Tonsillitis and Peritonsillar Abscess Clinical Presentation

  • Author: Udayan K Shah, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Aug 19, 2011
 

History

The patient's history determines the type of tonsillitis (ie, acute, recurrent, chronic) that is present.

  • Acute tonsillitis
    • Individuals with acute tonsillitis present with fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes.
    • Airway obstruction may manifest as mouth breathing, snoring, sleep disordered breathing, nocturnal breathing pauses, or sleep apnea.
    • Lethargy and malaise are common.
    • Symptoms usually resolve in 3-4 days but may last up to 2 weeks despite adequate therapy.
  • Recurrent streptococcal tonsillitis is diagnosed when an individual has 7 culture-proven episodes in 1 year, 5 infections in 2 consecutive years, or 3 infections each year for 3 years consecutively.
  • Individuals with chronic tonsillitis may present with chronic sore throat, halitosis, tonsillitis, and persistent tender cervical nodes.
  • Children are most susceptible to infection by those in the carrier state.
  • Individuals with peritonsillar abscess (PTA) present with severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and altered voice quality (the "hot potato" voice).
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Physical

Physical examination should begin by determining the degree of distress regarding airway and swallowing function. Examination of the pharynx may be facilitated by opening the mouth without tongue protrusion, followed by gentle central depression of the tongue. Full assessment of oral mucosa, dentition, and salivary ducts may then be performed by gently "walking" a tongue depressor about the lateral oral cavity. Flexible fiberoptic nasopharyngoscopy may be useful in selected cases, particularly with severe trismus. The images below depict the oral examination.

Examination of the tonsils and pharynx. Examination of the tonsils and pharynx. Oral mucosal examination. Oral mucosal examination.

Physical examination in acute tonsillitis reveals fever and enlarged inflamed tonsils that may have exudates as seen in the image below.

Acute bacterial tonsillitis is shown. The tonsils Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with exudates. The uvula is midline.

Group A beta-hemolytic Streptococcus pyogenes and Epstein-Barr virus (EBV) can cause tonsillitis that may be associated with the presence of palatal petechiae. Group A beta-hemolytic Streptococcus (GABHS) pharyngitis usually occurs in children aged 5-15 years.

Open-mouth breathing and voice change (ie, a thicker or deeper voice) result from obstructive tonsillar enlargement.

  • The voice change with acute tonsillitis is usually not as severe as that associated with peritonsillar abscess (PTA).
  • In peritonsillar abscess (PTA), the pharyngeal edema and trismus cause a hot potato voice.

Tender cervical lymph nodes and neck stiffness are observed in acute tonsillitis.

Examine skin and mucosa for signs of dehydration.

Consider infectious mononucleosis (MN) due to EBV in an adolescent or younger child with acute tonsillitis, particularly when tender cervical, axillary, and/or inguinal nodes; splenomegaly; severe lethargy and malaise; and low-grade fever accompany acute tonsillitis.

  • A gray membrane may cover tonsils that are inflamed from an EBV infection as seen in the image below. This membrane can be removed without bleeding. Tonsillitis caused by Epstein-Barr infection (infeTonsillitis caused by Epstein-Barr infection (infectious mononucleosis). The enlarged inflamed tonsils are covered with gray-white patches.
  • Palatal mucosal erosions and mucosal petechiae of the hard palate may be observed.

An individual with herpes simplex virus (HSV) pharyngitis presents with red, swollen tonsils that may have aphthous ulcers on their surfaces. Herpetic gingival stomatitis, herpes labialis, and hypopharyngeal and epiglottic lesions may be observed.

Physical examination of a peritonsillar abscess (PTA) almost always reveals unilateral bulging above and lateral to one of the tonsils. Trismus is always present in varying severity. The abscess rarely is located adjacent to the inferior pole of the tonsil.

