Tonsillitis

Author Credentials 

Megan M. Gaffey, MD
Instructor
Otolaryngology, Head and Neck Surgery
New York University Langone Medical Center
New York, NY

Philip G. Chen, MD
Associate Professor
Otolaryngology, Head and Neck Surgery
University of Texas Health San Antonio 
San Antonio, TX

Module Learning Objectives 
  1. Explain and describe the pathophysiology and diagnosis of tonsillitis and the impact that this common disease has on patients, their relatives’ quality of life, and their productivity.
  2. Cite and be well-versed in the indications for surgical treatment of tonsillitis and be familiar with its controversies, including specific considerations made for subtypes of tonsillitis.
  3. List several complications of tonsillitis and their respective risks.
  4. Review subtypes of tonsillitis and the treatment controversies that surround them.

 

Embryology

Learning Objectives 
  1. Name the branchial structure from which the palatine tonsil originates.
  2. Describe when lymphoid infiltration vs. lymphoid proliferation occurs in the prenatal and postnatal periods, respectively.

 

References 
  1. Isaacson G, Parikh T. Developmental anatomy of the tonsil and its implications for intracapsular tonsillectomy. International Journal of Pediatric Otorhinolaryngology, 2008; 72(1):89-96.

Anatomy

Learning Objectives 
  1. Name the ring of lymphoid tissue that includes the palatine tonsils.
  2. List the muscles which comprise the tonsillar fossa, then describe their orientation.
  3. Name the arterial blood supply to the tonsils.
  4. Identify and name the cranial nerve that lies closest to the tonsillar bed.
  5. Name the tissue that makes up the tonsil capsule.
  6. Define the boundaries of the peritonsillar space, the parapharyngeal space, and the retropharyngeal space.

 

References 
  1. Wiatrak BJ, Culbersh BD, Cavanagh JP. Adenotonsillar Disorders: Hypertrophy and Infection. In: Hartnick CJ. Ed. Sataloffs Comprehensive Textbook of Otolaryngology: Head and Neck Surgery: Pediatric Otolaryngology. Vol 6. 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 2016.
  2. Liming BJ, Anderson JA, Nieves-Robbins NM, Boseley ME. Pediatric Deep Neck Space Infections. In: Hartnick CJ. Ed. Sataloffs Comprehensive Textbook of Otolaryngology: Head and Neck Surgery: Pediatric Otolaryngology. Vol 6. 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 2016.
  3. Hollinshead WH.  Anatomy for surgeons, 3rd edn.  Philadelphia, PA: Harper & Row; 1982. V. 1, 3.
  4. Isaacson G, Parikh T. Developmental anatomy of the tonsil and its implications for intracapsular tonsillectomy. International Journal of Pediatric Otorhinolaryngology, 2008; 72(1):89-96.

 

Pathogenesis

Learning Objectives 
  1. Describe the natural growth and regression cycle of tonsil tissue.
  2. Name the muscle that encapsulates a peritonsillar abscess.
  • Hint – This is the same muscle violated during the development of a parapharyngeal space abscess

 

References 
  1. Valles-Ayoub Y, Govan III HL, Braun J. Evolving abundance and clonal pattern of human germinal center B cells during childhood. Blood, 1990;76(1): 17-23.
  2. Siegel F, Linse R, Macheleidt S. Factors of tonsillar involution: age-dependent changes in B-cell activation and Langerhans’ cell density. Arch. Otorhinolaryngol., 1982;236(3):261-269.
  3. Wiatrak BJ, Culbersh BD, Cavanagh JP. Adenotonsillar Disorders: Hypertrophy and Infection. In: Hartnick CJ. Ed. Sataloffs Comprehensive Textbook of Otolaryngology: Head and Neck Surgery: Pediatric Otolaryngology. Vol 6. 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 2016.
  4. Millar K, Johnson D, Drummond D, Kellner J. Suspected Peritonsillar Abscess in Children. Pediatr Emerg Care. 2007;23(7):431-438. 

 

Basic Science

Learning Objectives 
  1. List the most common bacterial organisms harbored in healthy children.
  • Of these, identify which is the most common cause of acute pharyngitis
  1. List the most common pathogenic bacteria in adult tonsillitis.
  2. List the viral organisms commonly involved in viral pharyngitis.
  3. Describe the accepted theory that would explain why bacteria in the tonsils appears resistant to antibiotics, leading to chronic tonsillitis.

