What is Tonsillitis

This is an infection of the tonsils. The latter are paired soft tissue masses located in three sites. The palatine tonsils at the back of the mouth (oropharyngeal tonsils), the nasopharyngeal (adenoid) or post nasal tonsil, and the lingual tonsil located at the base of the tongue. They are glands that form part of the immune system, and thus function to prevent infection from potential bacterial or viral organisms that enter through the mouth and nose. Although healthy tonsils offer protection, diseased tonsils are inefficient at serving this function. Diseased tonsils are associated with decreased antigen transport and decreased antibody production. Therefore, removal of diseased tonsils improves rather than compromise the patient’s resistance.

What Causes Tonsillitis

Tonsillitis is most frequently viral in origin; however, bacterial infections are also prevalent with the most common being the B-haemolytic streptococci, and to a lesser extent Streptococcus Pneumonia, Haemophilus Influenza. Though anaerobic tonsillitis occurs, it is rare.

Diagnosis

The diagnosis of tonsillitis is always clinical:

1. There is a typical short history of a progressive sore throat associated with pyrexia.
2. There often are associated nonspecific symptoms of an infection such as headaches.
3. Earache is very common due to referred pain.
4. Convulsions in children.
5. joint pains.
6. loss of appetite.
7. There are the usual signs of throat infection (redness, swelling, tonsillar exudate, enlarged lymph nodes in the neck).
8. Peritonsillar abscess formation (bulging of one tonsil toward the centre with a deviation of the uvula).
9. Airway compromise (muffled speech, drooling, inability to swallow or open mouth, difficulty breathing).

Treatment

Antibiotics are the primary mode of therapy and will cure most patients with bacterial tonsillitis. Surgery is usually reserved for patients with infections and complications that are resistant to medical management. Penicillin is still the antibiotic of choice for most cases of bacterial tonsillitis. This can be administered orally for five days or parentrally if the patient is in hospital.

Beta-lactamase resistance of streptococcal species may now be observed in up to a third of community-based streptococcal infections. This is probably due to the presence of co-pathogens that are beta-lactamase–producing organisms, such as H influenzae and Moraxella catarrhalis. Augmentin is an effective alternative to Penicillin where resistance occurs. Erythromycin is used where there is Penicillin allergy.

Ancillary measures

1. Use of corticosteroids is debatable. But, when used, may shorten the duration of fever and other severe symptoms.
2. Analgesia and antipyretics are routinely used in association with the antibiotics.
3. Rehydration where necessary.

Tonsillectomy

This is considered the most common operation done in children. It is a procedure still shrouded in controversy especially with regards indications and technique.

Absolute indications for tonsillectomy:

1. Enlarged tonsils with upper airway obstruction.
2. Cardio-pulmonary complications e.g. Cor Pulmonale
3. Tonsillitis leading to febrile convulsions.
4. Peri-tonsillar abscess.

Relative indications:

1. Three or more attacks per year.
2. Persistent halitosis due to chronic tonsillitis.
3. Unilateral hypertrophy that may be neoplastic.

Contra-indications:

1. Uncontrolled bleeding diatheses.
2. Uncontrolled medical illness e.g. heart disease.
3. Severe anaemia.

Complications of surgery:

1. Post-operative haemorrhage.
2. Dehydration and excessive weight loss are seen in children who do not eat.
3. Pyrexia.
4. Local oral tissue trauma.
5. Tonsillar remnants (these can grow and lead to post-operative attacks of tonsillitis).

Outcome and prognosis of tonsillectomy

Many studies suggest improved quality of life. Levels of alpha-streptococci, an inhibitory protective bacterium, have been shown to increase after tonsillectomy. This explains why tonsillectomy decreases the rate of streptococcal infections including pharyngitis.