  • Inferior pole peritonsillar abscess (PTA) is a difficult diagnosis to make, and radiologic imaging with a contrast-enhanced CT scan is helpful.
  • Tender cervical adenopathy and torticollis (neck turned in the cock-robin position) may be present.
  • Ipsilateral otalgia may be observed.
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Causes

  • Most episodes of acute pharyngitis and acute tonsillitis are caused by viruses such as the following:
    • HSV
    • EBV
    • Cytomegalovirus
    • Other herpes viruses
    • Adenovirus
    • Measles virus
  • One study showing that EBV may cause tonsillitis in the absence of systemic mononucleosis found EBV to be responsible for 19% of exudative tonsillitis in children.
  • Bacteria cause 15-30% of pharyngotonsillitis cases. Anaerobic bacteria play an important role in tonsillar disease.
    • GABHS causes most bacterial tonsillitis.
    • S pyogenes adheres to adhesin receptors that are located on the tonsillar epithelium.
    • Immunoglobulin coating of pathogens may be important in the initial induction of bacterial tonsillitis.
  • Organisms such as Mycoplasma pneumoniae, Corynebacterium diphtheriae, and Chlamydia pneumoniae rarely cause acute pharyngitis.
  • Arcanobacterium haemolyticum is an important cause of pharyngitis in Scandinavia and the United Kingdom but is not recognized as such in the United States. A rash similar to that of scarlet fever accompanies A haemolyticum pharyngitis.
  • Neisseria gonorrhea may cause pharyngitis in sexually active persons.
  • A polymicrobial flora consisting of both aerobic and anaerobic bacteria is observed in core tonsillar cultures from cases of recurrent pharyngitis.
    • Children with recurrent GABHS tonsillitis have different bacterial populations than do children who have not had as many infections. Other competing bacteria are reduced, offering less interference to GABHS infection.
    • Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae are the most common bacteria isolated in recurrent tonsillitis.
    • Bacteroides fragilis is the most common anaerobic bacterium isolated in recurrent tonsillitis.
    • The microbiology of recurrent tonsillitis in children and adults is different: adults show more bacterial isolates, with a higher recovery rate of Prevotella species, Porphyromonas species, and B fragilis organisms , while children show more GABHS. Also, adults more often have bacteria that produce beta-lactamase.
  • A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species identified.
    • One study, based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy, suggests that antibiotics prescribed 6 months before surgery do not alter the tonsillar bacteriology at the time of tonsillectomy.[8]
    • A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes.
    • H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids.
    • With regard to penicillin resistance or beta-lactamase production, the microbiology of tonsils removed from patients with recurrent GABHS pharyngitis is not significantly different from the microbiology of tonsils removed from patients with tonsillar hypertrophy.
  • Local immunological mechanisms are important in chronic tonsillitis.
    • The distribution of dendritic cells and antigen-presenting cells is altered during disease, with fewer dendritic cells on the surface epithelium and more in the crypts and extrafollicular areas.
    • Study of immunologic markers may permit differentiation between recurrent and chronic tonsillitis. Such markers in 1 study indicated that children more often experience recurrent tonsillitis, while adults requiring tonsillectomy more often experience chronic tonsillitis.[9]
  • A polymicrobial flora is isolated from peritonsillar abscesses. Predominant organisms are the anaerobes Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species; major aerobic organisms are GABHS, S aureus, and H influenzae.
  • Radiation exposure may relate to the development of chronic tonsillitis. A high prevalence of chronic tonsillitis was noted following the Chernobyl nuclear reactor accident in the former Soviet Union.
  • Overcrowded conditions and malnourishment promote tonsillitis.
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Contributor Information and Disclosures
Author

Udayan K Shah, MD  Associate Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Jefferson Medical College, Thomas Jefferson University; Director, Fellow and Resident Education in Pediatric Otolaryngology, Attending Surgeon, Division of Otolaryngology, Nemours-AI duPont Hospital for Children

Udayan K Shah, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Society of Pediatric Otolaryngology, International Society for Optical Engineering, Pennsylvania Medical Society, Phi Beta Kappa, and Society for Ear, Nose and Throat Advances in Children

Disclosure: Gyrus-ACMI Royalty Device development; Reiseman, Rosenberg LLC Consulting fee medico-legal case review

Specialty Editor Board

Ari J Goldsmith, MD  Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center

Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory C Allen, MD  Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

  1. Morens DM. Death of a president. N Engl J Med. Dec 9 1999;341(24):1845-9. [Medline].

  2. Kean J. Domestic Medical Lectures. Chicago, Ill: 1879.

  3. Pichichero ME, Casey JR. Defining and dealing with carriers of group A Streptococci. Contemporary Pediatrics. 2003;1:46.

