Tonsillitis describes inflammation of the tonsils and is usually spread from one person to another, either through inhaling droplets after an infected person coughs or sneezes, or by direct contact. In general, the incubation period - the time from exposure of the virus to symptom - is between two and four days.
In most cases, it causes only mild symptoms and resolves without intervention from a doctor. A number of patients, however, suffer enough to seek advice from either their local pharmacist or GP. Rarely, patients have serious complications of tonsillitis requiring hospital treatment.
CAUSES
From 50 to 80 per cent of cases of tonsillitis are caused by a virus, which may include adenovirus, rhinovirus, enterovirus, parainfluenza, influenza and herpes simplex (more commonly known as the cold sore virus). Glandular fever, caused by the Epstein-Barr virus, accounts for 1 to 10 per cent of tonsillitis cases. Sometimes referred to as infectious mononucleosis, glandular fever can also cause inflammation of the liver and makes the spleen more prone to rupture.
A number of different bacteria may cause tonsillitis, the most common being group A beta-haematolytic streptococcus. This is often referred to as a 'strep throat'. Other bacteria implicated in tonsillitis include chlamydia pneumonia, mycoplasma pneumonia and neisseria meningitides, which is one of the bacteria also responsible for meningitis, neisseria gonorrhoea and haemophilus influenza. Candida, a yeast which is also responsible for thrush, can also cause tonsillitis. There are also non-infective causes of tonsillitis, which, with the exception of hayfever, are rare.
DIAGNOSIS
Given the number of different organisms that may cause tonsillitis, it is difficult to make a precise diagnosis based on clinical examination alone. The main aim of clinical examination is to try to identify bacterial cases and serious complications of tonsillitis.
A set of criteria, known as the Centor scoring system, has been found useful in identifying strep throat and arguably guiding the use of antibiotics. The scoring system isn't valid for the children under the age of three.
One point is scored for each of pus on the tonsils, painful glands in the neck, fever and no cough. If a patient scores four points, the likelihood of having strep throat is up to 86 per cent, whereas a score of one may correlate to a chance as a low as 2 per cent.
Other features of tonsillitis include sore throat, cough, headache, earache, vomiting, stomach ache and bad breath.
TREATMENT
Throat swabs may be positive for bacteria in patients who have no symptoms or negative in patients with bacterial tonsillitis and, as such, are not useful in managing patients with sore throats.
The mainstay of treatment of patients with sore throats is education and painkillers. In those without allergic reactions, paracetamol or ibuprofen are the drugs of choice. Aspirin is not recommended for use in children due to the risk of Reye's syndrome, which is a potentially fatal disease affecting multiple organs. Clinical studies have not shown any benefit from taking Echinacea in patients with sore throats.
Many parents try to avoid antibiotics for their children, whereas others insist on them. In the majority of cases of sore throat, patients recover fully without antibiotics. Clinical data has shown that sore throats are no more likely to be better with antibiotics than without, and in general, antibiotics should not be prescribed to relieve the symptoms of simple sore throat. Antibiotics may be considered in bacterial tonsillitis or those with other medical conditions such as heart diseases.
In outbreaks of bacterial sore throat, public health doctors may recommend the prescription of antibiotics to help prevent spread throughout the community. In addition, antibiotics may be used when there are complications of tonsillitis. Ear and sinus infections are the commonest complications.
Scarlet fever is not commonly seen in everyday practice. Complications may be serious and require hospital admission, including breathing and swallowing difficulties which may be caused by an abscess in the throat, pneumonia, blood poisoning, rheumatic fever and kidney involvement known such as glomerulonephritis.
The routine use of antibiotics is not recommended for the prevention of rheumatic fever and glomerulonephritis. In children who suffer from recurrent tonsillitis, surgery may be offered with good results.
In general, simple painkillers, patience and prevention of spread are all that are required. If, however, the child has complications or other medical problems or you are concerned by how unwell they are, you should seek medical advice.
Dr Raj Thakkar BSc(Hons) MBBS MRCGP MRCP(UK) is a full-time GP in Buckinghamshire
