Tonsillitis is inflammation of the tonsils due to infection
The majority of tonsillitis and pharyngitis is viral and only requires symptomatic treatment
In bacterial tonsillitis (15-30%) an important pathogen is Group A β-Haemolytic Streptococcus
Viruses implicated in tonsillitis and pharyngitis include rhinovirus, coronavirus, respiratory syncytial virus, adenovirus, parainfluenza, influenza, herpes simplex virus, enteroviruses and cytomegalovirus
Both viruses and bacteria can cause an exudative tonsillitis
Epstein-Barr Virus (EBV) is a common cause of exudative tonsillitis and pharyngitis
Diphtheria, caused by Cornebacterium diphtheriae is rare in the developed world where immunisation against this disease is routine.
Mycoplasma pneumoniae can be another causative bacteria. Other bacterial causes of tonsillitis are rare.
Both viruses and bacteria can cause a high temperature
Streptococcal tonsillitis is most common in school-age children, and is uncommon in children less than 3 years old
Rapid onset of sore throat and high fever associated with an exudative tonsillitis is more suggestive of a Streptococcal tonsillitis, especially in the absence of typical viral features
Low socio-economic status
Aboriginal and Torres Strait Islander
It can be difficult to distinguish clinically between viral tonsillitis (majority) and bacterial tonsillitis (15-30%)
Viral tonsillitis is highly likely where there are other symptoms of a viral upper respiratory tract infection
Worsening sleep apnoea
Ear aches – referred pain
Symptoms of a viral upper respiratory tract infection: rhinorrhoea, cough, hoarseness, watery red eyes
Erythematous tonsils and pharynx with/without exudate
Enlarged and tender cervical lymph nodes
When severe there may be upper airway obstruction – stridor, drooling, signs of respiratory distress
With Epstein-Barr Virus (EBV) there is exudative tonsillitis and there may be significant malaise, hepato-splenomegaly and submandibular (and generalised) lymphadenopathy.
Clinical features that are more suggestive of GABHS include:
Soft palate petechiae – “doughnut lesions”
Exudate on pharynx and/or tonsils
Tender cervical lymphadenopathy
Absence of viral upper respiratory tract symptoms
Bacterial throat swab for culture is usually not indicated. Results take 24 to 48 hours.
Do not delay antibiotic treatment while awaiting results
Epstein-Barr Virus (Glandular Fever)
Peri-tonsillar abscess (Quinsy)
Oral thrush (Candidiasis)
Hand foot and mouth disease
The vast majority of children only need symptomatic treatment
Supportive care includes adequate hydration and simple analgesia
Airway: If there is airway compromise (eg: stridor) intravenous Dexamethasone (dose: 0.15mg/kg) can be used
Definitive prescription should be made empirically on clinical presentation
Antibiotic treatment of Streptococcal tonsillitis probably only reduces the duration of symptoms by 12-24 hours
The main benefits of antibiotics are the prevention of suppurative complications and the prevention of post-infectious immune-mediated acute rheumatic fever
Antibiotics administered within 7-9 days of the illness is almost 100% successful in preventing acute rheumatic fever. Delaying antibiotics pending the throat swab result will not reduce their efficacy in preventing acute rheumatic fever.
Aboriginal and Torres Strait Islander children have a higher rate of complications with rheumatic heart disease and post-streptococcal glomerulonephritis. Therefore there is a lower threshold for prescription of antibiotics for these children.
There is no evidence that antibiotic treatment will prevent post-streptococcal glomerulonephritis
Steroids can have a role in acute pain management. Studies have shown that 1-3 doses of Dexamethasone (dose: 0.15mg/kg) will improve pain faster and allow return to normal activities faster.
Analgesia must be used. Paracetamol is usually sufficient. Ibuprofen is an alternative.
Avoid aspirin in children because of the risk of Reye syndrome
Children older than 12 years may use aspirin gargles
Other symptomatic treatments such as salt water gargles, throat lozenges and sprays have varying anecdotal results and have not been proven to be of benefit in clinical trials
Supportive care also includes encouraging oral fluids and encouraging oral hygiene (brushing teeth and rinsing with an antiseptic mouthwash)
Intravenous fluids may be considered if dehydrated
Complications of GABHS:
Acute rheumatic fever
Antibiotics – Penicillin V for 10 days BD
If penicillin allergic, use Azithromycin once daily for 3 days