The tonsils are lymphoid tissue located in the throat that help the immune system. Acute tonsillitis is usually caused by viruses or bacteria like Streptococcus and is typically self-limiting. Treatment focuses on pain relief and hydration. Antibiotics may help if symptoms persist after 2-3 days. Complications are rare but include peritonsillar abscesses, which are treated with antibiotics and needle aspiration. The tonsils can also present lymphomas or cancers.

1. Diseases of the tonsil
Structure of the tonsil
The palatine tonsil consists of paired aggregates of lymphoid tissue, located in the pocket formed
between the palatoglossus & palatopharyngeus muscles & overlying folds of mucosa, which make up
the anterior pillar & posterior pillars. The tonsils share common structure with lymphoid tissue
elsewhere in the gastrointestinal & respiratory tracts including the adenoids& payer patches in the
small intestine & within the appendix.
Histologically they consists of lymphoid follicles(aggregations of lymphocytes) embedded in a stroma
of connective tissue. The stratified squamous mucosal covering of the tonsil extends irregular
convoluted invaginations into the parenchyma forming pits or crypts.
Microorganisms, desquamated epithelium, food debris are frequently present within the crypts &
may be implicated in the development of acute or recurrent inflammation.
Normal flora
The range of organisms cultured from the tonsils both in health & disease is extremely variable.
1. The organism most commonly identified from the surface of the tonsil in disease is the
group A beta haemolytic streptococcus. Up to 40% of the asymptomatic individuals will
have culture positive for this organism.
2. Haemophilus influenza;
3. Staphylococcus aureus;
4. Alpha haemolytic streptococcus
5. Branhamella sp.
6. Mycoplasma;
7. Chlamydia
8. Various anaerobes
9. A variety of respiratory virus.
Core samples obtained by FNAC in health & disease, core samples of normal tonsils usually failed to
grow pathogenic organisms.
Recurrent tonsillitis the predominant organisms are H. Influenza, & staphylococcus aureus. A mixed
flora is also common. Beta-haemolytic streptococcus is less common.

2. Function of tonsils
B lymphocyte predominates, implying both cell-mediated & humoral immune function. These cells
have capacity to synthsize specific antibodies. They appear to final differentiation, induced by
exposure to antigen of B cells to principally immunoglobulin IgG & IgA plasma cells.
It seems that they generate B cells which express polymeric IgA which migrate to the upper
respiratory tract mucocsa & associated with first line defense. Contact with allergens in the upper
respiratory tract therefore local immunity &also contributes to the development of systemic
immunity.
(old adage that the function of tonsil is to develop tonsillitis. Whether or not tonsillitis represents a
swamping of defense mechanism at local level or an exaggeration of the normal response is not
known).
Polymeric IgA production is reduced with recurrent tonsillitis. So tonsillectomy do not impaired
immunity. Because extensive back up in the immune system.
Presence of latent viruses ( particularly Epstein-Barr virus, adenovirus, herpes simplex virus)
sensitizing the pathogenic bacteria frequently present on the tonsils of asymptomatic individuals.
Acute tonsillitis
Acute inflammatory episodes affecting the tonsils may occur as an isolated, or in association with a
viral upper respiratory illness including generalised pharyngitis. Tonsillitis may also present as part of
a systemic infection such as infectious mononucleosis.
Epidemiology
Sore throat is a common presentation. Not all these sore throat due to true tonsillitis. Sore throat
affects both sexes & all age group but is much more common in children & during the autumn &
winter months.
Clinical evaluation
The diagnosis of acute tonsillitis is clinical. It is based on a history of a pyrexial illness, sore throat
with a painful swallow & finding of pharyngeal erythema with or without tonsillar exudates & painful
cervical adenopathy. It shoud not relied upon in diagnosis of bacterial or viral aetiology.
With the exception of tonsillitis associated with infectious mononucleosis, there is no evidence that
viral tonsillitis is more or less severe than bacterial tonsillitis or that the duration of illness varies
significantly in either ease.
Diagnosis of causative agent
Bacteriological culture or rapid antigen testing of throat swab for GABHS.(RAT is in common use in
north America but seldom in UK).
1. The incidence of a positive culture may be as high as 40% in asymptomatic carriers.

