Tonsillitis is an infection of the mucosa and parenchyma of the tonsils. The most common causative micro-organisms of an uncomplicated tonsillitis are viruses (e.g. coxsackievirus, respiratory syncytial virus) or bacteria (e.g. Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus). Epstein-Barr virus (EBV) is the causative agent in 2% of cases. The beta-haemolytic Streptococcus group A subtype (that may also cause scarlet fever) used to be notorious for causing complications but this is less common nowadays.
A distinction between the viral and bacterial causes of tonsillitis cannot reliably be made in the office.
Patients with tonsillitis most often present complaining of a sore throat. Other coldlike symptoms are often present. In addition, the tonsils are swollen and red and there is exudate present. Lymph nodes in the neck region may be swollen and painful. Patients’ temperatures can be (sub)febrile. Tonsillitis is a ‘clinical’ diagnosis and additional diagnostic tests are not necessary. It may occur in isolation or it may overlap with pharyngitis. Sometimes, the two conditions are referred to as ‘pharyngotonsillitis’. The clinical picture of the Epstein-Barr virus infection is called ‘infectious mononucleosis’ and includes fever, pharyngitis (or pharyngotonsillitis) and lymphadenopathy.
Tonsillitis in most cases tends to last between seven and ten days, regardless of the pathogen. Treatment is focused on symptom relief with analgesics. Dutch GPs will apply ‘watchful waiting’, which is possible in the context of easily accessible and continuous GP care for everyone in the Netherlands, allowing patients to come back if symptoms persist or worsen. The Dutch College of General Practitioners advises against antibiotics, unless the patient is seriously ill or has an increased risk of complications. In these cases, small-spectrum antibiotics are advised.
Complications may occur when the inflammation expands to the tissue between the tonsil and pharyngeal muscle. This is called a peritonsillar cellulitis (also named peritonsillitis) or a peritonsillar abscess (when pus is present). It is difficult to differentiate between these diagnoses and if suspected, the patient should be referred to the otorhinolaryngologist, especially when the patient is very ill, immunocompromised, or has difficulty swallowing or opening the mouth. If this is not the case, the GP should prescribe a broad-spectrum antibiotic and frequently check on the patient. In the very rare case of an (imminent) upper airway obstruction, an emergency referral is needed.
In young children, ‘cervical lymphadenitis’ is a rare complication of tonsillitis in which the lymph nodes themselves get infected, usually with a Staphylococcus or Streptococcus bacteria. Broad spectrum antibiotics or referral are indicated in this case.