Tonsillitis and Peritonsillar Abscess Follow-up

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

Further Inpatient Care

  • Discharge of patient from the hospital occurs after the patient and caregivers can demonstrate compliance with oral pain medication and antibiotics.
  • Home intravenous therapy under the supervision of qualified home health providers or the independent oral intake ability of patients ensures hydration.
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Further Outpatient Care

  • To confirm clinical improvement, follow-up care by telephone contact or physical examination may be useful in 2-4 weeks after the acute episode.
  • Follow-up throat swabs and cultures are usually not necessary, unless family or personal history of rheumatic fever exists, significant recurrent tonsillitis is evident, or family members continue to reinfect each other.
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Inpatient & Outpatient Medications

  • Order pain control, hydration, and antibiotics as discussed above for specific types of tonsillitis and associated complications.
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Transfer

  • Consider transfer of patient care when tonsillitis or its complications cannot be managed safely and expediently.
    • Ensure airway protection for transfer.
    • Ensure that appropriately trained personnel accompany the patient during transfer.
  • Children younger than 3 years may require transfer because of the special care needed during tonsillitis or its complications.
  • Patients with syndromic diagnoses (eg, trisomy 21) and patients with hematologic problems may benefit from transfer to facilities that have the availability of subspecialist care.
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Deterrence/Prevention

  • Avoidance of contact with individuals who are ill or patients who are immunocompromised is useful.
  • The use of the antipneumococcal vaccine may help to prevent acute tonsillitis; however, to date, experience is insufficient to determine whether prevention is likely to occur.
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Complications

  • Acute tonsillitis: Untreated or incompletely treated tonsillitis can lead to potentially life-threatening complications.
    • Acute oropharyngeal infections can spread distally to the deep neck spaces and then into the mediastinum. Such complications may require thoracotomy and cervical exposure for drainage. Spread beyond the pharynx is suspected in persons with symptoms of tonsillitis who also have high or spiking fevers, lethargy, torticollis, trismus, or shortness of breath. Radiologic imaging using plain films of the lateral neck or CT scans with contrast is warranted for patients in whom deep neck spread of acute tonsillitis (beyond the fascial planes of the oropharynx) is suspected.
    • The most common complication is adjacent spread just beyond the tonsillar capsule. Peritonsillar cellulitis develops when inflammation spreads beyond the lymphoid tissue of the tonsil to involve the oropharyngeal mucosa. Peritonsillar abscess (PTA), historically referred to as quinsy, is caused by purulence trapped between the tonsillar capsule and the lateral pharyngeal wall; the superior constrictor muscle primarily comprises the lateral pharyngal wall in this area.
    • Rarely, acute pharyngotonsillitis may lead to thrombophlebitis of the internal jugular vein (Lemierre syndrome). The usual cause of this condition is Fusobacterium necrophorum. A patient who appears toxic following tonsillitis presents with spiking fevers and unilateral neck fullness and tenderness. CT scanning with contrast is necessary to help make the diagnosis. A prolonged course of IV antibiotics and treatment of the source of infection (eg, an abscess) are required. Anticoagulation is controversial. Ligation or excision of the internal jugular vein is required after multiple septic emboli become evident.
  • Peritonsillar abscess
    • Peritonsillar abscess (PTA) may spread to the deep neck tissues; most often, peritonsillar abscess (PTA) spreads into the retropharyngeal space or into the parapharyngeal space. Spread may result in necrotizing fasciitis.
    • Treatment includes IV antibiotics, surgical debridement, and, in cases of associated toxic shock syndrome, possibly IV immunoglobulins. Distal abscess spread can be life threatening.
  • Complications specific to GABHS pharyngitis are scarlet fever, rheumatic fever, septic arthritis, and glomerulonephritis.
    • Scarlet fever manifests as a generalized, nonpruritic, macular erythematous rash that is worse on the extremities and spares the face. The classic strawberry tongue is bright red and tender because of papillary desquamation. The rash lasts up to 1 week and is accompanied by fever and arthralgias.
    • Individuals at risk for this rash are those who do not have antitoxin antibodies to the exotoxin produced by GABHS.
    • Acute poststreptococcal glomerulonephritis (AGN) occurs in 10-15% of pharyngitis cases that are caused by the type-12 serotype. AGN follows GABHS by 1-2 weeks. Urinalysis to detect excreted protein may allow detection of subclinical renal injury for persons with recurrent tonsillitis.
    • Rheumatic fever follows acute pharyngitis by 2-4 weeks and was observed in up to 3% of streptococcal pharyngitides in the mid-20th century. Today, far fewer persons experience this complication, largely because of appropriate antibiotic therapy. Cardiac valvular vegetations affect the mitral and tricuspid valves, leading to murmurs, persistent relapsing fevers, and valvular stenosis or incompetence. A throat swab does not identify the causative organism because a positive result may reflect colonization rather than pathogenicity. Elevated or rising titers of antistreptolysin (ASO) antibodies, anti-DNAse beta, or antihyaluronidase are required to make the diagnosis.
    • Septic arthritis results in a painful hot joint that contains fluid with bacteria. Arthrocentesis is diagnostic and partially therapeutic. Treatment with IV antibiotics for 6 weeks is required to prevent long-term joint complications.
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Patient Education

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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

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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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