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Acute and Chronic Tonsillitis

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1. Classification

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2. Etiology

Viral (majority of cases)

• Adenovirus (pharyngoconjunctival fever)
• Rhinovirus, coronavirus (common cold)
• Parainfluenza, influenza A/B
• Epstein-Barr virus (EBV) — infectious mononucleosis
• Cytomegalovirus (CMV) — CMV mononucleosis
• Coxsackievirus A — herpangina, hand-foot-mouth disease
• Herpes simplex types 1 & 2
• HIV — acute retroviral syndrome

Bacterial

• Group A β-hemolytic Streptococcus pyogenes (GABHS) — most common bacterial cause; responsible for scarlet fever; associated with rheumatic fever and post-streptococcal glomerulonephritis
• Non-group A β-hemolytic streptococci (groups B, C, G)
• Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus
• Mixed anaerobes — Vincent angina
• Neisseria gonorrhoeae
• Corynebacterium diphtheriae — diphtheria (grayish pseudomembrane)
• Arcanobacterium haemolyticum — scarlatiniform rash
• Mycoplasma pneumoniae, Chlamydia pneumoniae
• Mycobacterium tuberculosis (immunocompromised)

Fungal

• Candida spp. (usually immunocompromised)

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3. Pathogenesis

• Acute tonsillitis: Microorganisms colonize the tonsillar crypts → mucosal invasion → acute inflammatory response with hyperemia, edema, and exudate. GABHS produces streptolysin O/S, M-protein (antiphagocytic), pyrogenic exotoxins (scarlet fever), and spreads via respiratory droplets. The immune response leads to suppurative crypts, sometimes follicular exudate.
• Infectious mononucleosis: EBV infects B-lymphocytes via CD21 receptor → polyclonal B-cell activation → reactive atypical T-lymphocytosis → tonsillar and lymph node hypertrophy; oral transmission (hence "kissing disease").
• Chronic tonsillitis: Repeated infection leads to deep tonsillar crypts that accumulate debris (food particles, sloughed mucosa) → anaerobic bacterial overgrowth → tonsilliths (caseous/calcified material). Actinomyces colonization in crypts is a hallmark of chronic infection requiring surgery.

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4. Symptoms

Acute Tonsillitis — Viral

• Sore throat (mild to moderate), low-grade or no fever
• Rhinorrhea, nasal congestion, hoarseness, oral ulcers
• Pharyngeal erythema; no or minimal exudate
• Gradual onset

Acute Tonsillitis — GABHS Bacterial

• Severe sore throat, high fever (>38.3°C), rapid onset
• Dysphagia, odynophagia
• Headache, otalgia, nausea, abdominal pain (especially in children)
• Tonsillar hypertrophy with exudate; palatal petechiae
• Large, tender cervical lymphadenopathy
• Scarlatiniform rash, strawberry tongue (scarlet fever)

Acute Tonsillitis — EBV (Infectious Mononucleosis)

• High fever, profound malaise, headache
• Grayish-white or greenish tonsillar exudate (indistinguishable from GABHS)
• Palatal petechiae at hard-soft palate junction
• Massive, bilateral, tender cervical lymphadenopathy
• Hepatosplenomegaly
• Rash develops with amoxicillin/ampicillin (up to ~30%)

Chronic Tonsillitis

• Persistent or recurrent sore throat
• Halitosis (foul-smelling breath)
• Whitish/yellowish caseous debris emanating from tonsillar crypts (tonsilliths)
• Foul taste in mouth
• Mild dysphagia

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5. Diagnostics

Clinical Scoring

1. Tonsillar exudate
2. Tender anterior cervical adenopathy
3. History of fever (>38°C)
4. Absence of cough (+1 if age 3–14; −1 if age ≥45)

Laboratory Tests

Note: Antistreptolysin-O (ASO) titres are NOT recommended for diagnosing acute tonsillitis.

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6. Treatment

Acute Viral Tonsillitis

• Supportive: analgesics (NSAIDs, paracetamol), hydration, rest
• Antibiotics NOT indicated
• For EBV: avoid β-lactams (especially amoxicillin/ampicillin — risk of morbilliform rash); corticosteroids for significant tonsillar edema causing airway obstruction

Acute Bacterial Tonsillitis (GABHS)

• First-line: Penicillin V or amoxicillin (10-day course) — to prevent rheumatic fever and glomerulonephritis
• Penicillin allergy: Clindamycin, azithromycin, or first-generation cephalosporin
• Supportive: analgesics, antipyretics

Chronic Tonsillitis

• Frequent gargling with hydrogen peroxide mouthwash
• Manual expression of tonsilliths
• Long-term antibiotics (amoxicillin 500 mg TDS × 21 days or clindamycin 300 mg TDS × 21 days) — limited efficacy when Actinomyces is present

Surgical — Tonsillectomy Indications (Paradise/AAO-HNS criteria)

• ≥7 documented episodes of acute tonsillitis in 1 year, OR
• ≥5 episodes/year for 2 consecutive years, OR
• ≥3 episodes/year for 3 consecutive years
• Peritonsillar abscess
• Chronic tonsillitis with Actinomyces colonization (does not respond to antibiotics)
• Obstructive sleep apnea/tonsillar hypertrophy

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7. Differential Diagnosis

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8. Complications

Local

• Peritonsillar abscess (PTA): pus between tonsil capsule and superior pharyngeal constrictor — most common suppurative complication
• Parapharyngeal abscess (rupture through superior constrictor)
• Retropharyngeal abscess
• Airway obstruction (especially with EBV)
• Quincke disease: uvular edema associated with acute tonsillitis

Hematogenous/Spread

• Bacteremia, septicemia
• Endocarditis, thrombophlebitis
• Arterial involvement: thrombosis, hemorrhage, pseudoaneurysm
• Mediastinitis (descending necrotizing mediastinitis — rare, life-threatening)
• Brain abscess, meningitis
• Aspiration pneumonia

Immunological (GABHS-specific)

• Acute rheumatic fever (molecular mimicry — anti-M protein antibodies cross-react with cardiac tissue)
• Post-streptococcal glomerulonephritis
• PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections)
• PFAPA syndrome: Periodic Fever, Aphthous ulcers, Pharyngitis, Cervical Adenitis (episodes last ~3 days, recur every ~3 weeks)
• Scarlet fever

EBV-Specific Complications

• Splenic rupture
• Hematologic complications (thrombocytopenia, hemolytic anemia)
• CNS complications (encephalitis, Guillain-Barré)
• Cardiac complications (myocarditis)
• Chronic active EBV / post-transplant lymphoproliferative disease

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9. Prevention

Primary Prevention

• Avoid contact with infected individuals; respiratory hygiene (hand washing, covering coughs)
• Complete full antibiotic course for GABHS to prevent suppurative and non-suppurative complications (especially rheumatic fever)
• GABHS vaccination — currently in clinical trials (M-protein–based vaccines)

Secondary Prevention (Prevention of Complications)

• Prompt diagnosis and treatment of GABHS (within 9 days prevents rheumatic fever)
• Benzathine penicillin G prophylaxis after rheumatic fever to prevent recurrent GABHS and further cardiac damage
• Tonsillectomy in recurrent/chronic tonsillitis by Paradise criteria reduces subsequent episodes

Immunization

• Hib vaccine — prevents H. influenzae epiglottitis (reduces a common differential/complication)
• No routine vaccine exists specifically for GABHS pharyngitis

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Key Summary Table