This document provides information on the anatomy, clinical presentation, diagnosis and treatment of acute and chronic tonsillitis. It describes: 1. The anatomy of the palatine tonsils and their location in the oropharynx between the anterior and posterior pillars. 2. The clinical presentation of acute tonsillitis including sore throat, fever, and enlarged and inflamed tonsils. Common causes are streptococcus and staphylococcus bacteria. 3. The treatment of acute tonsillitis which involves pain medication, antibiotics for 7-10 days, and tonsillectomy for recurrent or severe cases.

1. Acute and chronic
tonsilitis

2. Applied anatomy of palatine (faucial)
tonsils :
Palatine tonsils are two in number. Each tonsil is an ovoid mass of
lymphoid tissue situated in the lateral wall of oropharynx between the
anterior and posterior pillars.
A tonsil presents two surfaces—a medial and a lateral, and two
poles—an upper and a lower.

3. Medial surface
Medial surface of the tonsil is
covered by nonkeratinizing
stratified squamous
epithelium which dips into the
substance of tonsil in the form
of crypts. Openings of 12–15
crypts can be seen on the
medial surface of the tonsil.
One of the crypts, situated
near the upper part of tonsil is
very large and deep and is
called crypta magna or
intratonsillar cleft (Figure
51.1). It represents the ventral
part of second pharyngeal

4. Bed of the tonsil :
Bed of the tonsil. It is formed by the
superior constrictor and
styloglossus muscles. The
glossopharyngeal nerve and styloid
process, if enlarged, may lie in
relation to the lower part of tonsillar
fossa. Both these structures can be
surgically approached through the
tonsil bed after tonsillectomy.
Outside the superior constrictor,
tonsil is related to the facial artery,
submandibular salivary gland,
posterior belly of digastric muscle,
medial pterygoid muscle and the
angle of mandible.

5. Blood supply:
The tonsil is supplied by five
arteries
1. Tonsillar branch of facial
artery. This is the main artery.
2. Ascending pharyngeal artery
from external carotid.
3. Ascending palatine, a branch
of facial artery.
4. Dorsal linguae branches of
lingual artery.
5. Descending palatine branch of
maxillary artery.

6. Venous, lymphatics drainage & nerve supply

7. Functions of tonsils
They act as sentinels to guard against foreign intruders like viruses, bacteria
and other antigens coming into contact through inhalation and ingestion.
There are two mechanisms:
1. Providing local immunity.
2. Providing a surveillance mechanism so that entire body is prepared for
defence. Both these mechanisms are operated through humoral and
cellular immunity.

8. Acute tonsillitis
1. Acute catarrhal or superficial
tonsillitis: Here tonsillitis is a part of
generalized pharyngitis and is
mostly seen in viral infections.
2. Acute follicular tonsillitis:
Infection spreads into the crypts
which become filled with purulent
material, presenting at the openings
of crypts as yellowish spots (Figure
51.4).
3. Acute parenchymatous tonsillitis:
Here tonsil substance is affected.
Tonsil is uniformly enlarged and red.
4. Acute membranous tonsillitis: It is
a stage ahead of acute follicular
tonsillitis when exudation from the
crypts coalesces to form a
membrane on the surface of tonsil

9. Aetiology
Acute tonsillitis often affects school-going children, but also affects adults. It is rare in infants
and in persons who are above 50 years of age.
Haemolytic streptococcus is the most commonly infecting organism.
Other causes of infection may be staphylococci, pneumococci or
H. influenzae. These bacteria may primarily infect the tonsil or may be secondary to a viral
infection.

10. Symptoms
The symptoms vary with severity of infection. The predominant symptoms
are:
1. Sore throat.
2. Difficulty in swallowing. The child may refuse to eat anything due to local
pain.
3. Fever. It may vary from 38 to 40 °C and may be associated with chills and
rigors. Sometimes, a child presents with an unexplained fever and it is only
on examination that an acute tonsillitis is discovered.
4. Earache. It is either referred pain from the tonsil or the result of acute
otitis media which may occur as a complication.
5. Constitutional symptoms. They are usually more marked than seen in
simple pharyngitis and may include headache, general body aches, malaise
and constipation. There may be abdominal pain due to mesenteric
lymphadenitis simulating a clinical picture of acute appendicitis.

