ACUTE AND CHRONIC TONSILLOPHARYNGITIS AND OBSTRUCTIVE
ADENOIDAL HYPERTROPHY
SCOPE OF THE PRACTICE GUIDELINE
This clinical practice guideline is for use by the Philippine Society of Otolaryngology-Head and
Neck Surgery. It covers the diagnosis and management of acute and chronic tonsillopharyngitis
and obstructive adenoidal hypertrophy in adults and children.
OBJECTIVES
The objectives of the guideline are (1) to describe clinical and epidemiologic features of tonsillitis
in children and adults including socioeconomic burden of disease; (2) to enumerate current
diagnostic techniques, and (3) to describe treatment options.
LITERATURE SEARCH
This guideline is based on the Clinical Practice Guidelines of the Philippine Society of
Otolaryngology – Head and Neck Surgery (1996) on Acute and Chronic Tonsillitis. This was
updated using available articles published in the past 10 years as found in The National Library of
Medicine’s PubMed database using the keyword tonsillitis. The search was limited to English
language articles involving humans. The search yielded 161 articles which were carefully
screened for relevance to the guideline. Of these, ninety-two (92) abstracts were selected and full
text journals were obtained whenever possible. In addition, several guidelines on sore
throat/pharyngitis and indications for tonsillectomy were included. These are the: Clinical Practice
Guideline on Tonsillitis by the American Academy of Otolaryngology-Head and Neck Surgery;
Clinical Practice Guidelines on the Management of Sore Throat of the Academy of Medicine
Malaysia (2003); National Clinical Guideline on the Management of Sore Throat and Indications
for Tonsillectomy of the Scottish Intercollegiate Guidelines Network (1999); Practice Guidelines
for the Diagnosis and Management of Group A Streptococcal Pharyngitis of the Infectious
Disease Society of America (2002); Practice Guidelines on the Diagnosis and Management of
Group A Streptococcal Pharyngitis of the American Family Physician (2003); Guideline on Sore
Throat and Tonsillitis of the Finnish Medical Society Duodecim (2004). The chosen articles were
divided as follows:
Meta-analysis
24
Randomized controlled trial
17
Non-randomized controlled study
7
Descriptive study
33
Committee report
12
Guidelines
6
DEFINITIONS
Acute Tonsillopharyngitis – the presence of erythematous and/or exudative tonsils with any
one of the following symptoms: sore throat, dysphagia, odynophagia, fever and accompanying
tender, enlarged cervical lymph nodes.
The panel further deliberated on whether tonsillitis with signs but without symptoms or
conversely with symptoms but without signs should be admitted in the definition.
However, neither the situation can be reliably taken to mean proof of tonsillar
inflammation and the criteria was considered broad enough to include much of the clinical
spectrum of acute tonsillar infection. Imposing a time frame for the development of
symptoms as an additional diagnostic criterion was also considered but disregarded
since available evidence does not support a definite clinically recognizable period beyond
which acute tonsillitis can be justifiably labeled chronic or persistent in the oropharynx,
oral cavity or systemically.
58
Viral tonsillopharyngitis – inflammatory condition of the tonsils caused by respiratory viruses
such as adenovirus, influenza, parainfluenza, and respiratory syncitial virus. Other viral agents
1,22
include coxsackie, echoviruses, herpes simplex and Epstein Barr Virus (EBV).
Bacterial tonsillopharyngitis – inflammatory condition of the pharynx and or tonsils caused by
22
Group A beta-hemolytic streptococci (GABHS), Hemophilus influenza and Moraxella catarrhalis.
Streptococcal tonsillopharyngitis – inflammatory condition of the pharynx caused by caused
by Group A beta-hemolytic streptococci (strep throat). It has an incubation period of two to five
days and is most common in children 5 - 12 years of age. The risk of acute rheumatic fever
complicating untreated streptococcal pharyngitis is 1%. This is associated with complications
such as glomerulonephritis and rheumatic heart disease.
