    • Presence of OCD and/or a tic disorder
    • Onset during childhood
    • Acute onset and episodic course
    • Temporal association with streptococcal infection
    • Neurological abnormalities during episodes (eg, motoric hyperactivity, choreiform movements of fingers/toes)
  • Treatment
    • Antibiotic eradication of GAS
    • Cognitive behavioral therapy and pharmacological treatment for OCD and tic disorder

Antibiotic therapy for GAS pharyngitis can decrease the risk of rheumatic fever but does not affect the risk of PSGN. ^[2]

Streptococcus "ph"yogenes is the most common cause of bacterial pharyngitis, which can result in rheumatic "phever" and poststreptococcal glomerulonephritis.

References: ^[3][48]

We list the most important complications. The selection is not exhaustive.