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Tonsillopharyngitis

(Tonsillitis; Pharyngitis)

By

Alan G. Cheng

, MD, Stanford University

Reviewed/Revised Feb 2024
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Topic Resources

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented by culture or rapid antigen test. Treatment depends on symptoms and, in the case of group A beta-hemolytic streptococcus, involves antibiotics.

The tonsils participate in systemic immune surveillance. In addition, local tonsillar defenses include a lining of antigen-processing squamous epithelium that involves B- and T-cell responses.

Tonsillopharyngitis of all varieties is a very common cause of all office visits to primary care physicians.

Etiology of Tonsillopharyngitis

Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus), but occasionally by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV.

In about 30% of patients, the cause is bacterial (1). Group A beta-hemolytic streptococcus (GABHS) is most common (see Streptococcal Infections Streptococcal Infections Streptococci are gram-positive aerobic organisms that cause many disorders, including pharyngitis, pneumonia, wound and skin infections, sepsis, and endocarditis. Symptoms vary with the organ... read more Streptococcal Infections ), but Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia pneumoniae are sometimes involved. Rare causes include pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea.

GABHS occurs most commonly between ages 5 and 15 and is uncommon before age 3. It is less common among older adults.

Etiology reference

  • 1. Pichichero ME: Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med 25 (3):390–403, 1995. doi: 10.1016/s0196-0644(95)70300-4

Symptoms and Signs of Tonsillopharyngitis

Pain when swallowing is the hallmark of tonsillopharyngitis and is often referred to the ears. Very young children who are not able to complain of sore throat often refuse to eat. High fever, malaise, headache, and GI upset are common, as are halitosis and a muffled voice. The tonsils are swollen and red and often have purulent exudates. Tender cervical lymphadenopathy may be present. Fever, adenopathy, palatal petechiae, and exudates are somewhat more common with GABHS than with viral tonsillopharyngitis, but there is much overlap; both tonsillopharyngitis and GABHS can cause petechiae. With GABHS, a scarlatiniform rash (scarlet fever) may be present.

Diagnosis of Tonsillopharyngitis

  • Clinical evaluation

  • Group A beta-hemolytic streptococcus (GABHS) ruled out by rapid antigen test, culture, or both, routinely or selectively

Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea and cough usually indicate a viral cause. Infectious mononucleosis Infectious Mononucleosis Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or... read more Infectious Mononucleosis is suggested by posterior cervical or generalized adenopathy, hepatosplenomegaly, fatigue, and malaise for > 1 week; a full neck with petechiae of the soft palate; and thick tonsillar exudates. A dirty gray, thick, tough membrane that bleeds if peeled away indicates diphtheria Diphtheria Diphtheria is an acute pharyngeal or cutaneous infection caused mainly by toxigenic strains of the gram-positive bacillus Corynebacterium diphtheriae and rarely by other, less common... read more Diphtheria (rare in the US).

Because GABHS requires antibiotics, it must be diagnosed early. Criteria for testing are controversial. Many authorities recommend testing with a rapid antigen test or culture for all children. Rapid antigen tests are specific but not sensitive and may need to be followed by a culture, which is about 90% specific and 90% sensitive. In adults, many authorities recommend using the following 4 criteria of the modified Centor score (1 Diagnosis reference Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented... read more Diagnosis reference ):

  • History of fever

  • Tonsillar exudates

  • Absence of cough

  • Tender anterior cervical lymphadenopathy

Patients who meet 1 or no criteria are unlikely to have GABHS and should not be tested. Patients who meet 2 criteria can be tested. Patients who meet 3 or 4 criteria can be tested or treated empirically for GABHS.

Diagnosis reference

  • 1. Fine AM, Nizet V, Mandl KD: Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med 172 (11):847–852, 2012. doi: 10.1001/archinternmed.2012.950

Treatment of Tonsillopharyngitis

  • Symptomatic treatment

  • Antibiotics for GABHS

  • Tonsillectomy considered for recurrent GABHS

Supportive treatments for tonsillopharyngitis include analgesia, hydration, and rest. Analgesics may be systemic or topical. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective systemic analgesics. Some clinicians also give a single dose of a corticosteroid (eg, dexamethasone 10 mg IM), which may help shorten symptom duration without affecting rates of relapse or adverse effects (1 Treatment references Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented... read more Treatment references ). Corticosteroids are commonly used to treat tonsillopharyngitis because they can help relieve pain and increase consumption of food. Some clinicians do not use corticosteroids because of their adverse effects.

Topical analgesics are available as lozenges and sprays; ingredients include benzocaine, phenol, lidocaine, and other substances. These topical analgesics can reduce pain but have to be used repeatedly and often affect taste. Benzocaine used for pharyngitis has rarely caused methemoglobinemia. Doses of topical analgesics must sometimes be limited.

Penicillin V is usually considered the drug of choice for GABHS tonsillopharyngitis (2 Treatment references Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented... read more Treatment references ); dose is 250 mg orally 2 times a day for 10 days for patients < 27 kg and 500 mg for those > 27 kg. Amoxicillin is effective and more palatable if a liquid preparation is required. If adherence is a concern, a single dose of benzathine penicillin 1.2 million units IM (600,000 units for children 27 kg) is effective. Other oral antibiotics include macrolides for patients allergic to penicillin, a first-generation cephalosporin, and clindamycin. Diluting over-the-counter hydrogen peroxide with water in a 1:1 mixture and gargling with it will promote debridement and improve oropharyngeal hygiene.