Chronic Tonsillopharyngitis – tonsillar inflammation resulting from recurrent clinically
documented attacks of acute tonsillitis occurring 4 times per year. This definition was adapted
from the textbooks of otolaryngology by Cummings and Paparella as well as Brodsky’s review.
The study by Paradise et. al. (1993) demonstrated that patient recall of the number of
sore throat episodes grossly overestimates the frequency of subsequent episodes. While
the study may be prone to maturation bias (i.e., the patients really got better with time) it
does question the validity of patients’ (or parental) recall when unverified by medical
consultation. Even medical validation is no guarantee of true tonsillitis because of the
lack of a widely accepted clinical definition among general practitioners, pediatricians and
otolaryngologists.
Obstructive Tonsillar Hypertrophy – presence of enlarged tonsils enough to cause symptoms
of functional obstruction of the air and food passages such as snoring and dysphagia.
The degree of obstruction may be expressed in terms of Clinically Assessed Size (CAS)
scale in which the distance between the tonsils and the distance between the anterior
tonsillar pillars are measured while the tongue is gently depressed. The ratio between the
two is a measure of tonsillar encroachment on oropharyngeal space. While the scale
lacks clinical validity at present the panel recognized its potential for standardizing
tonsillar examination findings.
Obstructive adenoidal hypertrophy – presence of enlarged adenoids enough to cause
symptoms of chronic mouth breathing, snoring, hyponasal speech and eustachian tube
dysfunction. Hyponasal speech can be detected by a lack of change in voice nasality whether
the nose is pinched shut or not. The test words recommended are “mama”, “mana”, “nina”,
“nganga”, “mga”, “mani” and “mano”.
PREVALENCE AND BURDEN OF ILLNESS
In an analysis of the health situation in Vietnam for children under 5 years, the World Health
Organization – Regional Office for the Western Pacific (2005) cited the incidence of acute
pharyngitis and acute tonsillitis as 251.39 rate per 100,000 population (0.25%) in 2002 and was
nd
ranked as 2 leading cause of morbidity.
It is estimated that approximately 50% of cases of acute pharyngotonsillitis have a viral etiology.
In 15 – 20% of cases, a primary bacterial pathogen, most commonly a streptococcal organism is
recovered (Discolo 2003). Epidemiological data from western countries, in general, as specifically
GABHS infections, both community and hospital based are more readily available. However,
there is considerable variation in the prevalence of GABHS sore throats from one country to
another. In Dhaka, Bangladesh, 22% of 601 children studied had a positive culture but only 2.2%
was due to GABHS (Faruq 1995). In Israel, the prevalence is 15% among 152 symptomatic
children aged 3 months to 5 years of age (Amir 1994). In the Italian –French study, 26% of 865
children from 5 months to 14 years had GABHS pharyngitis (Cauwenberge 1999). Overall, he
59
figure is less than 30% in most countries. In the adult population GABHS is responsible for 5-10%
of cases of acute pharyngitis (Bisno 2001).
In our local setting, the Philippine General Hospital – Out Patient Department ORL Clinic had 10
consults for Acute Tonsillitis, 4 consults for Acute Pharyngitis, and 21 consults for Acute
Tonsillopharyngitis and 76 consults for Chronic Hypertrophic Tonsils out of 13,517 patients during
the period of January to May of 2005. The prevalence rate is 7 out of 1000 patients for Acute
Tonsillitis, 3 out of 1000 patients for Acute Pharyngitis, 15 out of 1000 patients for Acute
Tonsillopharyngitis, and 56 out of 1000 patients for Chronic Hypertrophic Tonsils from January to
May of 2005 (Table 1).
