Inflammation of the tonsils is more common during childhood, but all groups can be affected. Hemolytic streptococcus- Lancerfield group A is the most common organism, but other pathogens causing pharyngitis may affect the tonsils as well. Tonsilitis is more common in poorer socio-economic groups, where chances for cross infection are high.
Clinical features
Symptoms start with sore throat, pain over the region of the tonsils, high fever, and dysphagia. Examination of the throat with a tongue depressor reveals enlarged, red tonsils covered with yellowish pus in the crypts on one or both sides. The exudates can be easily removed by a swab and the underlying mucosa does not bleed. Tonsillar and adjoining lymph nodes are moderately enlarged and tender. There is moderate neutrophil leukocytosis. Even if untreated, the acute symptoms and the tonsilar inflammation partially subside in 7-10 days, but in many the streptococci persist within the crypts and give rise to recurrence of symptoms over several years. This is referred to as “chronic tonsillitis”
Complications
Acute tonsillitis may lead to several complications.
1. Extension of infection due to contiguity Pharyngitis, laryngitis, tracheobronchitis, Eustachian catarrh and suppurative otitis media.
2. Systemic spread of infection Septicemia, pyemia.
3. Local complications Chronic tonsillitis, peritonsillar abscess.
4. Immunological complications Rheumatic fever, glomerulonephritis and rarely allergic purpura.
In India and other neighboring countries, acute streptococcal tonsillitis is the most common cause of rheumatic fever.
Diagnosis
Acute tonsillitis should be clinically diagnosed from the characteristic appearance of the tonsils, acute febrile onset, and neutrophil leukocytosis, The organism can be isolated by culture of the pus taken before exhibiting antibiotics. Acute tonsillitis has to be differentiated from faucial diphtheria in children who have not been immunized. Diphtheritic membrane is grayish white and adherent. It tends to extend beyond the tonsils. Lymphadenopathy is considerably more marked, but the fever is milder. In all cases Gram-stain of the smear and culture should be done. In neutropenic conditions necrotic ulceration of the throat may develop and this has to be kept in mind in all severe cases.
Treatment
The patient is put to rest. Aspirin relieves the pain and fever. Drug of choice is penicillin. Crystalline penicillin G sodium is given in an intramuscular does of 0.5 mega units 8 hours. Once this acute symptoms subside, procaine penicillin may be substituted in a dose of 0.5 meg units daily intramuscularly. In children, if injections are to be avoided, erythromycin, ampicillin or cotrimoxazole may be given in appropriate doses. It is important to administer the full course of treatment and repeat to ensure that the organisms are eradicated. The recurrent exacerbations of tonsillitis (more than four times in one year), occurring as a complication of chronic tonsillitis may warrant tonsillectomy if medical treatment is ineffective. Tonsillectomy has also to be considered if chronic tonsillitis is complicate by otitis media.
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