3. 2. Organism cultured from the surface of the tonsil may vary greatly from the bacterial flora
deep within the tonsillar crypts. It is by no means certain which is likely to be the more
relevant to clinical symptoms.
3. Inevitably , there is a delay of 24-48 hours before results are available, rendering its value
limited in treating a short-lived self-limited illness.
Rapid antigen testing as an office procedure has superficial attractions( ten minutes) but sensitivity
measured against throat swab culture varies between 61% & 95% with specificity from 88 to 100%.
Primary management of acute tonsillitis
Principally supportive with use of analgesics & adequate hydration until the symptoms subside. The
majority will find paracetamol in full dosage. Non-steroidal anti-inflammatory drugs may be used in
severe cases as a second-line treatment.
Specific treatment in those patient in whom the illness shows no sign of improvement within 48-72
hours, antibiotic therapy is appropriate & drug f choice remains benzylpenicillin for seven days.
Alternative antibiotic cephalosporins.
A single dose of dexamethasone as an adjuvant therapy is significant benefit in reducing pain in
acute pharyngotonsillitis with no abscess formation with the use of steroids.
Complications of acute tonsillitis
1)Peritonsillar abscess
the principal complication of tonsillitis is peritonsillar abscess in which collection of pus forms in the
potential space between the tonsil & its bed. Clinically, patient presents with a severe pharyngitis
with cervical lymphadenopathy. There may be severe trismus limited access for examination&
treatment.
Treatment antibiotic , incision & drainage of abscess or needle aspiration in hospital. In severe cases,
airway compromise & dehydration due to the inability to swallow result, which may necessitate
hospital admission for intravenous fluid therapy.
Peritonsillar abscess formerly regarded as an absolute indication for interval tonsillectomy. Now
second quinsy is a reasonable indication for operation.
2)Retropharyngeal abscess
Present mainly in infant & young children less than five years. It presents when infction has tracked
down into the lymphoid tissue between posterior pharyngeal wall & prevertebral fascia.
A plain x-ray of the neck may be helpful.
Treatment is initially high –dose of antibiotic therapy with urgent incision & drainage abscess
perorally.

4. 3)Parapharyngeal abscess
Peritonsillar & retropharyngeal abscess may occasionally be complicated by spread of infection to
the parapharyngeal space with formation of a large abscess which may require external drainage.
The patient is severely unwell, with severe trismus.
The use of broad-spectrum antibiotic intravenously covering against streptococci& anaerobes
organisms.
Deep neck space sepsis may be complicated by progressive, life-threatening spread of infection
including mediastinitis& even retroperitoneal sepsis.
Vigilance & a proactive management policy are thus essential in all cases.
4)Lermierre’s syndrome
This is rare but potentially fatal complication of oropharyngeal infection characterized by septic
thrombophlebitis in the internal jugular vein. The organism is typically fusiform bacillus. The
condition should be considered when there is severe neck pain,septicaemia or a prolonged
fulminant course in a patient with infection in the upper aerodigestive tract. It may occur secondary
to tympanomastoid infection.
Treatment is with prolonged antibiotics, for example a beta-lactum with metronidazole.
Anticoagulant may be considered if there is evidence of spreading thrombophlebitis. There is
significant mortality.
5)Immune complex disorders
Acute tonsillitis caused by GABHS are occasionally complicated by disease related to immune
complex formation. ( ARF& AGN).
In communities where rheumatic fever is common,antibiotic therapy for sore throat may have a role
in reducing the incidence of this complication.
6)Tonsillitis & psoriasis
GABHS causes acute tonsillitis& exacerbation of psoriasis, particularly of the guttate variety. This
appear to be an immune phenomenon. Some advice tonsillectomy but ther is no evidence that this
relieves the condition.
6)Recurrent tonsillitis
Acute episodes appear to follow a pattern of recurring infection every few weeks or months.
7)Subacute tonsillitis
A subacute course where they are never free of low grade discomfort in the throat associated with
enlarged inflamed looking tonsils.
8)Chronic tonsillitis
Patients complain of chronic low grade symptoms affecting their quality of life because of throat
discomfort & production of unpleasant smelly white or yellow debris from the tonsillar crypts.