11. Signs
1. Often the breath is foetid and tongue is
coasted.
2. There is hyperaemia of pillars, soft
palate and uvula.
3. Tonsils are red and swollen with
yellowish spots of purulent material
presenting at the opening of crypts (acute
follicular tonsillitis) or there may be a
whitish membrane on the medial surface of
tonsil which can be easily wiped away with
a swab (acute membranous tonsillitis). The
tonsils may be enlarged and congested so
much so that they almost meet in the
midline along with some oedema of the
uvula and soft palate (acute
parenchymatous tonsillitis)
4. The jugulodigastric lymph nodes are
enlarged and tender

12. Treatment
1. Patient is put to bed and encouraged to take plenty of fluids.
2. Analgesics (aspirin or paracetamol) are given according to the age
of the patient to relieve local pain and bring down the fever.
3. Antimicrobial therapy. Most of the infections are due to
Streptococcus and penicillin is the drug of choice. Patients allergic to
penicillin can be treated with erythromycin.
Antibiotics should be continued for 7–10 days.

13. Complications
1 Chronic tonsillitis with recurrent acute attacks. This is due to incomplete
resolution of acute infection. Chronic infection may persist in lymphoid
follicles of the tonsil in the form of microabscesses.
2. Peritonsillar abscess.
3. Parapharyngeal abscess.
4. Cervical abscess due to suppuration of jugulodigastric lymph nodes.
5. Acute otitis media. Recurrent attacks of acute otitis media may coincide
with recurrent tonsillitis.
6. Rheumatic fever. Often seen in association with tonsillitis due to Group A
beta-haemolytic Streptococci.
7. Acute glomerulonephritis. Rare these days.
8. Subacute bacterial endocarditis. Acute tonsillitis in a patient with valvular
heart disease may be complicated by endocarditis. It is usually due to
Streptococcus viridans infection

14. Differential diagnosis of membrane over the tonsil
1. Membranous tonsillitis. It occurs due to pyogenic organisms. An exudative
membrane forms over the medial surface of the tonsils, along with the features
of acute tonsillitis.
2. Diphtheria. Unlike acute tonsillitis which is abrupt in onset, diphtheria is
slower in onset with less local discomfort, the membrane in diphtheria extends
beyond the tonsils, on to the soft palate and is dirty grey in colour. It is adherent
and its removal leaves a bleeding surface. Urine may show albumin. Smear and
culture of throat swab will reveal Corynebacterium diphtheriae.
3. Vincent angina. It is insidious in onset with less fever and less discomfort in
throat. Membrane, which usually forms over one tonsil, can be easily removed
revealing an irregular ulcer on the tonsil. Throat swab will show both the
organisms typical of disease, namely fusiform bacilli and spirochaetes.
4. Infectious mononucleosis. This often affects young adults. Both tonsils are
very much enlarged, congested and covered with membrane. Local discomfort is
marked. Lymph nodes are enlarged in the posterior triangle of neck along with
splenomegaly. Attention to disease is attracted because of failure of the
antibiotic treatment. Blood smear may show more than 50% lymphocytes, of
which about 10% are atypical. White cell count may be normal in the first week
but rises in the second week. Paul–Bunnell test (mono test) will show high titre of

