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Am Fam Physician. 2023;107(1):35-41

Related letter to the editor: Removal of Stones and Food for Relief of Pain and Recurrence of Tonsillitis

Patient information: See related handouts on tonsillitis (strep throat) and tonsil stones.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States. Tonsillitis is caused by a viral infection in 70% to 95% of cases. However, bacterial infections caused by group A beta-hemolytic streptococcus (Streptococcus pyogenes) account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age. It is important to differentiate group A beta-hemolytic streptococcus from other bacterial or viral causes of pharyngitis and tonsillitis because of the risk of progression to more systemic complications such as abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever after infection with group A beta-hemolytic streptococcus. A variety of diagnostic tools are available, including symptom-based validated scoring systems (e.g., Centor score), and oropharyngeal and serum laboratory testing. Treatment is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic. In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years. Tonsilloliths, or tonsil stones, are managed expectantly, and small tonsilloliths are common clinical findings. Rarely, surgical intervention is required if they become too large to pass on their own.

Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States and is usually caused by a viral infection.13 Transmission occurs via droplets from patients with acute tonsillitis or rarely by asymptomatic carriers.3 Tonsilloliths, or tonsil stones, may be a result of recurrent tonsillitis, although the exact cause is unclear.

Tonsillitis

The tonsils are located in the lateral oropharynx between the anterior palatoglossal arch and the posterior palatopharyngeal arch. Tonsillitis is caused by a viral infection in 70% to 95% of cases.2,3 The most common viral causes include rhinovirus, respiratory syncytial virus, adenovirus, and coronavirus. Less common causes include Epstein-Barr virus, cytomegalovirus, hepatitis A, and rubella. Bacterial infections caused by group A beta-hemolytic streptococcus (GABHS) account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age. Viral etiologies are more common in children younger than five years, and GABHS is rare in children younger than two years.2

Tonsillitis is less commonly caused by other bacteria such as groups C and G streptococci, Hemophilus influenzae, Nocardia, and Corynebacteriaceae.3 Syphilis, gonorrhea, chlamydia, and HIV should be considered in sexually active patients. Tuberculosis can cause recurrent tonsillitis.2 Only one-half to two-thirds of patients with tonsillitis have a detectable pathogen.3

CLINICAL MANIFESTATIONS

Acute tonsillitis is an inflammatory process of the tonsillar tissues. It may occur in isolation or as part of a generalized pharyngitis.4 The most common symptoms are fever, tonsillar exudate, sore throat, and tender anterior cervical lymphadenopathy5 (Figure 16). Other symptoms include odynophagia and dysphagia, particularly if tonsillar swelling is present. On physical examination, the tonsils may appear enlarged or erythematous, decreasing visualization of the posterior oropharynx. Tonsillar exudate can appear yellow or white.2 Data have shown that palatal petechiae are associated with GABHS pharyngitis and tonsillitis and are possibly more predictive than the presence of tonsillar exudate.7

DIAGNOSIS

The differential diagnosis of tonsillitis includes pharyngitis, retropharyngeal abscess, epiglottitis, peritonsillar abscess, and submandibular space infections (Ludwig angina).2 It is important to differentiate GABHS pharyngitis and tonsillitis from other bacterial and viral causes due to the risk of complications with GABHS.4 Physical examination of the oropharynx alone is not sufficient for this differentiation; therefore, a clinical scoring scale, such as the widely used Centor score (Table 18,9), is recommended to guide diagnosis and treatment of GABHS oropharyngeal infections.

SymptomsPoints
Tonsillar exudate or swelling1
Swollen, tender anterior cervical lymph nodes1
Lack of cough1
Fever1
Total:__________

The Centor score was developed in 1981 based on a study of 286 adults from a single emergency department.8,10 A second clinical scoring system, the McIsaac score/modified Centor score (https://www.mdcalc.com/centor-score-modified-mcisaac-strep-pharyngitis) was developed in 1998 based on 621 children and adults from 49 Ontario, Canada, communities.8 This score adds an adjustment for the patient's age because GABHS infections are more prevalent in younger patients. Because the initial sample sizes supporting these scores were small, both scoring systems underwent large-scale validation.8 A meta-analysis comparing the two scoring systems in a primary care setting found that they were similar in performance.9

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