 

References 
  1. Ingvarsson L, Lundgren K, Olofsson B, et al. Epidemiology of acute otitis media in children.  Acta Otolarygol Suppl. 1982;388:1-52.
  2. Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, Verheij T. Guideline for the management of acute sore throat. Clin Microbiol Infect, 2012; 18 (1_suppl):S1-S28. 

 

Incidence

Learning Objectives 
  1. Estimate the prevalence of acute and/ or chronic tonsillitis in the pediatric population in the United States.
  2. Estimate the percentage of ambulatory pediatric visits attributable to tonsillitis or sore throats.
  3. Name the most common deep-neck space infection.

 

References 
  1. V.M. Freid, D.M. Makuc, R.N. Rooks. Ambulatory health care visits by children: principal diagnosis and place of visit. National Center for Health Statistics. Vital Health Stat. 1998;13:137.
  2. Duarte V, McGrath C, Shapiro N, Bhattacharrya N. Healthcare costs of acute and chronic tonsillar conditions in the pediatric population in the United States. Int J Pediatr Otorhinolaryngol. 2015;79(6):921-925. 

 

Genetics

Learning Objectives 
  1. Name factors that might influence familial clustering of recurrent tonsillitis.
  2. A Danish study has shown that genetic variants of _____ are associated with infectious tonsil diseases. 

 

References 
  1. Kvestad E, Kværner KJ, Røysamb E, Tambs K, Harris JR, Magnus P. Heritability of Recurrent Tonsillitis. Arch Otolaryngol Head Neck Surg. 2005;131(5):383–387.
  2. Feenstra B, Bager P, Liu X, et al. Genome-wide association study identifies variants in HORMAD2 associated with tonsillectomy. Journal of Medical Genetics 2017;54:358-364.

 

Patient Evaluation

Learning Objectives 
  1. List the Paradise Criteria for tonsillectomy.
  • Define other modifying factors that may lead a clinician to recommend tonsillectomy
  1. Name the signs and symptoms of a peritonsillar abscess.
  2. Explain how airway complications can arise from abscesses related to advanced tonsillitis.
  • List signs and symptoms of airway compromise in the setting of a deep neck space abscess

 

References 
  1. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA. et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery. 2019;60(1_suppl), S1–S42.
  2. Grant MC, Guarisco JL. Association Between Computed Tomographic Scan and Timing and Treatment of Peritonsillar Abscess in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(11):1051–1055.

 

Imaging

Learning Objectives 
  1. Describe the ways in which CT scan and transoral ultrasound might be beneficial in the workup of a peritonsillar abscess.
  • Explain why neither modality has become standard-of-care in the workup of pediatric patients with suspected peritonsillar abscess

 

References 
  1. Grant MC, Guarisco JL. Association Between Computed Tomographic Scan and Timing and Treatment of Peritonsillar Abscess in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(11):1051–1055.
  2. Nogan, S., Jandali, D., Cipolla, M. and DeSilva, B. The use of ultrasound imaging in evaluation of peritonsillar infections. The Laryngoscope, 2015;125(11):2604-2607.
  3. Malloy K, Christenson T, Meyer J, Tai S, Deutsch E, Barth P O’Reilly R. Lack of association of CT findings and surgical drainage in pediatric neck abscesses. International Journal of Pediatric Otorhinolaryngology. 2008;72(2), pp.235-239.
  4. Daya H, Lo S, Papsin B et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol. 2005 Jan;69(1):81-6.
  5. Klug T, Fischer A, Antonsen C, Rusan M, Eskildsen H, Ovesen T. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. European Archives of Oto-Rhino-Laryngology. 2014;271(6):1701-1707.

 

Pathology

Learning Objectives 
  1. Name the two most common origins of peritonsillar abscesses.
  2. Identify the origin of parapharyngeal space abscesses.

 

References 
  1. Klug T, Fischer A, Antonsen C, Rusan M, Eskildsen H, Ovesen T. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. European Archives of Oto-Rhino-Laryngology. 2014;271(6):1701-1707. 
  2. Marie S, Tham R, van der Mey A, Meerdink G, van Furth R, van der Meer J. Clinical Infections and Nonsurgical Theatment of Parapharyngeal Space Infections Complicating Throat Infection. Clinical Infectious Diseases. 1989;11(6):975-982.

