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 constitutes about 15% of all office visits to primary care physicians.
(See also Streptococcal Infections.)
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. Group A beta-hemolytic streptococcus (GABHS) is most common (see 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.
Pain with swallowing is the hallmark 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. A rash may also be present. 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. With GABHS, a scarlatiniform rash (scarlet fever) may be present.
Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea and cough usually indicate a viral cause. 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 (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):
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.
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
Supportive treatments 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). 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.
Penicillin V is usually considered the drug of choice for GABHS tonsillopharyngitis; 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 drugs include macrolides for patients allergic to penicillin, a 1st-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 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 disorder, 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 individual, based on patient age, multiple risk factors, and response to infection recurrences (2).
Numerous effective surgical techniques are used to perform tonsillectomy, including electrocautery dissection, microdebrider, radiofrequency coblation, and sharp dissection. 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 generally are 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 IV rehydration is necessary in ≤ 3% of patients, possibly in fewer patients with use of optimal preoperative hydration, perioperative antibiotics, analgesics, and corticosteroids.
Postoperative airway obstruction occurs most frequently in children < 2 years who have preexisting severe obstructive sleep disorders and in patients who are morbidly obese or have neurologic disorders, craniofacial anomalies, or significant preoperative obstructive sleep apnea. Complications are generally more common and serious among adults. Accumulating evidence suggests that tonsillotomy (partial intracapsular removal of tonsil tissue), when done to treat various disorders is as efficacious as traditional tonsillectomy and preferable because of better outcomes related to pain, postoperative complications, and patient satisfaction (3).
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. 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
3. 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
Pharyngitis itself is easily recognized clinically, but only in 25 to 30% of cases is testing likely to be required to determine if it is due to 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.