Treatment may be started immediately or delayed until culture results are known. If treatment is started presumptively, it should be stopped if cultures are negative. Follow-up throat cultures are not done routinely. They are useful in patients with multiple GABHS recurrences or if pharyngitis spreads to close contacts at home or school.

Tonsillectomy

Tonsillectomy has often been considered if GABHS tonsillitis recurs repeatedly (> 6 episodes/year, > 4 episodes/year for 2 years, or > 3 episodes/year for 3 years) or if acute infection is severe and persistent despite antibiotics. Other criteria for tonsillectomy include obstructive sleep apnea, recurrent peritonsillar abscess, and suspicion of cancer. (See also American Academy of Otolaryngology–Head and Neck Surgery Clinical Practice Guideline: Tonsillectomy in Children [Update].) Decisions should be individualized, based on patient age, multiple risk factors, and response to infection recurrences (3 Treatment references Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Diagnosis is clinical, supplemented... read more Treatment references ).

Numerous effective surgical techniques are used to perform tonsillectomy; they include electrocautery dissection, microdebrider, radiofrequency coblation, and sharp dissection. Postoperative IV rehydration is necessary in 3% of patients, possibly in fewer patients who have had optimal preoperative hydration, perioperative antibiotics, analgesics, and corticosteroids. Significant intraoperative or postoperative bleeding occurs in < 2% of patients, usually within 24 hours of surgery or after 7 days, when the eschar detaches. Patients with bleeding should go to the hospital. If bleeding continues on arrival, patients are usually examined in the operating room, and hemostasis is obtained. Any clot present in the tonsillar fossa is removed, and patients are observed for 24 hours.

Postoperative airway obstruction occurs most frequently in children < 2 years who have preexisting severe obstructive sleep disorders and in patients with morbid obesity or neurologic disorders, craniofacial anomalies, or significant preoperative obstructive sleep apnea. Complications are generally more common and serious among adults.

Treatment references

  • 1. Hayward G, Thompson MJ, Perera R, et al: Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev., 2012. doi: 10.1002/14651858.CD008268.pub2

  • 2. Shulman ST, Bisno AL, Clegg HW, et al: Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 15;55 (10):e86-102, 2012. doi: 10.1093/cid/cis629 Epub 2012 Sep 9.

  • 3. Ruben RJ: Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: how random are the studies and what are their limitations? Otolaryngol Head Neck Surg. 139(3):333-9, 2008. doi: 10.1016

  • 4. Wong Chung JERE, van Benthem PPG, Blom HM: Tonsillotomy versus tonsillectomy in adults suffering from tonsil-related afflictions: a systematic review. Acta Otolaryngol 138(5):492-501, 2018. doi: 10.1080/00016489.2017.1412500

  • 5. Blackshaw H, Springford LR, Zhang L-Y, et al: Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 4 (4):CD011365, 2020. doi: 10.1002/14651858.CD011365.pub2

Key Points

  • Pharyngitis itself is easily recognized clinically; however, in 25 to 30% of cases, testing is likely to be required to determine whether the infection is a streptococcal infection (ie, strep throat).

  • Clinical criteria (modified Centor score) can help to select patients for further testing or empiric antibiotic treatment, although some authorities recommend testing all children using a rapid antigen test and sometimes culture.

  • Penicillin remains the drug of choice for streptococcal pharyngitis; cephalosporins or macrolides are alternatives for patients allergic to penicillin.

Drugs Mentioned In This Article

Drug Name Select Trade
AK-Dex, Baycadron, Dalalone, Dalalone D.P, Dalalone L.A, Decadron, Decadron-LA, Dexabliss, Dexacort PH Turbinaire, Dexacort Respihaler, DexPak Jr TaperPak, DexPak TaperPak, Dextenza, DEXYCU, DoubleDex, Dxevo, Hemady, HiDex, Maxidex, Ocu-Dex , Ozurdex, ReadySharp Dexamethasone, Simplist Dexamethasone, Solurex, TaperDex, ZCORT, Zema-Pak, ZoDex, ZonaCort 11 Day, ZonaCort 7 Day
Advocate Pain Relief Stick, Americaine, Anbesol, Anbesol Baby , Anbesol Jr , Banadyne-3, Benzodent, Benz-O-Sthetic, Boil-Ease, Cepacol Sensations, Chloraseptic, Comfort Caine , Dry Socket Remedy, Freez Eez, HURRICAINE, HURRICAINE ONE, Little Remedies for Teethers, Monistat Care, Orabase, OraCoat CankerMelts, Orajel, Orajel Baby, Orajel Denture Plus, Orajel Maximum Strength, Orajel P.M., Orajel Protective, Orajel Severe Pain, Orajel Swabs, Orajel Ultra, Oral Pain Relief , Oticaine , Otocain, Outgro, Pinnacaine, Pro-Caine, RE Benzotic, Topex, Topicale Xtra, Zilactin-B
Castellani Paint, Chloraseptic, Chloraseptic Kids, Phenaseptic, Sore Throat
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine For Her, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido
Beepen VK, Veetids
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
CLEAR CARE PLUS with HydraGlyde, ESKATA, HYLAMEND
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