  4. Wald ER. Commentary: Antibiotic treatment of pharyngitis. Pediatrics in Review. 2001;22 (8):255-256.

  5. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. Aug 1995;105(8 Pt 3 Suppl 74):1-17. [Medline].

  6. Kvestad E, Kvaerner KJ, Roysamb E, Tambs K, Harris JR, Magnus P. Heritability of recurrent tonsillitis. Arch Otolaryngol Head Neck Surg. May 2005;131(5):383-7. [Medline].

  7. Schmidt RJ, Herzog A, Cook S, O'Reilly R, Deutsch E, Reilly J. Complications of tonsillectomy. Arch Otolaryngol Head and Neck Surg. 2007;133:925-928.

  8. Woolford TJ, Hanif J, Washband S, Hari CK, Ganguli LA. The effect of previous antibiotic therapy on the bacteriology of the tonsils in children. Int J Clin Pract. Mar 1999;53(2):96-8. [Medline].

  9. Bussi M, Carlevato MT, Panizzut B, Omede P, Cortesina G. Are recurrent and chronic tonsillitis different entities? An immunological study with specific markers of inflammatory stages. Acta Otolaryngol Suppl. 1996;523:112-4. [Medline].

  10. Shah, Udayan K. Peritonsillar and Retropharyngeal Abscess. In: Shah, Samir S. Pediatric Pracice: Infectious Diseases. China: McGraw-Hill; 2009:Chapter 25, pp. 216-22.

  11. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America. Clin Infect Dis. Sep 1997;25(3):574-83. [Medline].

  12. [Guideline] Chiappini E, Regoli M, Bonsignori F, Sollai S, Parretti A, Galli L, et al. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther. Jan 2011;33(1):48-58. [Medline].

  13. [Guideline] Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. Jan 2011;144(1 Suppl):S1-30. [Medline].

  14. Sivaji N, Arshad FA, Karkos PD. A novel method of draining a peritonsillar abscess. Clin Otolaryngol. Apr 2011;36(2):189-90. [Medline].

  15. Shah, Udayan K. Tonsillectomy & Adenoidectomy: Techniques and Technologies. Madison WI. 2008: Omnipress, Inc. ISBN 978-0-615-23355-0.; 2008.

  16. Adam D, Scholz H, Helmerking M. Comparison of short-course (5 day) cefuroxime axetil with a standard 10 day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrob Chemother. Feb 2000;45 Suppl:23-30. [Medline].

  17. Agren K, Lindberg K, Samulesson A, Blomberg S, Forsgren J, Rynnel-Dagoo B. What is wrong in chronic adenoiditis/tonsillitis immunological factor. Int J Pediatr Otorhinolaryngol. Oct 5 1999;49 Suppl 1:S137-9. [Medline].

  18. Berkovitch M, Vaida A, Zhovtis D, Bar-Yohai A, Earon Y, Boldur I. Group A streptococcal pharyngotonsillitis in children less than 2 years of age--more common than is thought. Clin Pediatr (Phila). Jun 1999;38(6):361-3. [Medline].

  19. Bisno AL. Acute pharyngitis. N Engl J Med. Jan 18 2001;344(3):205-11. [Medline].

  20. Brodsky L. Tonsillitis, tonsillectomy and adenoidectomy. In: Bailey B, Johnson JT, Kohut RI, Pillsbury HC, Tardy ME Jr, eds. Head and Neck surgery-Otolaryngology. Vol 1. Philadelphia, Pa: Lippincott Williams & Wilkins; 1993:833-47.

