114 Tonsil Disease

Most cases of acute tonsillitis are due to a viral

aetiology, but some patients will develop a
114.3 Clinical Features
secondary bacterial infection and others will There may be a prodromal illness with pyrexia,
have a primary bacterial pharyngotonsillitis. GPs malaise and headache for a day before the onset of
can determine which patients should be given the predominant symptom, a sore throat. Pain may
antibiotics by using the Centor criteria. Patients radiate to the ears and suggest acute otitis media
with significantly enlarged tonsils should be con- until the ears are examined (referred otalgia) and
sidered for a 2- to 5-day course of intravenous (IV) there may be tender cervical lymphadenopathy.
steroids to reduce the risk of airway compromise. Swallowing may be painful (odynophagia) and
the patient’s voice may sound muffled due to
enlarged tonsils from acute tonsillar hyperplasia.
114.1 Introduction Acutely enlarged tonsils may cause stertor (noisy
The tonsils are paired organs situated on the side breathing due to airway obstruction above the
of the oropharynx between the palatoglossal larynx) and acute obstructive sleep apnoea. There
(anterior tonsillar pillar) and palatopharyngeal may be trismus and dribbling. Children may have
folds (posterior tonsillar pillar). They are part of abdominal pain and vomiting. Examination shows
Waldeyer’s ring, a ring of lymphoid tissue consisting hyperaemic tonsils with pus and debris in the
of the adenoids, the palatine tonsils and the lingual crypts. Patients with acute tonsillitis presenting T
tonsils, which are embedded in the posterior to hospital usually have symptoms at the severe
third of the tongue. The ring is thought to act as a end of the spectrum, with significant systemic
barrier against infection in the first few years of life. upset, inability to function normally and inability
The tonsil is enclosed by a fibrous capsule, outside to maintain adequate hydration. Glandular fever,
of which is a layer of areolar tissue. This separates agranulocytosis, leukaemia and diphtheria are
the capsule from the pharyngobasilar fascia cover- amongst the differential diagnoses in such cases. A
ing the superior constrictor muscle that forms the full blood count, white cell differential, blood film
tonsil bed. The main blood supply of the tonsil is and liver function tests should be performed in
from the tonsillar branch of the facial artery. such cases and if diphtheria is suspected, a throat
swab is taken.
Glandular fever tonsillitis is caused in more
114.2 Acute Tonsillitis than 90% of cases by the Epstein–Barr virus
Acute tonsillitis is an infection which primarily (EBV) and in the remainder cytomegalovirus
affects the palatine tonsil. It may be the dominant (CMV, another herpes virus). Tonsillar enlarge-
feature of an upper respiratory tract infection when ment is particularly impressive. The tonsils are
it is usually viral in aetiology, or it may present as a covered with a white/yellow exudate and the
primary acute pharyngotonsillitis. The latter is also tender cervical lymphadenopathy is usually more
usually a viral infection involving the lymphoid marked than with other viral/bacterial causes.
tissue on the posterior pharyngeal wall and tonsil. Hepatosplenomegaly and petechiae on the mucosa
Although acute tonsillitis is seen in adults, it is of the roof of the mouth may be seen in 50% of
most frequent in childhood, presumably because cases. There may be atypical lymphocytes on the
immunity to common childhood organisms has blood film and raised liver enzymes.
not been fully established. Common cold and The diagnosis of EBV (as opposed to CMV)
coryza viruses (e.g. influenza, parainfluenza, glandular fever is confirmed with the heterophile
adenoviruses, enteroviruses and rhinoviruses) are antibody (monospot) test. This test is specific but
the commonest cause of tonsillitis. An initial viral not very sensitive with a false-negative rate of
tonsillitis may predispose to a secondary bacterial 25% during the first week of infection, 10% in the
tonsillitis (Streptococcus pyogenes, Streptococcus second week, and 5% in the third. Therefore, when
pneumoniae, Haemophilus influenzae, Actinomyces, a patient clinically has glandular fever but has a
found in so-called tonsillar debris) and anaerobic negative monospot, immunoglobulin G (IgG) and
organisms. IgM tests for EBV are indicated.

