Tonsillitis notes based on Dingra
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I now have comprehensive content. Let me compile complete notes based on the ENT textbooks (KJ Lee's and Cummings, which are the standard references aligned with Dhingra's content). Note: Dhingra's own textbook isn't in the library, but KJ Lee's Essential Otolaryngology and Cummings Otolaryngology cover identical clinical content for tonsillitis.
Tonsillitis — Notes Based on ENT Textbooks (KJ Lee / Cummings)
Note: Dhingra's Diseases of Ear, Nose & Throat is not available in the library. These notes are drawn from KJ Lee's Essential Otolaryngology and Cummings Otolaryngology Head & Neck Surgery, which cover the same ENT content at an equivalent or greater depth.
1. Anatomy of the Tonsils (Waldeyer's Ring)
- Palatine tonsils — the "tonsils" of clinical relevance; located in the tonsillar fossa between the anterior (palatoglossal) and posterior (palatopharyngeal) pillars
- Adenoids (pharyngeal tonsil) — on the roof/posterior wall of nasopharynx
- Lingual tonsil — base of tongue
- Tubal tonsils — near eustachian tube orifices
- Together they form Waldeyer's lymphatic ring, guarding the aerodigestive tract entry
2. Etiology of Tonsillitis
Viral (majority of cases)
| Virus | Features |
|---|---|
| Adenovirus | Pharyngoconjunctival fever |
| Rhinovirus | Most common cold cause |
| Coxsackie A | Herpangina (vesicular ulcers on soft palate/anterior pillar), hand-foot-mouth disease |
| Epstein-Barr Virus (EBV) | Infectious mononucleosis |
| Cytomegalovirus (CMV) | CMV mononucleosis |
| Herpes simplex 1 & 2 | Pharyngitis, gingivostomatitis |
| Parainfluenza | Croup |
| Influenza A, B | Widespread outbreaks |
| RSV | Children |
| HIV | Acute retroviral syndrome |
Bacterial
| Organism | Condition |
|---|---|
| Group A β-hemolytic Streptococcus pyogenes (GABHS) | Most common bacterial cause; tonsillitis, scarlet fever |
| Groups B, C, G Streptococcus | Pharyngitis/tonsillitis |
| Streptococcus viridans | Tonsillitis |
| Staphylococcus aureus | Tonsillitis (often beta-lactamase producing) |
| Haemophilus influenzae | Tonsillitis |
| Streptococcus pneumoniae | Tonsillitis |
| Mixed anaerobes | Vincent's angina |
| Neisseria gonorrhoeae | Pharyngitis/tonsillitis |
| Corynebacterium diphtheriae | Diphtheria (grey pseudomembrane) |
| Mycoplasma pneumoniae | Pharyngitis, pneumonia |
| Treponema pallidum | Secondary syphilis |
Adult tonsils show mixed infections; ¾ of patients have beta-lactamase-producing organisms
- KJ Lee's Essential Otolaryngology
Fungal
- Candida spp. — typically in immunocompromised patients
3. Acute Tonsillitis
Types
- Acute catarrhal/superficial tonsillitis — mucosal involvement only; viral, tonsils red and congested
- Acute follicular tonsillitis — crypts filled with purulent material (yellowish spots)
- Acute parenchymatous tonsillitis — whole tonsil substance involved; tonsils uniformly enlarged and red
- Acute membranous tonsillitis — membrane of fibrin forms over the tonsil (must distinguish from diphtheria)
Clinical Features — Viral vs. Bacterial
| Feature | Viral | Infectious Mononucleosis (EBV) | Group A Strep (GABHS) | Diphtheria |
|---|---|---|---|---|
| Population | Any age | Older children/adolescents | Peak 5–6 years | Unimmunized |
| Onset | Slow | Variable | Rapid | Rapid |
| Fever | None/low-grade | High | High | High |
| Sore throat | Mild–moderate | Moderate–severe | Severe | Severe |
| Exudate | Absent | Grey-white exudate | Tonsillar exudate | Thick membranous exudate |
| Cervical nodes | Minimal | Large, tender | Large, tender | — |
| Rhinorrhea, hoarseness | Yes | No | No | No |
| Special signs | Oral ulcers | Petechiae at hard-soft palate junction; hepatosplenomegaly; rash with amoxicillin | Palatal petechiae; strawberry tongue; scarlatiniform rash | Airway obstruction; cardiac toxicity |
| Diagnosis | None | Monospot; EBV serology; CBC | Rapid Strep (RADT); throat culture | Culture on tellurite media |
| Treatment | Supportive | Supportive; NSAIDs; steroids for airway | Penicillin/amoxicillin | Antitoxin + Penicillin G |
4. Diagnosis
For Bacterial (GABHS) Tonsillitis
- Sore throat plus one or more of:
- Tonsillar exudate
- Cervical adenopathy
- Fever > 38.3°C
- Positive RADT or throat culture
- RADT (Rapid Antigen Detection Test): if negative, perform throat culture
- ASO titres — NOT recommended for acute diagnosis; only indicate prior infection
For EBV Mononucleosis
- CBC: ≥50% lymphocytes, ≥10% atypical lymphocytes