Table 1-Philippine General Hospital – Out Patient Department ORL Clinic
(January to May 2005)
Acute
Tonsillitis
Acute
Pharyngitis
Acute
Tonsillopharyngitis
Chronic
Hypertrophic
Tonsils
Total
OPD
consults
Consults
10
4
21
76
13,517
Prevalence
7 / 1000
3 / 1000
15 / 1000
56 / 1000
----------
In the University of Perpetual Help Binan and Rizal and Sta. Rosa Polyclinic and Community
Hospital 4,080 patients with ages ranging from 1 to 18 years old, and 680 age >19 years old were
referred to the Out Patient Department of these institutions for tonsillitis in 2004. They admitted
148 patients from these for peritonsillar abscess. For the University of Sto. Tomas (UST)-Out
Patient Department, they had 3,456 consults for tonsillitis in 2004 for both pediatric and adult
patients. 85 of these patients subsequently underwent surgery.
The economic impact of tonsillitis locally is not known due to paucity of studies. Research from
other countries may provide insight into the socioeconomic impact of this condition. In the adult
population, about 6.7 million visits annually were for sore throat (Barlet 1997). In the UK, it is
estimated that visits for consultation for sore throat alone cost the NHS 60 million pounds per
annum (National Ambulatory Medical Care Survey 1989-1999).
RECOMMENDATIONS
ON
THE
DIAGNOSIS
OF
ACUTE
AND
TONSILLOPHARYNGITIS AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY
CHRONIC
1. The diagnosis of acute tonsillopharyngitis may be made clinically for both children
and adults. It is important to differentiate whether the infection is viral or bacterial in
etiology.
Grade B Recommendation
Approximately 30 to 60% have a viral etiology (rhinovirus, adenovirus, and others) only 5 to
10% are caused by bacteria, with Group A beta-hemolytic streptococci being the most
common bacterial etiology. In Hongkong, 2.65% of those more than 14 years of age have
GABHS pharyngitis. In the US, the 1988 prevalence rates of recurrent tonsillitis was 14.9%
among white non-Hispanics, 6.5% among black non-Hispanics and 10.2% among Hispanics
2
(1988 National Health Survey on Child Health, US) .
There are several reasonable approaches to the diagnosis of GABHS in an otherwise healthy
adult, such as use of clinical criteria alone or use of rapid antigen testing as an adjunct to
clinical screening. Either of these strategies is associated with reasonable diagnostic
accuracy (approximate sensitivity > 70%, specificity > 70% and allows treatment decisions to
60
3
be made early in the course of illness, when patients can receive symptomatic benefit . (refer
to Table 2)
Table 2. Clinical features of acute tonsillopharyngitis
1,16
Features suggestive of bacterial etiology
Sudden onset
Sore throat /Dysphagia
Fever
Petechiae
Headache
Nausea, vomiting, and abdominal pain
Inflammation of pharynx and tonsils
Patchy discrete exudates
Tender, enlarged anterior cervical nodes
Patients aged 5-15 years
History of exposure
Features suggestive of viral etiology
Conjunctivitis
Coryza
Cough
Hoarseness
Diarrhea
Highlighted features are adapted from the Centor Criteria
2. The diagnosis of acute group A streptococcal infection should be suspected on
1
clinical grounds and may be supported by performance of a laboratory test.
Grade B Recommendation
2.1. Throat culture remains to be the gold standard for the diagnosis of streptococcal
9
pharyngitis with a sensitivity of 90-95%.
Grade B Recommendation
2.2. A positive rapid antigen detection test (RADT) may be considered definitive
evidence for treatment of streptococcal pharyngitis, with specificity of 95% and
sensitivity of 89.1%. These values are similar to those of throat culture which has
a 99% specificity and 83.4% sensitivity. RADT, however, is not widely available
1
locally and cannot be considered part of routine diagnostic assessment.
Grade C Recommendation
2.3. Either a positive throat culture or RADT provides adequate confirmation of
GABHS in the pharynx, but a negative RADT result should be confirmed with a
23
throat culture whenever possible.
Grade C Recommendation
61
2.4. However, the value of early diagnosis in the minority of cases when
streptococcus is present should be weighed against the higher cost incurred in
testing the majority of cases seen. Selective use of diagnostic studies is
8
suggested.
Consequent to the risk of complications developing from untreated GABHS
infection, early diagnosis and appropriate antimicrobial treatment is warranted.
