Tonsillitis

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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Aim

To guide PCH ED staff with the assessment and management of tonsillitis in children.

Definition

Tonsillitis is inflammation of the tonsils due to infection.

Background

  • The majority of tonsillitis and pharyngitis is viral and only requires symptomatic treatment.
  • In bacterial tonsillitis (15 to 30% of cases of tonsillitis) an important pathogen is Group A β-Haemolytic Streptococcus (GABHS).
  • Mycoplasma pneumoniae can be another causative bacteria. Other bacterial causes of tonsillitis are rare.
  • Rapid onset of sore throat and high fever associated with an exudative tonsillitis is more suggestive of a Streptococcal tonsillitis, especially in the absence of typical viral features.
  • Viruses implicated in tonsillitis and pharyngitis includes rhinovirus, coronavirus, res Streptococcal tonsillitis is most common in school-age children, and is uncommon in children less than 3 years old.
  • Respiratory syncytial virus, adenovirus, parainfluenza, influenza, herpes simplex virus, enteroviruses and cytomegalovirus.
  • Both viruses and bacteria can cause an exudative tonsillitis.
  • Epstein - Barr virus (EBV) is a common cause of exudative tonsillitis and pharyngitis.
  • Diphtheria, caused by Corynebacterium diphtheriae is rare in the developed world where immunisation against this disease is routine.
  • Both viruses and bacteria can cause a high temperature.

Risk factors

  • Low socio-economic status
  • Aboriginal and Torres Strait Islander.

Assessment

  • It can be difficult to distinguish clinically between viral tonsillitis (majority) and bacterial tonsillitis (15 to 30%)
  • Viral tonsillitis is highly likely where there are other symptoms of a viral upper respiratory tract infection.

History

  • Sore throat
  • Difficulty swallowing
  • Cervical lymphadenopathy
  • Fever
  • Headaches
  • Abdominal pain
  • Worsening sleep apnoea
  • Ear aches – referred pain
  • Symptoms of a viral upper respiratory tract infection: rhinorrhoea, cough, hoarseness, watery red eyes.

Examination

  • Fever
  • Erythematous tonsils and pharynx with / without exudate
  • Enlarged and tender cervical lymph nodes
  • When severe there may be upper airway obstruction – stridor, drooling, and signs of respiratory distress.
Clinical features that are more suggestive of GABHS include:
  • Scarlantiniform rash
  • Soft palate petechiae – 'doughnut lesions'
  • Exudate on pharynx and / or tonsils
  • Vomiting
  • Tender cervical lymphadenopathy
  • High fever
  • Absence of viral upper respiratory tract symptoms.

With Epstein - Barr virus (EBV) there is exudative tonsillitis and there may be significant malaise, hepato-splenomegaly and submandibular (and generalised) lymphadenopathy.

Investigations

  • Bacterial throat swab for culture is usually not indicated. Results take 24 to 48 hours.
    • Do not delay antibiotic treatment while awaiting results.

Differential diagnoses

Management

  • The vast majority of children only need symptomatic treatment
  • Supportive care includes adequate hydration and simple analgesia.

Resuscitation

  • Airway: If there is airway compromise (eg: stridor) intravenous Dexamethasone (dose: 0.15mg/kg) can be used.

Initial management

  • Definitive prescription should be made empirically on clinical presentation
  • Antibiotic treatment of Streptococcal tonsillitis probably only reduces the duration of symptoms by 12 to 24 hours
  • The main benefits of antibiotics are the prevention of suppurative complications and the prevention of post-infectious immune-mediated acute rheumatic fever
  • Antibiotics administered within 7 to 9 days of the illness is almost 100% successful in preventing acute rheumatic fever. Delaying antibiotics pending the throat swab result will not reduce their efficacy in preventing acute rheumatic fever.
  • Aboriginal and Torres Strait Islander children have a higher rate of complications with rheumatic heart disease and post-streptococcal glomerulonephritis. Therefore there is a lower threshold for prescription of antibiotics for these children.
  • There is no evidence that antibiotic treatment will prevent post-streptococcal glomerulonephritis
  • Steroids can have a role in acute pain management. Studies have shown that 1 to 3 doses of Dexamethasone (dose: 0.15mg/kg) will improve pain faster and allow return to normal activities faster.
  • Analgesia must be used. Paracetamol is usually sufficient. Ibuprofen is an alternative.
  • Avoid aspirin in children because of the risk of Reye syndrome
  • Children older than 12 years may use aspirin gargles
  • Other symptomatic treatments such as salt water gargles, throat lozenges and sprays have varying anecdotal results and have not been proven to be of benefit in clinical trials
  • Supportive care also includes encouraging oral fluids and encouraging oral hygiene (brushing teeth and rinsing with an antiseptic mouthwash)
  • Intravenous fluids may be considered if dehydrated.

Complications

Suppurative Complications

  • Peritonsillar abscess
  • Retro-pharyngeal abscess
  • Cervical lymphadenitis
  • Sinusitis
  • Mastoiditis
  • Otitis media.

Complications of GABHS

  • Acute rheumatic fever
  • Post-Streptococcal glomerulonephritis

Other complications

Medications

Admission criteria

  • Upper airway obstruction
  • Severe dysphagia and inadequate oral hydration (require intravenous fluids)
  • Fever with significant signs of sepsis
  • Suppurative complications
  • Pain not controlled with oral analgesia.

Referrals and follow-up

  • GP follow up regarding clinical status +/- swab results within 48 hours
  • Indications for referral to a Paediatric Ear, Nose and Throat surgeon to consider an elective tonsillectomy:
    • recurrent tonsillitis
    • episodes of severe tonsillitis requiring hospital admission
    • peritonsillar abscess
    • obstructive sleep apnoea
  • Referral to a paediatric respiratory physician for further investigations should be considered where there is a history or obstructive sleep apnoea.

Bibliography

  1. Pichichero ME (2017) Treatment and prevention of streptococcal tonsillopharyngitis. UpToDate. Accessed at www.uptodate.com on 14/08/2017
  2. Wald ER (2012) Approach to diagnosis of acute infectious pharyngitis in children and adolescents. Up-to-date. Accessed at www.uptodate.com on 31/05/13.


Endorsed by:  Director, Emergency Department  Date:  Aug 2017


 Review date:   Aug 2020


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