  21. Brodsky L, Moore L, Stanievich J. The role of Haemophilus influenzae in the pathogenesis of tonsillar hypertrophy in children. Laryngoscope. Oct 1988;98(10):1055-60. [Medline].

  22. Brook I. The role of anaerobic bacteria in tonsillitis. Int J Pediatr Otorhinolaryngol. Jan 2005;69(1):9-19. [Medline].

  23. Brook I, Gober AE. Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis. Arch Otolaryngol Head Neck Surg. May 1999;125(5):552-4. [Medline].

  24. Brook I, Yocum P, Foote PA Jr. Changes in the core tonsillar bacteriology of recurrent tonsillitis: 1977-1993. Clin Infect Dis. Jul 1995;21(1):171-6. [Medline].

  25. Cannon CR, Chambers A. Peritonsillar abscess (PTA) in children. J Miss State Med Assoc. Mar 1999;40(3):78-80. [Medline].

  26. Casselbrant ML. What is wrong in chronic adenoiditis/tonsillitis anatomical considerations. Int J Pediatr Otorhinolaryngol. Oct 5 1999;49 Suppl 1:S133-5. [Medline].

  27. Cohen JI. Epstein-Barr virus infection. N Engl J Med. Aug 17 2000;343(7):481-92. [Medline].

  28. Curtin JM. The history of tonsil and adenoid surgery. Otolaryngol Clin North Am. May 1987;20(2):415-9. [Medline].

  29. Dhawan B, Chaudhry R, Pandey A, Nisar N, Singh M. Anaerobic septicaemia by Fusobacterium necrophorum: Lemierre's syndrome. Indian J Pediatr. May-Jun 1998;65(3):469-72. [Medline].

  30. Gerber MA. Streptococcal infections: Group A B-hemolytic streptococci. In: Rudolph AM, Hoffman JIE, Rudolph CD, eds. Rudolph's Pediatrics. 20th ed. Stamford, Conn: Appleton & Lange; 604-9.

  31. Handler SD, Myer CM III. Atlas of Ear, Nose and Throat Disorders in Children. Hamilton, Ontario: BC Decker; 1998:91.

  32. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med. Mar 30 2000;342(13):938-45. [Medline].

  33. Kvestad E, Kvaerner KJ, Roysamb E, Tambs K, Harris JR, Magnus P. Heritability of recurrent tonsillitis. Arch Otolaryngol Head Neck Surg. May 2005;131(5):383-7. [Medline].

  34. Lan AJ, Colford JM, Colford JM Jr. The impact of dosing frequency on the efficacy of 10-day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis. Pediatrics. Feb 2000;105(2):E19. [Medline].

  35. Lascaratos J, Assimakopoulos D. Surgery on the larynx and pharynx in Byzantium (AD 324-1453): early scientific descriptions of these operations. Otolaryngol Head Neck Surg. Apr 2000;122(4):579-83. [Medline].

  36. Licameli GR, Grillone GA. Inferior pole peritonsillar abscess. Otolaryngol Head Neck Surg. Jan 1998;118(1):95-9. [Medline].

  37. Lilja M, Silvola J, Bye HM, Raisanen S, Stenfors LE. SIgA- and IgG-coated Streptococcus pyogenes on the tonsillar surfaces during acute tonsillitis. Acta Otolaryngol. 1999;119(6):718-23. [Medline].

  38. Lomat L, Galburt G, Quastel MR, Polyakov S, Okeanov A, Rozin S. Incidence of childhood disease in Belarus associated with the Chernobyl accident. Environ Health Perspect. Dec 1997;105 Suppl 6:1529-32. [Medline].

  39. Lopez-Gonzalez MA, Lucas M, Mata F, Delgado F. Microalbuminuria as renal marker in recurrent acute tonsillitis and tonsillar hypertrophy in children. Int J Pediatr Otorhinolaryngol. Oct 25 1999;50(2):119-24. [Medline].