Attempts to study the predictive value of the various signs and symptoms have
19
not been particularly reliable.
Grade C Recommendation
3. The diagnosis of chronic tonsillitis can be made by a history of medically documented
episodes of acute tonsillitis for at least 4 times a year.
Grade C Recommendation
There are four randomized controlled trials (RCT) on tonsillectomy versus non-surgical
intervention studies in children but no RCT in adults. Scottish Intercollegiate Guidelines
Network advised more than 5 episodes and American Academy of Otolaryngology-Head and
Neck Surgery more than 3 episodes as indication for tonsillectomy. Non-controlled studies
demonstrated reduction in number of sore throats and improved general health with
tonsillectomy. The panel concensus for this CPG is at least 4 episodes a year.
4. The diagnosis of obstructive adenoidal hypertrophy should be made on the basis of
enlarged adenoids and a persistent difficult in breathing and/or swallowing.
Grade C Recommendation
The following may be used in the diagnosis of obstructive adenoidal hypertrophy:
• Anterior rhinoscopy
• Posterior rhinoscopy
• Intraoral palpation (palpation can be done in children with and without
anesthesia
• Soft tissue lateral films of the nasopharynx may be used to determine the
adenoid enlargement but its low sensitivity and the need for proper radiologic
techniques is emphasized
RECOMMENDATIONS ON THE MANAGEMENT OF ACUTE AND CHRONIC TONSILITIS AND
OBSTRUCTIVE ADENOIDAL HYPERTROPHY
Management includes symptomatic treatment, antibiotic therapy for GABHS pharyngitis and, if
clinically indicated, surgical treatment.
1. Symptomatic treatment is an integral part in the management of children and adults
with sore throat. This includes maintaining adequate fluid intake, warm saline gargle,
23,24,25
bed rest, use of analgesics and antipyretics, maintaining good oral hygiene.
Grade B Recommendation
1.1. Paracetamol or Ibuprofen is effective in treatment (in the first 48 hours) of
26
associated with sore throat.
Grade A Recommendation
62
2. Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis based on
clinical and epidemiological findings with/without supported by laboratory
27
examinations.
Grade A Recommendation
Early antibiotic therapy will suppress rapidly infection and lower the risk of transmission within
24 hours allowing children to return to school. Untreated patients usually will improve in 3 – 5
28
days unless a complication develops .
The majority of the studies and guidelines mostly involved patients with acute
tonsillopharyngitis.
2.1. Penicillin is the drug of choice for the treatment of streptococcal pharyngitis. The
antibiotic has proven efficacy and safety, a narrow spectrum of activity and low
cost.
Grade A Recommendation
Amoxicillin (Pediatric dose: 50mg/kg/day in 3 divided doses, Adult dose: 250-500 mg
capsule every 8 hours) is often used in place of Penicillin V (Pediatric dose: 50-100
mg/kg/day in 3-4 divided doses, Adult dose: 1-4 g/day in 3-4 divided doses) as oral
therapy for young children, the efficacy seems equal. This choice is primarily related to
acceptance of the taste of suspension. Intramuscular Benzathine Penicillin G therapy
(Pediatric dose: 100,000 – 250,000 units/kg/day in 4-6 divided doses, Adult dose:
600,000-1.2 M units IM) is preferred for those patients unlikely to complete full 10 day
30
course of oral therapy.
2.2
The likelihood of bacteriologic and clinical cure of GABHS tonsillopharyngitis in
children is significantly higher after 10 days of oral cephalosporin therapy with
cephalexin, cefadroxil, cufuroxime, cefpodoxime, cefprozil, cefixime, ceftibuten,
19
or cefdinir than after 10 days of oral penicillin .
Grade A Recommendation
Penicillin is inexpensive, narrow in spectrum, endorsed by many treatment
guidelines as the sole agent of choice. Cephalosporins are more expensive and have a
broader spectrum of antibacterial activity. On the other hand, the acquisition cost of the
antibiotic represents a very small percentage of the total cost of management of a patient
with GABHS tonsillopharyngitis. Additional medical visits and loss of school and work
productivity represent the largest cost of treatment failure. We would advocate the
addition of cephalosporins as a treatment of choice for GABHS tonsillopharyngitis based
on our findings that these agents more often produce bacteriologic eradication and
19
clinical cure compared with penicillin .
