Overview
Definition:
Recurrent tonsillitis is defined as a significant number of tonsil infections within a given period, causing substantial morbidity
While definitions vary, a commonly cited criterion is at least 7 episodes in the past year, or at least 5 episodes per year in the past 2 years, or at least 3 episodes per year in the past 3 years, especially when associated with fever or difficulty swallowing.
Epidemiology:
Tonsillitis is common in school-aged children (5-15 years)
Recurrence impacts approximately 10-20% of children experiencing frequent tonsillar infections
Viral infections are more common overall, but bacterial infections, particularly Group A Streptococcus (GAS), are a primary concern for recurrence and sequelae.
Clinical Significance:
Recurrent tonsillitis leads to missed school days, parental work absence, and can significantly impact a child's quality of life
It also presents a diagnostic challenge in differentiating viral from bacterial causes and determining the appropriate timing for surgical intervention, which is crucial for DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
Sore throat, often severe
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Fever, typically high-grade
Headache
Malaise
Sometimes, halitosis (bad breath)
Neck stiffness or pain due to enlarged lymph nodes.
Signs:
Pharyngeal erythema
Tonsillar enlargement and erythema
Exudates on tonsils (white or yellowish patches)
Palpable, tender anterior cervical lymphadenopathy
Possible petechiae on the palate.
Diagnostic Criteria:
Clinical diagnosis based on symptoms and signs
Confirmation of bacterial etiology often involves rapid antigen detection tests (RADTs) or throat cultures for Group A Streptococcus
Centor criteria can aid in assessing likelihood of GAS pharyngitis in older children and adults but are less reliable in very young children.
Diagnostic Approach
History Taking:
Detailed history of sore throat frequency, severity, and duration
Documented episodes with fever or antibiotic treatment
Associated symptoms like snoring or obstructive sleep apnea
History of complications (e.g., peritonsillar abscess)
Previous tonsillectomy status.
Physical Examination:
Thorough oral examination focusing on tonsillar appearance, exudates, and size
Palpation of cervical lymph nodes for tenderness and size
Assessment of airway patency
Examination of the ears and nose to rule out other infections.
Investigations:
Throat swab for rapid antigen detection test (RADT) for Group A Streptococcus
If RADT is negative but suspicion remains high, send for throat culture
Complete blood count (CBC) may show leukocytosis
Monospot test if infectious mononucleosis is suspected.
Differential Diagnosis:
Viral pharyngitis
Infectious mononucleosis (Epstein-Barr virus)
Diphtheria (rare but serious)
Peritonsillar abscess
Retropharyngeal abscess
Foreign body ingestion
Scarlet fever
Kawasaki disease.
Management
Medical Management:
For confirmed or suspected bacterial tonsillitis: Antibiotics are indicated
Penicillin V (e.g., 500 mg BID for adults, 25 mg/kg/day divided into 2-3 doses for children) or Amoxicillin are first-line
Duration typically 10 days
For viral tonsillitis: Supportive care including analgesics (paracetamol, ibuprofen), antipyretics, and hydration.
Surgical Management:
Indications for tonsillectomy: Documented recurrent episodes meeting specific criteria (e.g., >7 in 1 year, >5/yr for 2 yrs, >3/yr for 3 yrs)
History of peritonsillar abscess
Tonsillar hypertrophy causing airway obstruction or obstructive sleep apnea (OSA)
Chronic tonsillitis with persistent symptoms
Suspected tonsillar malignancy (rare).
Perioperative Care:
Preoperative: Optimize hydration and nutritional status
Rule out bleeding diathesis (coagulation profile if indicated)
Counsel parents on risks and recovery
Postoperative: Pain management is paramount (scheduled analgesics, multimodal approach)
Adequate hydration
Monitor for bleeding (hematemesis, coffee-ground emesis, bright red blood)
Soft diet
Avoidance of straws and forceful spitting
Close follow-up.
Supportive Care:
Encourage fluid intake to prevent dehydration
Humidification of air
Rest
Antipyretics and analgesics as needed
Soft, bland diet to ease swallowing.
Complications
Early Complications:
Hemorrhage (primary or secondary, most common within 24 hours or 5-10 days post-op)
Dehydration
Airway obstruction (especially in children with underlying OSA)
Anesthesia-related complications
Pain
Infection.
Late Complications:
Chronic pain
Scarring and adhesions
Voice changes (nasal regurgitation)
Taste disturbances (rare)
Velopharyngeal insufficiency (rare).
Prevention Strategies:
Strict adherence to surgical indications
Meticulous surgical technique
Aggressive pain management postoperatively
Close monitoring for bleeding
Adequate hydration
Patient and parental education on post-operative care and warning signs.
Prognosis
Factors Affecting Prognosis:
Adequacy of surgical technique
Effective pain control
Patient compliance with post-operative instructions
Underlying comorbidities
The presence of obstructive sleep apnea.
Outcomes:
Tonsillectomy significantly reduces the frequency and severity of recurrent sore throats
Improved quality of life, reduced school absenteeism
Resolution of OSA symptoms when present
Most children recover fully within 1-2 weeks.
Follow Up:
Routine follow-up 2-4 weeks post-operatively to assess healing, pain control, and hydration
Longer-term follow-up may be needed for OSA resolution or persistent symptoms
Advise immediate medical attention for significant bleeding or signs of dehydration.
Key Points
Exam Focus:
Know the specific criteria for tonsillectomy (e.g., Paradise criteria or equivalent)
Understand the rationale behind surgical intervention
Differentiate viral vs
bacterial pharyngitis
Be aware of the most common and most serious complications of tonsillectomy, especially bleeding and dehydration.
Clinical Pearls:
Always consider infectious mononucleosis in adolescents with severe pharyngitis and fatigue
Aggressive pain control is key to successful post-tonsillectomy recovery and preventing complications like dehydration
Assess for sleep-disordered breathing preoperatively, as it can impact airway management and post-op recovery.
Common Mistakes:
Over-prescription of antibiotics for viral tonsillitis
Underestimating the severity of post-tonsillectomy pain and its impact on hydration
Failing to adequately assess for obstructive sleep apnea prior to surgery
Inadequate patient and parental education regarding post-operative care and warning signs of complications.