Cases in Tonsil Disease: From the Routine to the Serious

Gordon H. Sun, MD, MS


May 23, 2017


Although tonsillitis is putatively considered inflammation of the pharyngeal tonsils typically caused by an infection, no gold standard diagnostic test for the condition exists, and the term "tonsillitis" is often used interchangeably with pharyngitis or sore throat.[1] The most well-known clinical definition for an episode of tonsillitis, established by Paradise and colleagues,[2,3] includes sore throat plus at least one of the following characteristics:

  • Oral temperature ≥38.3º C;

  • Tender or enlarged (>2 cm) cervical lymph nodes;

  • Tonsillar exudate; or

  • Positive group A beta-hemolytic streptococcus (GABHS) culture.

Centers for Disease Control and Prevention data[4] indicate that acute tonsillitis and pharyngitis accounted for about 15 million visits in outpatient settings in 1996. GABHS causes 5%-10% of adult and 15%-30% of pediatric pharyngitis cases, and it is the only commonly occurring etiologic agent necessitating antibiotic therapy.[5] GABHS infection can lead to severe complications such as rheumatic fever, poststreptococcal glomerulonephritis, and toxic shock syndrome.[6,7,8,9] Despite medical treatment, 20%-30% of patients diagnosed with GABHS-related pharyngitis acquire a recurrent infection within 60 days of antibiotic therapy.[10] In addition to significant medical risks, GABHS-related pharyngitis among US children accrues estimated costs of $224-$539 million annually.[8] More frequent sore throats have been correlated with worse quality of life (QOL) in children,[11] and patients who have had tonsillectomy for recurrent or chronic tonsillitis have reported significantly improved QOL, significantly fewer missed days of work or school, and fewer visits to primary care providers after surgery.[12,13]

Medical treatment for tonsillitis and pharyngitis not due to GABHS is very controversial. Most causes of sore throat are viral and do not respond to antibiotics.[5] Despite recent recommendations for medical treatment for streptococcal pharyngitis,[14,15] overuse and inappropriate selection of antibiotics for sore throat remain common in adult and pediatric populations.[16,17,18]

Surgery or More Antibiotics?

Anna, accompanied by her mother, visited her pediatrician about a year later with a complaint of multiple episodes of sore throat. She reported having a fever and sore throat nearly every month since her first visit to the school clinic. Medical records indicated that the patient had eight visits to either the school nurse practitioner or the pediatrician for sore throat during the past 12 months and was prescribed penicillin on half of those occasions. Physical examination revealed findings consistent with acute tonsillitis, and a rapid strep test was positive. She was again placed on oral antibiotics.

The patient was frustrated with the frequency of infections, particularly as a result of the negative impact the illnesses were having on her studies and extracurricular activities. She asked whether surgery would help reduce or eliminate her sore throat symptoms.


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