2.3 Erythromycin (Pediatric dose: 30-50 mg/kg/day in 4 divided doses, Adult dose: 1-2
g/day in 4 divided doses) is a suitable alternative for patients allergic to penicillin
who manifest hypersensitivity to beta lactam antibiotics.
Grade C Recommendation
For patients allergic to Penicillin and Erythromycin-intolerant Clindamycin (Pediatric
dose: 20-30mg/kg/day in 3 or 4 divided doses, Adult dose: 150-300 mg in 3 or 4 divided
1
doses) is recommended as an alternate antibiotic .
63
2.4. Failure to resolve the infection within 3-4 days justifies shifting to augmented
rd
penicillins, clindamycin, 3 generation cephalosporins or higher generation
macrolides. Higher generation macrolides may be used for 3-5 days.
Grade C Recommendation
3. Surgical treatment (Tonsillectomy with or without Adenoidectomy) – Tonsillectomy
may be recommended in patients with the following conditions:
3.1 Tonsillar hyperplasia accompanied by any of the following: upper airway
obstruction, dysphagia, speech impairment or halitosis
3.2 Recurrent or chronic tonsillitis - majority of the panel voted 4 episodes of
tonsillitis in a year is the indication for Tonsillectomy instead of 5 episodes (SIGN
Recommendation is 5 episodes and AAO-HNS is more than 3 episodes).
31
3.3 Peritonsillar abscess occurring in the background of chronic tonsillitis.
3.4 Cases with high ASO, both IgG and IgM subclasses, were considered to have an
indicative factor for tonsillectomy
Grade C Recommendation
The significance of antibody for streptolysin-O concerning tonsillectomy was studied. The
results obtained were as follows. 1. The upper limit of ASO titer in 5,121 school children
was 250 u and a value of more than 333 u was considered abnormal. But the level of the
normal limit was different from year to year. 2. Among 143 cases with a high ASO titer of
more than 833 u, only 12 cases had recurrent tonsillitis. There was no correlation
between the tonsillar hypertrophy and the height of streptococcal antibodies. 3. There
was a correlation between the titers determined by ELISA IgG-ASO and ASO in Todd
units (r = 0.69), but there was no agreement between the titers determined by ELISA
IgM-ASO and ASO in Todd units. 4. IgM-ASO determined by ELISA showed high levels
in cases with early stages of streptococcal infection, focal infection and streptococcal
31
carriers.
Tonsillectomy resulted in yearly mean decreases in number of weeks on antibiotics by
5.9 weeks, number of workdays missed by 8.7 days, and physician visits by 5.3 visits.
Tonsillectomy results in significant improvement in quality of life, decreases health care
utilization, and diminish the economic burden of chronic tonsillitis in the adult population.
30
3.5 Patients with obstructive adenoidal hypertrophy may benefit from adenoidectomy.
Grade C Recommendation
3.6 New surgical modalities for tonsillectomy may be available but are not
recommended as routine procedures because of unproven effectiveness and
higher expense. These include coblation, radiofrequency and ultrasonic harmonic
11,13,14,15,16
scalpel.
Grade C Recommendation
64
Child or Adult with
signs and symptoms
of tonsillitis
4 or more
times
a
year?
No
No
Acute
Tonsillitis
Bacterial?
Supportive management
Yes
No
Yes
•
•
GABHS?
Appropriate antibiotics
Supportive management
Chronic Tonsillitis
Yes
•
•
•
•
•
Appropriate antibiotics
Supportive management
Consider tonsillectomy
Appropriate antibiotics
Supportive management
No
Resolution?
Throat
Swab
Yes
Observe
No
Confirms
GABHS?
Reassess
Yes
Revise antibiotics
No
Resolution?
Reassess
Yes
Observe
65
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