 

Treatment

Learning Objectives 
  1. Clinicians should have a high suspicion for _______ prior to prescribing oral antibiotics for pharyngitis.
  2. Define Epstein Barr tonsillitis and how its treatment differs from that of other forms of tonsillitis.
  3. Name which antibiotics have been shown to be most effective in: 
  • Preventing tonsillitis
  • Treating acute tonsillitis
  • Treating recurrent tonsillitis
  1. Discuss the outcomes and benefits on quality of life after tonsillectomy for adults with chronic or recurrent tonsillitis.

 

References 
  1. Windfuhr JP, Toepfner N, Steffen G et al. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol 2016;273: 973.
  2. Munck H, Jørgensen AW, Klug TE. Antibiotics for recurrent acute pharyngo-tonsillitis: systematic review. Eur J Clin Microbiol Infect Dis. 2018;37: 1221.
  3. Witsell DL, Orvidas LJ, Stewart MG, et al. Quality of life after tonsillectomy in adults with recurrent or chronic tonsillitis. Otolaryngol Head Neck Surg. 2008; 138(1_suppl):S1-8. 
  4. Tzelnick S, Hilly O, Vinker S, Bachar G, Mizrachi A. Long-term outcomes of tonsillectomy for recurrent tonsillitis in adults. Laryngoscope. 2019; Mar 25 [epub ahead of print].

 

Medical Therapies

Learning Objectives 
  1. The duration of contagiousness of acute bacterial tonsillitis is _______ with the use of antibiotics.
  2. Define the acronym PFAPA, and explain why tonsillectomy for patients with this diagnosis is controversial.
  • Name non-surgical treatment options
  1. Define the acronym PANDAS, and explain why tonsillectomy for patients with this diagnosis is controversial.
  • Name non-surgical treatment options

 

References 
  1. Windfuhr JP, Toepfner N, Steffen G et al. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol. 2016;273: 973.
  2. Leong SC, Karkos PD, Apostolidou MT, Is there a role for the otolaryngologist in PFAPA syndrome? A systematic review. Int J Pediatr Otorhinolaryngol, 2006;70: 1841-1845.
  3. Wurster V, Carlucci J, Feder H, Edwards K. Long-Term Follow-Up of Children with Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome. J Pediatr. 2011;159(6).
  4. Rajgor AD, Hakim NA, Ali S, Darr A. Paediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Beta-Haemolytic Streptococcal Infection: An Indication for Tonsillectomy? A Review of the Literature. Int J Otolaryngol. 2018 Feb 21;2018:2681304.

 

Surgical Therapies

Learning Objectives 
  1. Name the most common indication for total tonsillectomy in the pediatric population.
  2. Name the most common indication for total tonsillectomy in the adult population.
  3. Define a Qunisy tonsillectomy.
  4. Define a tonsillotomy.
  • Identify which age group benefits the most from the decreased morbidity and mortality of tonsillotomy
  1. Define total tonsillectomy.
  • Identify which tonsil disorders would indicate tonsillectomy over tonsillotomy
  1. Describe when incision and drainage of a deep neck space abscess related to tonsillitis is necessary.

 

References 
  1. Hoddeson E, Gourin C. Adult tonsillectomy: Current indications and outcomes. Otolaryngology–Head and Neck Surgery. 2009;140(1):19-22.
  2. Simon L, Matijasec J, Perry A, Kakade A, Walvekar R, Kluka E. Pediatric peritonsillar abscess: Quinsy ie versus interval tonsillectomy. Int J Pediatr Otorhinolaryngol. 2013;77(8):1355-1358.
  3. Hultcrantz E, Ericsson E: Factors Influencing the Indication for Tonsillectomy: A Historical Overview and Current Concepts. ORL 2013;75:184-191.
  4. Foki S, Seemann R, Stelter K, Lill C. The effect of tonsillotomy on chronic recurrent tonsillitis in children, Acta Oto-Laryngologica. 2017;137:9, 992-996.
  5. Doshi H, Rosow D, Ward R, April M. Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy. Int J Pediatr Otorhinolaryngol. 2011;75(11):1395-1398.
  6. Bhattacharyya N, Kepnes LJ, Shapiro J. Efficacy and Quality-of-Life Impact of Adult Tonsillectomy. Arch Otolaryngol Head Neck Surg. 2001;127(11):1347–1350.
  7. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery, 2019;160(1_suppl), S1–S42.
  8. Daya H, Lo S, Papsin B et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol. 2005;69(1):81-86. 

