EN4.38 | Acute and Chronic Tonsillitis — Summary & Reflection

KEY TAKEAWAYS

Tonsillitis is a common infection of the palatine tonsils — acute episodes are most often caused by Group A beta-haemolytic Streptococcus (GABHS) or viruses (adenovirus, EBV). The four Centor criteria (tonsillar exudate, tender anterior cervical lymphadenopathy, fever >38°C, absence of cough) estimate the probability of GABHS infection and guide antibiotic prescribing. First-line antibiotic is Penicillin V for a full 10 days — mandatory to prevent rheumatic fever and post-streptococcal glomerulonephritis. Never prescribe amoxicillin without ruling out EBV (glandular fever) — it causes a characteristic maculopapular rash. The most important complication of acute tonsillitis is peritonsillar abscess (quinsy) — recognised by unilateral peritonsillar bulging, uvular deviation to the contralateral side, trismus, and 'hot-potato' voice; managed by needle aspiration or incision and drainage. Tonsillectomy is indicated when Paradise criteria are met (≥7 episodes/1 year, or ≥5/year for 2 years, or ≥3/year for 3 years — each episode documented). Secondary haemorrhage (5–10 days post-tonsillectomy) is the most clinically significant post-operative complication in the community setting.

REFLECT

Tonsillitis is one of the most frequently over-treated and under-treated conditions in medicine simultaneously — over-treated with antibiotics in viral cases, and under-treated in terms of completing the course in bacterial cases. Reflect on the societal factors in India that might lead a patient to stop penicillin after 2–3 days when they feel better — cost of the remaining tablets, inconvenience, misinformation. How might you counsel such a patient at the point of prescribing? Now reflect on the quinsy scenario from the hook: if this patient had been seen 24 hours earlier when he just had a unilateral tonsillar swelling without trismus or uvular deviation, would you have recognised the early quinsy? What signs would prompt you to return him urgently before the abscess fully formed?