Tonsillitis is a common childhood illness characterized by inflammation of the palatine tonsils. It is particularly prevalent in school-aged children and adolescents, with peak incidence between 5 and 15 years of age. Understanding tonsillitis is crucial for pediatricians and family physicians due to its frequency and potential complications.
Key anatomical considerations:
The palatine tonsils are lymphoid tissues located in the oropharynx.
They form part of Waldeyer's ring, a ring of lymphoid tissue in the pharynx.
Tonsils play a role in the immune system, particularly in young children.
Tonsillitis can be classified as:
Acute: Sudden onset, lasting less than 2 weeks
Recurrent: Multiple episodes of acute tonsillitis in a year
Chronic: Symptoms persisting for more than 3 months
Etiology of Tonsillitis in Children
Tonsillitis can be caused by various pathogens, both viral and bacterial:
Viral Causes (70-80% of cases):
Adenovirus
Epstein-Barr virus (EBV)
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial virus (RSV)
Coronavirus
Bacterial Causes (20-30% of cases):
Group A beta-hemolytic Streptococcus (GABHS) - most common bacterial cause
Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Neisseria gonorrhoeae (in sexually active adolescents)
Corynebacterium diphtheriae (rare in vaccinated populations)
Factors that may predispose children to tonsillitis include:
Age (school-aged children are most susceptible)
Close contact with infected individuals
Seasonal variations (more common in winter and early spring)
Immunodeficiency states
Environmental factors (poor hygiene, crowded living conditions)
Clinical Presentation of Tonsillitis in Children
The clinical presentation of tonsillitis can vary depending on the causative agent and the child's age. Common symptoms include:
Sore throat (odynophagia)
Difficulty swallowing (dysphagia)
Fever (usually higher in bacterial infections)
Enlarged, erythematous tonsils with or without exudates
Cervical lymphadenopathy
Halitosis
Malaise and fatigue
Headache
Abdominal pain (particularly in younger children)
Specific clinical features may suggest certain etiologies:
Viral Tonsillitis:
Often associated with other upper respiratory symptoms (cough, rhinorrhea)
Conjunctivitis may be present (particularly with adenovirus)
EBV infection may present with splenomegaly and generalized lymphadenopathy
Bacterial Tonsillitis (especially GABHS):
Abrupt onset of symptoms
Higher fever (>38.5°C)
Absence of cough
Tonsillar exudates
Tender anterior cervical lymphadenopathy
Possible scarlatiniform rash
It's important to note that clinical presentation alone is not always sufficient to differentiate between viral and bacterial etiologies.
Diagnosis of Tonsillitis in Children
Diagnosis of tonsillitis is based on a combination of clinical presentation, physical examination, and, when indicated, laboratory tests:
Physical Examination:
Oropharyngeal inspection: Look for enlarged, erythematous tonsils with or without exudates
Palpation of cervical lymph nodes
Assessment for signs of dehydration
Examination for associated symptoms (e.g., rash, hepatosplenomegaly)
Laboratory Tests:
Rapid Antigen Detection Test (RADT) for Group A Streptococcus
High specificity (95%) but variable sensitivity (70-90%)
Negative RADT should be confirmed with throat culture in high-risk populations
Throat culture
Gold standard for diagnosis of GABHS pharyngitis
Results typically available in 24-48 hours
Complete Blood Count (CBC)
May show leukocytosis in bacterial infections
Lymphocytosis and atypical lymphocytes may be seen in EBV infection
Monospot test or EBV-specific antibodies (if infectious mononucleosis is suspected)
Diagnostic Criteria:
The Centor criteria or the modified McIsaac score can be used to assess the likelihood of GABHS pharyngitis:
Fever >38°C
Absence of cough
Tender anterior cervical adenopathy
Tonsillar swelling or exudate
Age 3-14 years (in McIsaac score)
A score of ≥3 suggests a high likelihood of GABHS infection and the need for testing.
Management of Tonsillitis in Children
The management of tonsillitis in children depends on the etiology and severity of the condition:
Supportive Care (for both viral and bacterial tonsillitis):
Penicillin V: 250 mg (for <27 kg) or 500 mg (for ≥27 kg) orally, twice daily for 10 days
Amoxicillin: 50 mg/kg/day in divided doses (max 1000 mg/day) for 10 days
For penicillin-allergic patients:
Cephalexin: 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days
Clindamycin: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days
Azithromycin: 12 mg/kg once daily (max 500 mg/day) for 5 days
Indications for Tonsillectomy:
Consider tonsillectomy for:
Recurrent tonsillitis: ≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years
Chronic tonsillitis unresponsive to antimicrobial therapy
Peritonsillar abscess unresponsive to medical management or drainage
Obstructive sleep apnea due to tonsillar hypertrophy
The decision for tonsillectomy should be made in consultation with an otolaryngologist, considering the child's overall health and the impact of recurrent infections on their quality of life.