- ESR more likely elevated in EBV than bacterial infection
- Monospot (heterophile antibody test): 85% sensitive (less sensitive in first 2 weeks), 100% specific
- If initial test negative → repeat weekly for 6 weeks
- EBV serology: use if monospot still negative after 6 weeks
5. Treatment
Viral Tonsillitis
- Supportive: analgesics (paracetamol/NSAIDs), adequate hydration, rest
- No antibiotics indicated
EBV Mononucleosis
- NSAIDs for pain control
- Avoid amoxicillin/ampicillin — precipitates a morbilliform rash in ~30%
- Corticosteroids for mild airway obstruction; nasopharyngeal airway for severe obstruction
- Rarely: tonsillectomy/intubation/tracheotomy for critical airway
- Contact sports restricted while splenomegaly persists (risk of splenic rupture)
Bacterial (GABHS) Tonsillitis
- First line: 10-day course of penicillin V or amoxicillin
- Penicillin allergy: first-generation cephalosporin, clindamycin, clarithromycin, or azithromycin
- Analgesics: paracetamol/NSAIDs; avoid aspirin (Reye's syndrome in children)
- Steroids not routinely indicated
- Penicillin failure rate: 7–37% (due to beta-lactamase producing co-pathogens, poor tissue penetration); in these cases use cephalosporins, clindamycin, or amoxicillin-clavulanate
6. Chronic Tonsillitis
- Persistent infection of tonsillar tissue between acute attacks
- Features: persistent or recurrent sore throats, halitosis, tonsillar hypertrophy or scarring, expressed pus from crypts (caseous debris), persistent cervical lymphadenopathy
- Organisms: often mixed flora including anaerobes and beta-lactamase producers
7. Complications of Tonsillitis
Suppurative (Local)
| Complication | Notes |
|---|---|
| Peritonsillar abscess (Quinsy) | Most common complication; pus in space between tonsil capsule and superior constrictor; presents with trismus, "hot potato" voice, uvular deviation to contralateral side |
| Parapharyngeal abscess | Spread from peritonsillar space through superior constrictor |
| Retropharyngeal abscess | Particularly in children |
| Otitis media | Via eustachian tube involvement |
| Cervical lymphadenitis | Suppurative lymph node involvement |
Non-Suppurative (Distant/Systemic)
| Complication | Notes |
|---|---|
| Acute Rheumatic Fever | Follows GABHS pharyngitis; polyarthritis, carditis (mitral valve most common), Sydenham chorea, erythema marginatum, subcutaneous nodules. Rate: <4/100,000 in non-endemic countries. Penicillin prophylaxis mandatory |
| Poststreptococcal Glomerulonephritis | 1–2 weeks after GABHS infection; acute nephritic syndrome; mechanism = molecular mimicry (shared antigen). Antibiotics do NOT reduce attack rate |
| PANDAS | Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; OCD and/or tic disorders, onset between 3 years and puberty, abrupt episodic course |
| Scarlet fever | Erythrogenic toxin from GABHS; scarlatiniform rash, strawberry tongue |
8. PFAPA Syndrome
- Periodic Fever, Aphthous ulcers, Pharyngitis, Adenitis
- May be caused by periodic GABHS infection
- Pattern: each episode lasts ~3 days, ≥3 episodes, recurs every ~3 weeks, with symptom-free intervals
- Must rule out cyclical neutropenia
- Treatment: tonsillectomy may be considered for severe pharyngitis symptoms
9. Indications for Tonsillectomy (Paradise Criteria)
| Parameter | Threshold |
|---|---|
| Frequency | ≥7 episodes in 1 year, OR ≥5/year × 2 years, OR ≥3/year × 3 years |
| Each episode must include: | Sore throat with fever >38.3°C, cervical lymphadenopathy, tonsillar exudate, or positive GABHS test |
| Other indications | Peritonsillar abscess; OSA/airway obstruction; dysphagia; suspicion of malignancy (unilateral enlargement); diphtheria carrier; febrile seizures from recurrent tonsillitis; PFAPA with severe symptoms |
Morbidity of tonsillectomy:
- Postoperative hemorrhage: 2–4% (primary within 24h, secondary at 5–10 days)
- Mortality: 1 in 25,000 (hemorrhage, airway obstruction, anesthesia)
10. Tonsillitis vs. Peritonsillar Abscess — Key Differences
| Feature | Tonsillitis | Peritonsillar Abscess |
|---|---|---|
| Trismus | Absent | Present (best indicator) |
| Voice | Normal/muffled | Hot potato voice |
| Uvula | Midline | Deviated to opposite side |
| Tonsil | Bilaterally enlarged | Unilateral bulge of soft palate |
| Treatment | Antibiotics | Needle aspiration / Incision & drainage + antibiotics |
Sources: KJ Lee's Essential Otolaryngology, 11th ed. | Cummings Otolaryngology Head and Neck Surgery, 7th ed.
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