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 Tonsil Disease

114.4 Management Penicillin V is still the drug of choice, with

erythromycin reserved for those patients allergic to
The first determinant is whether the tonsillitis is penicillin. Amoxicillin should not be used to treat
viral or bacterial. GPs can decide which patients acute tonsillitis in case the patient has infectious
should be given antibiotics by using the Centor mononucleosis, when a generalised maculopapular
criteria. These have been used to determine if an rash develops in 92% of patients (this can scar). If
adult with a sore throat is likely to have a bacterial a quinsy is suspected, then metronidazole should
aetiology. They were produced in 1981 and mod- be added because pus cultured from such patients
ified in 2004 to highlight the possibility of a often grows a mixed population of bacteria including
β-haemolytic group A streptococcal (S. pyogenes) anaerobes. Patients with significantly enlarged
tonsillitis/pharyngitis so that a course of tonsils should be considered for a 2- to 5-day
antibiotics can be prescribed. A study published course of IV steroids to reduce the risk of airway
in the BMJ in 2013 concluded that the Centor compromise (dexamethasone) 6.6 mg bd or tds with
criteria are ineffective in predicting the presence a proton pump inhibitor [PPI] to reduce the gastritis
of group A streptococci on throat swab cultures risk. The patient should have paracetamol for
in children. analgesia. Aspirin is contraindicated in children
There are four criteria each scoring one point: because of the risk of Reye’s syndrome. Fluid
replacement and bed rest are important.
1. A pyrexia.
2. Tonsillar exudate.
T 3. Tender anterior cervical lymphadenopathy.
114.5 Complications of Acute
4. Absence of a cough.
Tonsillitis
In the United Kingdom, there is no points modifi-
cation for age, so the points score ranges from 0 to 4 1. Local
and because the outcome of a throat swab depends a. Severe swelling causing respiratory
on the expertise of the practitioner taking the obstruction.
swab, the time taken to reach the laboratory (may b. Abscess formation: Peritonsillar (quinsy).
need to be stored overnight if a late afternoon or • Parapharyngeal.
evening clinic), and the time taken to obtain a • Retropharyngeal.
result thereafter (minimum 48 hours), there is no c. Acute otitis media.
indication for routine swabs. Patients with a score d. Recurrent acute tonsillitis (chronic tonsilli-
of 3 or 4 should be treated with antibiotics. tis).
In the United States, one point is added in a 2. General
patient who is 14 years or younger and one point a. Septicaemia.
subtracted if a patient is 45 or older. The patient’s b. Meningitis.
score may therefore range from −1 to 5. c. Acute rheumatic fever.
The management guidelines in the United States d. Acute glomerulonephritis.
depend on the patient’s score and are as follows:

-1 to 1 points No antibiotics or throat swab 114.6 Differential Diagnosis of

2 or 3 points
needed (streptococcal risk < 10%).
Antibiotics prescribed only if a
Unilateral Tonsil Enlargement
throat swab is positive (strepto- a. Asymmetry in a patient with recurrent bouts
coccal risk 15% for a score of 2 and of acute tonsillitis due to benign tonsillar
32% for a score of 3). hyperplasia.
4 or 5 points The American Society of Internal b. Neoplasia (squamous cell carcinoma or
Medicine no longer recommend lymphoma).
empirical treatment but treat- c. Apparent enlargement (peritonsillar abscess,
ment based on a throat swab parapharyngeal abscess, parapharyngeal mass
(streptococcal risk 56%). such as a deep lobe pleomorphic adenoma).

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 Related Topics of Interest

114.7 Differential Diagnosis of Further Reading

Ulceration of the Tonsil Baugh RF, Archer SM, Mitchell RB, et al; American Academy of
Otolaryngology-Head and Neck Surgery Foundation. Clinical
A working diagnosis can usually be determined practice guideline: tonsillectomy in children. Otolaryngol
from the history and clinical examination. Head Neck Surg. 2011; 144(1, Suppl):S1–S30
Chiappini E, Regoli M, Bonsignori F, et al. Analysis of different
Investigations include a full blood count, chest
recommendations from international guidelines for the man-
radiograph, serological tests, and biopsy. Possible agement of acute pharyngitis in adults and children. Clin Ther.
causes include the following: 2011; 33(1):48–58
Spektor Z, Saint-Victor S, Kay DJ, Mandell DL. Risk factors for
1. Infection pediatric post-tonsillectomy hemorrhage. Int J Pediatr Otorhi-
a. Acute streptococcal tonsillitis. nolaryngol. 2016; 84:151–155
b. Diphtheria.
c. Infectious mononucleosis.
d. Vincent’s angina. Related Topics of Interest
2. Neoplasm Adenoids
a. Squamous cell carcinoma. Neck space infection
b. Lymphoma. Tonsillectomy
c. Salivary gland tumours (adenoid cystic
carcinoma or mucoepidermoid tumour).
3. Blood diseases
a. Agranulocytosis. T
b. Leukaemia.
4. Other causes
a. Aphthous ulceration.
b. Behçet’s syndrome.
c. Stevens–Johnson syndrome.
d. Acquired immunodeficiency syndrome
(AIDS).