  40. Manecke GR Jr, Marghoob S, Finzel KC, Madoff DC, Quijano IH, Poppers PJ. Catastrophic caudad spread of a peritonsillar abscess: a case report. Anesthesiology. Dec 1999;91(6):1956-8. [Medline].

  41. Martin JM, Green M, Barbadora KA, Wald ER. Group A streptococci among school-aged children: clinical characteristics and the carrier state. Pediatrics. Nov 2004;114(5):1212-9. [Medline].

  42. Nord CE. The role of anaerobic bacteria in recurrent episodes of sinusitis and tonsillitis. Clin Infect Dis. Jun 1995;20(6):1512-24. [Medline].

  43. Puchalski R, Shah UK. Plasma-mediated ablation for the management of obstructive sleep apnea. In: Anderson R, et al, eds. Lasers in Surgery: Advanced Characterization, Therapeutics, and Systems X. Proceedings of SPIE. Vol 3907. 2000:317-20.

  44. Raut VV, Yung MW. Peritonsillar abscess: the rationale for interval tonsillectomy. Ear Nose Throat J. Mar 2000;79(3):206-9. [Medline].

  45. Roberson DW, Kirse DJ. Infectious and inflammatory disorders of the neck. In: Wetmore RF, Muntz HR, McGill TJ. Pediatric Otolaryngology: Principles and Practical Pathways. New York, NY: Thieme; 2000:969-991.

  46. Robinson AC, Hanif J, Dumbreck LA, Prichard AJ, Manners BT. Throat swabs in chronic tonsillitis: a time-honoured practice best forgotten. Br J Clin Pract. Apr-May 1997;51(3):138-9. [Medline].

  47. Sancho LM, Minamoto H, Fernandez A, Sennes LU, Jatene FB. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg. Aug 1999;16(2):200-5. [Medline].

  48. Shah UK, Tufano RP, Handler SD. Post-tonsillectomy observation and admission: Annual Meeting of the American Academy of Pediatrics. In: an American Society of Pediatric Otolaryngology (ASPO) member survey. Paper presented at: Washington, DC; 1999.

  49. Skitarelic N, Mladina R, Matulic Z, Kovacic M. Necrotizing fasciitis after peritonsillar abscess in an immunocompetent patient. J Laryngol Otol. Aug 1999;113(8):759-61. [Medline].

  50. Smitheringdale AJ. Acquired diseases of the oral cavity and pharynx. In: Wetmore RF, Muntz HR, McGill TJ. Pediatric Otolaryngology: Principles and Practical Pathways. New York, NY: Thieme; 2000:606-18.

  51. Stjernquist-Desatnik A, Holst E. Tonsillar microbial flora: comparison of recurrent tonsillitis and normal tonsils. Acta Otolaryngol. Jan 1999;119(1):102-6. [Medline].

  52. Suskind DL, Park J, Piccirillo JF, Lusk RP, Muntz HR. Conscious sedation: a new approach for peritonsillar abscess drainage in the pediatric population. Arch Otolaryngol Head Neck Surg. Nov 1999;125(11):1197-200. [Medline].

  53. Suzuki M, Ueyama T, Mogi G. Immediate tonsillectomy for peritonsillar abscess. Auris Nasus Larynx. Jul 1999;26(3):299-304. [Medline].

  54. Wolf M, Kronenberg J, Kessler A, Modan M, Leventon G. Peritonsillar abscess in children and its indication for tonsillectomy. Int J Pediatr Otorhinolaryngol. Nov 1988;16(2):113-7. [Medline].

  55. Yoda K, Sata T, Kurata T, Aramaki H. Oropharyngotonsillitis associated with nonprimary Epstein-Barr virus infection. Arch Otolaryngol Head Neck Surg. Feb 2000;126(2):185-93. [Medline].

 
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Acute bacterial tonsillitis is shown. The tonsils are enlarged and inflamed with exudates. The uvula is midline.
Tonsillitis caused by Epstein-Barr infection (infectious mononucleosis). The enlarged inflamed tonsils are covered with gray-white patches.
Examination of the tonsils and pharynx.
Oral mucosal examination.
 
 
 
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