Tonsillitis

Inflammation of the palatine tonsils (lymphoid tissue in the throat), usually due to infection by common respiratory viruses or *Group A Streptococcus* bacteria. It typically causes a sore throat, fever, and swollen tonsils (often with exudates).

• Sore throat (tonsillitis/pharyngitis) is extremely common, especially in children, and a major reason for outpatient visits and antibiotic prescriptions. Proper evaluation identifies the cases due to group A strep (to prevent serious sequelae like rheumatic fever) and avoids unnecessary antibiotics for viral infections.

• Children/Adolescents: Classic *"strep throat"* in school-age kids presents with sudden onset throat pain, high fever, difficulty swallowing, and markedly inflamed tonsils often with white exudative patches. Anterior cervical lymph nodes are tender and enlarged. Headache, abdominal pain, or even vomiting can occur in kids with strep. *Viral* sore throat is more likely if there are cough, runny nose, hoarse voice, or conjunctivitis (these symptoms are usually absent in GAS infection).
• Adults: Pharyngitis in adults is usually *viral* (GAS causes only ~5–15% of adult sore throats). True bacterial tonsillitis is less frequent beyond adolescence (tonsil immune tissue tends to shrink after puberty), but when it occurs, the symptoms are similar: fever, severe sore throat, odynophagia (painful swallowing), and tonsillar inflammation. Infectious mononucleosis (EBV) in teens/young adults can mimic strep throat but typically includes profound fatigue and posterior or generalized lymph node swelling (± splenomegaly).

1. Apply Centor criteria to decide likelihood of strep: give 1 point each for fever >38°C, tonsillar exudates, tender anterior cervical nodes, and absence of cough. Higher scores (≥3) indicate higher probability of GAS – perform a rapid strep test (RADT) for confirmation. In children and teens, a negative rapid test should be backed up by a throat culture to definitively rule out strep.
2. If obvious viral features are present (e.g. cough, runny nose, oral ulcers), testing for strep is usually not necessary. If clinical suspicion for strep is low (Centor 0–1), manage with supportive care; if high (Centor 4), some clinicians may empirically treat while awaiting confirmation.
3. Consider mononucleosis (EBV) testing if a patient (especially adolescent) has protracted sore throat, negative strep tests, or marked fatigue. Use the heterophile antibody test (Monospot) to detect mono – remembering it can be *falsely negative* early in illness or in young children. EBV infection often causes posterior cervical adenopathy and can produce a diffuse rash if exposed to amoxicillin.
4. For recurrent tonsillitis, evaluate frequency: ≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years meets criteria for possible tonsillectomy. Also involve ENT if complications arise (e.g. a history of peritonsillar abscess or airway obstruction).

1. Supportive care is important for all cases: hydration, warm saltwater gargles, throat lozenges, rest, and NSAIDs/acetaminophen for pain and fever. In severe cases with tonsillar swelling threatening the airway, a single dose of a corticosteroid (eg, dexamethasone) can help reduce edema.
2. For confirmed or highly suspected GAS: start antibiotics. Penicillin V or amoxicillin (oral, 10 days) is first-line therapy; this shortens symptom duration and (more importantly) prevents rheumatic fever. If penicillin-allergic, use a first-generation cephalosporin (if allergy mild) or azithromycin / clindamycin. Patients are generally not contagious after ~24 hours on antibiotics.
3. No antibiotics are needed for viral tonsillitis – it will self-resolve. Educate patients on symptomatic relief and the importance of avoiding unnecessary antibiotics (to prevent resistance). Return for care if symptoms worsen (watch for abscess). For chronic tonsillitis or obstructive tonsillar hypertrophy, an elective tonsillectomy may be indicated.

• Mnemonic – CENTOR: Cough absent, Exudate, Nodes, Temperature, Old/young (age <15 +1, >44 −1 for modified score).
• Penicillin (or amoxicillin) for 10 days is first-line for strep throat – treating within ~9 days of illness onset prevents rheumatic fever, though it does *not* prevent post-strep glomerulonephritis.
• Strep throat with a fine sandpaper rash suggests scarlet fever (GAS strain producing erythrogenic toxin).
• An amoxicillin rash (widespread non-allergic rash after taking amoxicillin) in a patient with sore throat is a classic clue for EBV mononucleosis.

• Airway compromise: Stridor, drooling, inability to handle secretions, or severe muffled voice suggests possible epiglottitis or deep neck space infection – emergency evaluation needed.
• Abscess formation: Unilateral throat swelling with extreme pain, trismus (jaw lock), and "hot potato" voice → suspect a peritonsillar abscess; requires prompt drainage to prevent spread of infection.
• Post-strep complications: Watch for signs of acute rheumatic fever (eg, migrating joint pains, new heart murmur, rash) a few weeks after strep infection, or post-streptococcal glomerulonephritis (tea-colored urine, edema) ~1–3 weeks later.

• A 7‑year‑old boy with abrupt onset fever to 39°C, severe sore throat, and no cough. Exam: enlarged tonsils with white exudates, and tender anterior cervical lymph nodes → Streptococcal tonsillitis ("strep throat").
• An 18‑year‑old college student with persistent sore throat, marked fatigue, and diffuse lymphadenopathy (including posterior cervical). Initially tested strep-positive and given amoxicillin, then developed a generalized pink rash → Infectious mononucleosis (EBV).
• A 17‑year‑old with worsening unilateral throat pain after a week of tonsillitis. She speaks with a muffled "hot potato" voice, and exam shows a bulging left tonsil and deviated uvula → Peritonsillar abscess (collection of pus needing urgent drainage).