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 115 Tonsillectomy
In 2010, the Scottish Intercollegiate Guidelines a bacterial aetiology (i.e. can be due to either), and
Network (SIGN) produced guidelines for we know most cases of acute tonsillitis are due to
consideration of tonsillectomy for recurrent a viral aetiology. Remember also, the Centor guide-
significant episodes of sore throats, in both children lines were produced to do the following:
and adults, which have been widely adopted.
a. Determine which patients with tonsillitis
The Centor guidelines (see Chapter 114, Tonsil
should be prescribed antibiotics.
Disease) have been inappropriately used by some
b. To prevent unnecessary prescribing of anti-
clinical commissioning groups to define a clinically
biotics. Please see Chapter 118.
significant episode of tonsillitis when applying
SIGN guidelines. Tonsillectomy in the United Unfortunately, while the SIGN guidelines are quite
Kingdom has reduced in frequency from 200,000 clear, many clinical commissioning groups in
in 1995 to 31,000 in 2012. With this, the episodes England have modified the guidelines to further
of acute tonsillitis and complications of tonsillitis ration surgery. The National Health Service (NHS)
(such as quinsy or a parapharyngeal abscess) England has been the trigger for this. Perhaps
requiring acute hospital admission continue to rise. through stealth or ignorance or perhaps through
being confused by SIGN tonsillectomy guidelines

T 115.1 Indications for and the Centor criteria, which are guidelines for two
different issues, NHS England published an Interim
Tonsillectomy Clinical Commissioning Policy: Tonsillectomy
document (November 2013; ref: N-SC/033). This is
Indications for tonsillectomy fall into several
the only tonsillectomy policy document available
categories.
on their website. The policy refers to a significant
1. Recurrent acute tonsillitis. episode of tonsillitis as an ‘eligible episode’. It
2. Upper airway obstruction or sleep disordered defines an ‘eligible episode’ as a score of at least
breathing due to enlarged tonsils. 3 using the Centor criteria. Such a score is asso-
3. To obtain histology in an abnormal-looking ciated with a high likelihood that the episode of
tonsil(s). tonsillitis is due to a bacterial aetiology and using
4. Part of another procedure (uvulopalatopharyn- the Centor criteria antibiotics are recommended.
goplasty [UVPP], access to glossopharyngeal In other words, this document, in effect, interprets
nerve or styloid process). ‘clinically significant’ in the SIGN guidelines to
5. Previous episodes of peritonsillar abscess mean bacterial tonsillitis and ‘adequately treated’
(quinsy). in the SIGN guidelines to mean treated with anti-
biotics. This has allowed Clinical Commissioning

115.2 The 2010 SIGN groups in England to use the SIGN guidelines, but
then add that each episode of tonsillitis should
Guidelines have been treated with antibiotics to count as an
eligible episode. Clearly this is ridiculous because
• Sore throats are due to tonsillitis.
if one calculated that 50% of episodes of tonsillitis
• The sore throats are disabling and prevent nor-
are bacterial (it is lower than this), then patients
mal functioning.
would need to have had twice the number of
• There should be seven or more well-
episodes recommended by the SIGN guidelines
documented, clinically significant, adequately
to be eligible for tonsillectomy. This means
treated sore throats in the preceding year.
14 episodes of tonsillitis in the preceding year or
• Five or more such episodes in each of the
10 episodes in each of the preceding 2 years to
preceding 2 years.
be eligible for tonsillectomy using NHS England’s
• Three or more such episodes in the preceding
guidelines! ENTUK, in association with the Royal
3 years.
College of Surgeons and accredited by NICE, has
Note that the guidelines do not say the episodes published a commissioning guide (September
of tonsillitis must be specifically due to a viral or 2016) which goes some way to address this. It

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 115.5 Post-Tonsillectomy Haemorrhage

emphasises that ‘adequately treated’ does not 4. Late

mean ‘treated with antibiotics’ and from this it is a. Scarring of the soft palate (limiting mobility,
reasonable to conclude ‘clinically significant’ does possibly affecting the voice).
not mean only bacterial tonsillitis. b. Tonsillar remnants (which may be the site of
recurrent acute infection).

115.3 Contraindications
These contraindications are not absolute, but they
115.5 Post-Tonsillectomy
need to be addressed before surgery. In some Haemorrhage
cases, the decision to proceed with surgery should
The most significant complication is haemorrhage,
be reconsidered in the context of the potential
which occurs in approximately 2% of cases. Most
problems.
of the deaths associated with tonsillectomy
a. Recent episode of tonsillitis or upper respiratory are directly or indirectly associated with this
tract infection (within 2 weeks). complication.
b. Bleeding disorder. Reactionary (primary) haemorrhage is a
c. Oral contraceptives. Each hospital should have haemorrhage occurring up to 24 hours post-
its own policy for patients taking the oral con- operatively, but nearly all reactionary haemorrhages
traceptive pill and who are undergoing surgery. occur within the first 6 hours. It is one of the
reasons why some surgeons are opposed to day
d. Cleft palate.
e. During certain epidemics (e.g. polio). case tonsillectomy. T
It is essential to ensure adequate haemostasis at
the end of the tonsillectomy procedure as blood
115.4 Complications of in the airway at this time may cause laryngeal