15. Differential diagnosis of membrane over the tonsil
5. Agranulocytosis. It presents with ulcerative necrotic lesions not only on the tonsils
but elsewhere in the oropharynx. Patient is severely ill. In acute fulminant form, total
leucocytic count is decreased to 100,000/cu mm. It may be normal or less than normal.
Anaemia is always present and may be progressive. Blasts cells are seen on
examination of the bone marrow.
6. Leukaemia. In children, 75% of leukaemias are acute lymphoblastic and 25% acute
myelogenous or chronic, while in adults 20% of acute leukaemias are lymphocytic and
80% nonlymphocytic. Peripheral blood shows TLC >100,000/cu mm. It may be normal
or less than normal. Anaemia is always present and may be progressive. Blasts cells are
seen on examination of the bone marrow
7. Aphthous ulcers. They may involve any part of oral cavity or oropharynx. Sometimes,
it is solitary and may involve the tonsil and pillars. It may be small or quite large and
alarming. It is very painful.
8. Malignancy tonsil (see p. 305)
9. Traumatic ulcer. Any injury to oropharynx heals by formation of a membrane.
Trauma to the tonsil area may occur accidently when hit with a toothbrush, a pencil
held in mouth or fingering in the throat. Membrane appears within 24 h.
10. Candidal infection of tonsil

16. Faucial diphtheria
Aetiology:
It is an acute specific infection caused by the Gram-positive bacillus,
C. diphtheriae. It spreads by droplet infection. Incubation period is 2–
6 days. Some persons are “carriers” of this disease, i.e. they harbour
organisms in their throat but have no symptoms.
Clinical features :
Children are affected more often though no age group is immune.
Oropharynx is commonly involved and the larynx and nasal cavity
may also be affected. In the oropharynx, a greyish white membrane
forms over the tonsils and spreads to the soft palate and posterior
pharyngeal wall. It is quite tenacious and causes bleeding when
removed. Cervical lymph nodes, particularly the jugulodigastric,
become enlarged and tender, sometimes presenting a “bull-neck”
appearance. Patient is ill and toxaemic but fever seldom rises above
38 °C.

17. COMPLICATIONS
Exotoxin produced by C. diphtheriae is toxic to the heart and nerves.
It causes myocarditis, cardiac arrhythmias and acute circulatory
failure. Neurological complications usually appear a few weeks after
infection and include paralysis of soft palate, diaphragm and ocular
muscles.
In the larynx, diphtheritic membrane may cause airway obstruction.

18. TREATMENT
Treatment of diphtheria is started on clinical suspicion without
waiting for the culture report.
Aim is to neutralize the free exotoxin still circulating in the blood and
to kill the organisms producing this exotoxin. Dose of antitoxin is
based on the site involved and the duration and severity of disease. It
is 20,000–40,000 units for diphtheria in less than 48 h, or when the
membrane is confined to the tonsils only; and 80,000–120,000 units,
if disease has lasted longer than 48 h, or the membrane is more
extensive. Antitoxin is given by i.v. infusion in saline in about 60 min.
Sensitivity to horse serum should be tested by conjunctival or
intracutaneous test with diluted antitoxin and adrenaline should be at
hand for any immediate hypersensitivity. In the presence of
hypersensitivity reaction, desensitization should be done. Antibiotics
used are benzyl penicillin 600 mg 6 hourly for 7 days. Erythromycin is
used in penicillin-sensitive individuals (500 mg 6 hourly orally).

19. CHRONIC TONSILLITIS

20. AETIOLOGY
1. It may be a complication of acute tonsillitis. Pathologically,
microabscesses walled off by fibrous tissue have been seen in the
lymphoid follicles of the tonsils.
2. Subclinical infections of tonsils without an acute attack.
3. Mostly affects children and young adults. Rarely occurs after 50
years.
4. Chronic infection in sinuses or teeth may be a predisposing factor.

21. TYPES
1. Chronic Follicular Tonsillitis. Here
tonsillar crypts are full of infected
cheesy material which shows on the
surface as yellowish spots.
2. Chronic Parenchymatous
Tonsillitis. There is hyperplasia of
lymphoid tissue. Tonsils are very
much enlarged and may interfere
with speech, deglutition and
respiration Attacks of sleep apnoea
may occur. Long-standing cases
develop features of cor pulmonale.
3. Chronic Fibroid Tonsillitis. Tonsils
are small but infected, with history
of repeated sore throats.