Complications of Tonsillitis in Children
While most cases of tonsillitis resolve without incident, complications can occur, especially with bacterial infections or recurrent episodes:
Local Complications:
Peritonsillar abscess (quinsy)
Collection of pus between the tonsil and its capsule
Presents with severe pain, trismus, and "hot potato" voice
May require drainage and IV antibiotics
Parapharyngeal abscess
Retropharyngeal abscess
Tonsillar hypertrophy leading to obstructive sleep apnea
Systemic Complications (particularly associated with GABHS):
Acute rheumatic fever
Inflammatory disease affecting heart, joints, skin, and brain
Typically occurs 2-4 weeks after untreated streptococcal pharyngitis
Post-streptococcal glomerulonephritis
Immune complex-mediated kidney disease
Can occur 1-2 weeks after streptococcal infection
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)
Sudden onset of OCD or tic disorders following streptococcal infection
Controversial and still under research
Other Complications:
Dehydration due to reduced oral intake
Chronic tonsillitis
Sepsis (rare)
Early recognition and appropriate management of tonsillitis can significantly reduce the risk of these complications.
Prevention of Tonsillitis in Children
While it's not always possible to prevent tonsillitis, certain measures can reduce the risk of infection and transmission:
General Preventive Measures:
Hand hygiene
Regular handwashing with soap and water
Use of alcohol-based hand sanitizers when soap and water are not available
Respiratory hygiene
Covering mouth and nose when coughing or sneezing
Proper disposal of used tissues
Avoiding close contact with infected individuals
Not sharing utensils, drinking glasses, or personal items
Maintaining good overall health through proper nutrition, adequate sleep, and regular exercise
Specific Preventive Strategies:
Vaccination
While there's no vaccine specifically for tonsillitis, keeping up-to-date with routine childhood vaccinations can prevent some causative agents (e.g., diphtheria, influenza)
Prophylactic antibiotics
May be considered in cases of recurrent GABHS tonsillitis
Not routinely recommended due to risk of antibiotic resistance
Environmental Factors:
Maintaining clean living spaces
Ensuring proper ventilation in homes and schools
Avoiding exposure to secondhand smoke, which can irritate the throat and increase susceptibility to infections
Education:
Teaching children about proper hygiene practices
Educating parents and caregivers about recognizing early signs of tonsillitis
Promoting awareness about the importance of completing full courses of prescribed antibiotics
While these preventive measures can reduce the risk of tonsillitis, it's important to remember that some children may be more susceptible due to genetic or environmental factors. Regular check-ups with a pediatrician can help in early detection and management of recurrent or chronic tonsillitis.
Tonsillitis in Children
What is the most common bacterial cause of acute tonsillitis in children?
Group A beta-hemolytic streptococcus (GABHS)
Which age group is most commonly affected by streptococcal tonsillitis?
5-15 years
What is the gold standard for diagnosing streptococcal tonsillitis?
Throat culture
Which of the following is NOT a typical symptom of tonsillitis?
Cough
What is the appropriate first-line antibiotic for streptococcal tonsillitis?
Penicillin V
How long should antibiotic treatment be continued for streptococcal tonsillitis?
10 days
Which of the following is a potential complication of untreated streptococcal tonsillitis?
Rheumatic fever
What is the Centor score used for in tonsillitis?
Predicting likelihood of streptococcal infection
Which of the following is NOT a criterion in the Centor score?
Rhinorrhea
What is the sensitivity of rapid antigen detection tests for streptococcal tonsillitis?
70-90%
How soon after starting antibiotics is a child with streptococcal tonsillitis considered non-infectious?
24 hours
Which of the following is an indication for tonsillectomy in children?
Recurrent streptococcal tonsillitis (7 episodes in 1 year or 5 per year for 2 years)
What is the most common viral cause of tonsillitis in children?
Adenovirus
How does viral tonsillitis differ from bacterial tonsillitis in presentation?
Viral often associated with conjunctivitis, rhinorrhea, and cough
What is the appropriate management for viral tonsillitis?
Supportive care
Which of the following is NOT a typical finding in streptococcal tonsillitis?
Vesicular lesions on tonsils
What is the role of corticosteroids in the treatment of tonsillitis?
May provide symptomatic relief in severe cases
How does tonsillitis affect swallowing in children?
Causes odynophagia (painful swallowing)
What is the appropriate fluid management for children with tonsillitis?
Encourage increased fluid intake
Which of the following is a potential complication of tonsillitis?
Peritonsillar abscess
What is the typical duration of symptoms in viral tonsillitis?
5-7 days
How does the appearance of tonsils differ in viral vs. bacterial tonsillitis?
Bacterial often has exudates, viral typically does not
What is the role of acetaminophen or ibuprofen in tonsillitis management?
Fever reduction and pain relief
Which of the following is NOT a typical complication of tonsillectomy?
Epiglottitis
What is the appropriate antibiotic for penicillin-allergic patients with streptococcal tonsillitis?
Erythromycin or clindamycin
How does chronic tonsillitis differ from recurrent acute tonsillitis?
Chronic involves persistent symptoms between acute episodes
What is the Paradise criteria used for in tonsillitis management?
Determining eligibility for tonsillectomy
Which age group is most likely to develop peritonsillar abscess as a complication of tonsillitis?
Adolescents and young adults
What is the appropriate management for peritonsillar abscess?
Incision and drainage, antibiotics
How does tonsillitis affect school attendance in children?
May require 24-48 hours absence after starting antibiotics for streptococcal tonsillitis