5. 9)Infectious mononucleosis
Acute pharyngotonsillitis is a frequent manifestation of infectious mononucleosis. This disease
commonly seen in young adults is caused by EBV(Epstein –Barr virus), one of the B lymphotropic
human herpes viruses.
In addition to throat manifestations, the disease causes severe systemic upset, haematological &
liver function disturbance & splenomegaly.
Diagnosis is by the monospot blood test( sensitivity<50% in children& > 70-90% in adults.
Confirmation by EBV antibody.
Although the disease is viral, secondary infection of the tonsils occurs 30% of cases with GSBHS.
Penicillin in high –doses intravenously. Ampicillin must be avoided due to severe allergic rash. A
short course of antibiotic is frequently employed as an adjunct.
Noninflammatory disease of tonsil
1)Asymmetry
A recent study of tonsil size after tonsillectomy revealed no significant difference in cases of
apparent asymmetry. Tonsil asymmetry is not absolute indication for tonsillectomy but in cases,
particularly in adults, the clinician should be alert for the possibility of neoplasia, notably lymphoma.
There is wide variation in the degree to which the tonsils are buried in the lateral wall giving a false
impression of the size.
The tonsil tends to involute during late childhood& early adult life but in presence of disease may
remain prominent into adulthood. The rate of involution varies between the two individuals &
sometimes this process varies between the two tonsils, giving an asymmetric appearance.
2)Spontaneous tonsillar haemorrhage
Occasionally , spontaneous bleeding from inflamed tonsils may take place. Or trauma on tonsils.
Occasionally if persistly troublesome, tonsillectomy may be indicated.
3)Neoplasia
Asymmetry of the tonsil may give rise to the suspicion of malignancy as may be an irregular or
ulcerated appearance of one the tonsils. In childhood, it is not unusual for the tonsils to involute
asymmetrically & accordingly, a disparity in size of tonsils is not always an indication for biopsy in
childhood. However unusual appearances should be treated with caution further investigation.
4)Lymphoma
In keeping the structure primarily of lymphoid origin, lymphoma may occur within the tonsils &
although this is most likely in the adult age group.
5) Squamous carcinoma
In common with the rest of the upper aerodigestive tract & oral cavity, in particular, squamous
carcinoma most common malignancy encountered.

6. Key points
1. Acute tonsillitis is common & self-limiting.
2. Complications are rare.
3. Treatment is largely symptomatic with an emphasis on analgesic & rehydration.
4. Antimicrobial therapy has a small but measurable effect on outcome.
5. The tonsil rarely may be the site of presentation of lymphoma or malignant disease.
Best clinical practice
1. In acute tonsillitis clinical diagnosis alone should not be relied upon in distingishing between a
bacterial or viral aetiology.
2. Both throat swab culture & RAT are of questionable value in guiding prescription of antibiotics
for sore throat.
3. Widespread indiscriminate antibiotic prescription promotes the genesis of resistant organisms,
allergy & anaphylaxis. There is no justification for routine use of antibiotics in children with sore
throat.
4. In those patients in whom the illness shows no sign of improvement within 48-72 hours or in
whom there is clinical concern because of the severity of symptoms, antibiotics therapy is
appropriate & the drug of choice remains benzylpenicillin. A seven day course is usually
adequate.
5. A single dose of dexamethasone as adjuvant therapy reduces pain in acute pharyngotonsillitis.
6. Aspiration using a wide bore a wide bore needle & syringe, together with antibiotic therapy, is
now the management of choice for quinsy. As significant number of peritonsillar abscesses grow
anaerobes, metronidazole should be considered.
7. Treatment of both parapharyngeal & retropharyngeal abscess is initially high dose antibiotic
therapy. When pus formation is suspected, incision & drainage under G/A with airway protected
by intubation by a skilled & experienced anaesthetist is recommended.
8. Ampicillin must be avoided in infectious mononucleosis as patients may suffer a severe allergic
rash in consequence.
9. Systemic glucocorticoid are of value in infectious mononucleosis where there is extreme
swelling of the pharyngeal mucosa with impending airway compromise.

7. Key points
1. Acute tonsillitis is common & self-limiting.
2. Complications are rare.
3. Treatment is largely symptomatic with an emphasis on analgesic & rehydration.
4. Antimicrobial therapy has a small but measurable effect on outcome.
5. The tonsil rarely may be the site of presentation of lymphoma or malignant disease.
Best clinical practice
1. In acute tonsillitis clinical diagnosis alone should not be relied upon in distingishing between a
bacterial or viral aetiology.
2. Both throat swab culture & RAT are of questionable value in guiding prescription of antibiotics
for sore throat.
3. Widespread indiscriminate antibiotic prescription promotes the genesis of resistant organisms,
allergy & anaphylaxis. There is no justification for routine use of antibiotics in children with sore
throat.
4. In those patients in whom the illness shows no sign of improvement within 48-72 hours or in
whom there is clinical concern because of the severity of symptoms, antibiotics therapy is
appropriate & the drug of choice remains benzylpenicillin. A seven day course is usually
adequate.
5. A single dose of dexamethasone as adjuvant therapy reduces pain in acute pharyngotonsillitis.
6. Aspiration using a wide bore a wide bore needle & syringe, together with antibiotic therapy, is
now the management of choice for quinsy. As significant number of peritonsillar abscesses grow
anaerobes, metronidazole should be considered.
7. Treatment of both parapharyngeal & retropharyngeal abscess is initially high dose antibiotic
therapy. When pus formation is suspected, incision & drainage under G/A with airway protected
by intubation by a skilled & experienced anaesthetist is recommended.
8. Ampicillin must be avoided in infectious mononucleosis as patients may suffer a severe allergic
rash in consequence.
9. Systemic glucocorticoid are of value in infectious mononucleosis where there is extreme
swelling of the pharyngeal mucosa with impending airway compromise.