22. CLINICAL FEATURES
1. Recurrent attacks of sore throat or acute tonsillitis.
2. Chronic irritation in throat with cough.
3. Bad taste in mouth and foul breath (halitosis) due to pus in crypts.
4. Thick speech, difficulty in swallowing and choking spells at night
(when tonsils are large and obstructive)

23. EXAMINATION
1. Tonsils may show varying degree of enlargement. Sometimes they
meet in the midline (chronic parenchymatous type).
2. There may be yellowish beads of pus on the medial surface of
tonsil (chronic follicular type).
3. Tonsils are small but pressure on the anterior pillar expresses
frank pus or cheesy material (chronic fibroid type).
4. Flushing of anterior pillars compared to the rest of the pharyngeal
mucosa is an important sign of chronic tonsillar infection.
5. Enlargement of jugulodigastric lymph nodes is a reliable sign of
chronic tonsillitis. During acute attacks, the nodes enlarge further
and become tender

24. TREATMENT
1. Conservative treatment consists of attention to
-general health,
-diet,
-treatment of coexistent infection of teeth, nose and sinuses.
2. Tonsillectomy is indicated when tonsils interfere with speech,
deglutition and respiration or cause recurrent attacks.

25. COMPLICATIONS OF CHRONIC
TONSILITIS
1. Peritonsillar abscess
2. Parapharyngeal abscess. 3.
Intratonsillar abscess.
4. Tonsilloliths.
5. Tonsillar cyst.
6. Focus of infection in rheumatic
fever, acute glomerulonephritis,
eye and skin disorders.

26. INDICATIONS OF TONSILLECTOMY
They are divided into:
A. ABSOLUTE
1. Recurrent infections of throat. This is the most common indication.
Recurrent infections are further defined as:
(a) Seven or more episodes in 1 year, or
(b) Five episodes per year for 2 years, or
(c) Three episodes per year for 3 years, or
(d) Two weeks or more of lost school or work in 1 year.

27. INDICATIONS OF TONSILLECTOMY
A. ABSOLUTE
2. Peritonsillar abscess. In children, tonsillectomy is done 4–6 weeks after
abscess has been treated. In adults, second attack of peritonsillar abscess
forms the absolute indication.
3. Tonsillitis which causes febrile seizures.
4. Hypertrophy of tonsils causing
(a) airway obstruction (sleep apnoea),
(b) difficulty in deglutition and
(c) interference with speech.
5. Suspicion of malignancy. A unilaterally enlarged tonsil may be a lymphoma
in children and an epidermoid carcinoma in adults. An excisional biopsy is
done.

28. INDICATIONS OF TONSILLECTOMY
B. RELATIVE
1. Diphtheria carriers, who do not respond to antibiotics.
2. Streptococcal carriers, who may be the source of infection to
others.
3. Chronic tonsillitis with bad taste or halitosis which is unresponsive
to medical treatment.
4. Recurrent streptococcal tonsillitis in a patient with valvular heart
disease.

29. INDICATIONS OF TONSILLECTOMY
C. AS A PART OF ANOTHER OPERATION
1. Palatopharyngoplasty which is done for sleep apnoea syndrome.
2. Glossopharyngeal neurectomy. Tonsil is removed first and then IX
nerve is severed in the bed of tonsil.
3. Removal of styloid process.

30. CONTRAINDICATIONS OF
TONSILLECTOMY
1. Haemoglobin level less than 10 g%.
2. Presence of acute infection in upper respiratory tract, even acute
tonsillitis. Bleeding is more in the presence of acute infection.
3. Children under 3 years of age. They are poor surgical risks.
4. Overt or submucous cleft palate.
5. von Willebrand disease. Bleeding disorders, e.g. leukaemia,
purpura, aplastic anaemia, haemophilia or sickle cell disease.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac disease,
hypertension or asthma.
8. Tonsillectomy is avoided during the period of menses