 

Rehabilitation

Learning Objectives 
  1. Describe the role that postoperative steroids play in recovery after total tonsillectomy.
  2. Discuss post tonsillectomy pain control.
  3. While most tonsillectomies are done on an outpatient basis, recommendations exist for overnight stay following total tonsillectomy.  List these
  4. Define the current recommendations regarding perioperative antibiotics in tonsillectomy.
  5. Overall, pediatric and adult patients who have undergone tonsillectomy for tonsillitis report greatly __________ quality of life.
  6. List the most common reasons for emergency room visits and hospital readmissions after tonsillectomy in adults and children.

 

References 
  1. Carpenter P, Hall D, Meier J. Postoperative care after tonsillectomy: what is the evidence?. Curr Opin Otolaryngol Head Neck Surg. 2017;25(6):498-505.
  2. Redmann AJ, Maksimoski M, Brumbaugh C, Ishman S. The effect of postoperative steroids on post‐tonsillectomy pain and need for postoperative physician contact. The Laryngoscope. 2018; 128:2187-2192.
  3. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngology–Head and Neck Surgery. 2019;60(1_suppl), S1–S42.
  4. Bhattacharyya N, Kepnes LJ, Shapiro J. Efficacy and Quality-of-Life Impact of Adult Tonsillectomy. Arch Otolaryngol Head Neck Surg. 2001;127(11):1347–1350.
  5. Hoddeson E, Gourin C. Adult tonsillectomy: Current indications and outcomes. Otolaryngology–Head and Neck Surgery. 2009;140(1):19-22.
  6. Lavin J, Lehmann D, Silva A et al. Variables associated with pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients. Int J Pediatr Otorhinolaryngol. 2019 Apr 26;123:10-14.

 

Case Studies

  1. A 12 year old girl is brought to your office by her mother for a tonsillectomy consultation.  The patient has had 9 cases of tonsillitis in the last 11 months.  6 of these have been confirmed as strep tonsillitis by the pediatrician, and treated with oral antibiotics.  The other 3 episodes were observed at home.  Mom is very interested in a tonsillectomy, but wants answers to the following questions prior to agreeing to proceed:
  • Besides strep, what could the other tonsil infections could have been caused by?
  • Is a partial tonsillectomy appropriate?
  • How likely is the patient to bleed after total tonsillectomy?
  • Will you prescribe narcotics after surgery?
  • Does the patient need to go on antibiotics after surgery?
  • How long before she can return to a regular diet?

 

  1. You are consulted on a 30-year-old male in the emergency department.  The patient has had 6 days of a sore throat, which has gradually worsened.  He now has left otalgia and mild trismus.  In the ED, his temperature is 101.2F.  When you examine him, his uvula is deviated to the right, and there is a palatal bulge on the left side.  As you begin recommending a bedside incision and drainage of what you suspect to be a peritonsillar abscess, the patient adamantly states that he is afraid of needles.  He asks if he can just start antibiotics and go home.  
  • What do you tell the patient?
  • If the abscess is not addressed, what other areas could it spread to?  
  • What risk could that pose to the airway?
  • What major thoracic complication could arise if the infection spreads to the thorax, and what fascial planes would it travel on to get there?

 

Complications

Learning Objectives 
  1. Explain the post-tonsillectomy bleeding risk in pediatric and adult populations
  • Discuss the controversy surrounding ibuprofen in regards to post-tonsillectomy hemorrhage.
  1. Describe the relationship of parapharyngeal and retropharyngeal abscesses with peritonsillar abscess.
  2. List the signs and symptoms of mediastinitis.
  3. List the signs and symptoms of internal jugular vein thrombosis.

 

References 
  1. Carpenter P, Hall D, Meier J. Postoperative care after tonsillectomy: what is the evidence?. Curr Opin Otolaryngol Head Neck Surg. 2017;25(6):498-505. 
  2. Krishna P, Lee D. Post-tonsillectomy bleeding: a meta-analysis Laryngoscope. 2001;111(8):1358-1361.
  3. Daya H, Lo S, Papsin B et al. Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol. 2005.
  4. Klug TE, Fischer ASL, Antonsen C. et al. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. Eur Arch Otorhinolaryngol. 2014;271:1701.

 

Review

Review Questions 
  1. What muscle does tonsil bacteria violate as it spreads outside of the tonsil capsule and turns purulent?
  2. What is the purpose of post-tonsillectomy oral steroids?
  3. How can mediastinitis arise after tonsillitis?
  4. What percentage of children will experience a post-tonsillectomy bleed?

 

Resources 

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