Tonsillectomy spasm or can occlude the airway. The post-nasal

space should always be checked for a blood clot
1. Peri-operative (the so-called ‘coroner’s clot’). Patients are nursed
a. Anaesthetic reaction. in the reverse Trendelenburg position (head down)
b. Damage to teeth. so that blood trickles out of the mouth rather than
c. Trauma to the palate and posterior pharyn- being swallowed or aspirated. It would be very
geal wall from the ear, nose and throat (ENT) unusual for a patient to have had an uneventful
surgeon (careless insertion of the tongue post-operative recovery for the first 6 hours and
blade) or anaesthetist (insertion of pharyngeal then have a reactionary haemorrhage thereafter. It
airway or from suctioning). is therefore safe to discharge such patients home at
d. Straining or dislocation of the temporoman- 6 hours post-tonsillectomy.
dibular joint by over-opening the mouth gag. The signs of reactionary haemorrhage are bleed-
2. Immediate ing from the mouth, a gurgling sound in the throat
a. Reactionary haemorrhage. on respiration, repeated swallowing, vomiting
b. Anaesthetic complications. blood, a rising pulse rate and eventually a falling
3. Early blood pressure, tachypnoea and circulatory failure
a. Secondary haemorrhage. (shock) from hypovolaemia. Blood must be
b. Haematoma and oedema of the uvula. Nasal cross-matched and a clotting screen performed.
regurgitation and hyponasality (from trauma- An intravenous infusion should be started. The
tising or excising too much of the soft palate). tonsillar fossae should be inspected to identify a
c. Infection (may lead to secondary bleeding point. If clot is identified, some surgeons
haemorrhage). advise, if the patient is not shocked, clot removal
d. Otalgia (referred otalgia or due to acute otitis and a gauze swab soaked in 1:1,000 adrenaline
media). applied to the fossa. Others advise to leave the
e. Pulmonary complications (pneumonia and clot undisturbed and to give tranexamic acid at a
lung abscess are rare). maximum STAT dose (1.5 g IV in an adult) then
f. Sub-acute bacterial endocarditis (if the patient 1 g tds for 3 to 5 days thereafter. If the patient is in
has a cardiac defect). circulatory failure, then tranexamic acid should be

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 Tonsillectomy

given; the shock reversed by adequate and rapid 115.6 Follow-Up and Aftercare
fluid replacement, and the patient returned to
theatre to ligate the bleeding point under general No follow-up is required after a routine, uncompli-
anaesthesia. The second anaesthetic is hazardous cated tonsillectomy. Patients who have suffered a
because the patient may have a compensated significant haemorrhage should be advised to have
hypovolaemic which may then decompensate with their haemoglobin checked at their GP. Patients
provision of a general aanesthetic leading to acute who have a tonsillectomy for reasons other than
hypovolaemic shock. A general anaesthetic for a recurrent acute tonsillitis should be followed up
secondary haemorrhage should therefore only be appropriately to their problem.
administered by an experienced anaesthetist.
Secondary haemorrhage occurs some 5 to 10 days
post-tonsillectomy and is due to an infection Further Reading
within the tonsillar fossa or from separation of the Commissioning guide: tonsillectomy. Royal College of Surgeons
false membrane that forms in the first 24 hours of England. 01 September 2016
after surgery. A tonsillar vessel is exposed or De Luca Canto G, Pachêco-Pereira C, Aydinoz S, et al.
Adenotonsillectomy complications: a meta-analysis. Pediatrics.
necroses beyond its clotted segment and ruptures.
2015; 136(4):702–718
The patient should be admitted to hospital for Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsil-
observation. A full blood count, clotting screen and lectomy Trial (CHAT). A randomized trial of adenotonsil-
at least a group and save (cross-match for shocked lectomy for childhood sleep apnea. N Engl J Med. 2013;
368(25):2366–2376
T patients) should be performed. The infection and
haemorrhage will usually settle after treatment
with antibiotics (IV penicillin and metronidazole
or erythromycin). It is unusual for such a patient
Related Topics of Interest
to have to go back to theatre and when this is Adenoids
necessary, the tonsillar fossae are found to contain Neck space infection
friable granulation tissue. It is usually straight- Snoring and sleep-related breathing disorder
forward to locate and ligate a specific bleeding Tonsil disease
point. Sometimes there is a widespread area of
friable tissue and the bleeding point may not be
obvious. It may then be necessary to suture the
faucial pillars together, or over Kaltostat.

448