QuestionSBA
QuestionChoice
This is only indicated in tonsillitis that is very severe and impairs the patient's ability to swallow which is not the case here.
10035811
e
IV maintenance fluids
QuestionChoice
This patient is presenting with features of tonsillitis. As his Centor score is only 2 (tonsillar exudate and absence of a cough) antibiotics are not warranted currently. Antibiotics are only given if the Centor score is 3 or above. Therefore, this patient requires analgesia and appropriate safety netting to return in case the symptoms do not resolve. 

[NICE guidelines](https://www.nice.org.uk/guidance/ng84/chapter/Recommendations) currently advise using the **original** Centor scoring criteria, which **does not include age.** The modified/McIsaac Centor score, which is available via MDCalc however, does include age, which is why some users may have calculated this patient's score as 3.

10035807
a
Encourage regular paracetamol and fluid intake
QuestionChoice
This patient has a Centor score of 2 and therefore, they do not warrant antibiotics. Oral clarithromycin would be an option if they had a Centor score of 3 or more and a penicillin allergy.
10035810
d
Oral clarithromycin
QuestionChoice
This patient has a Centor score of 2. Therefore, antibiotics are not warranted. IV antibiotics would be used if the patient were septic or had severe consequences from the tonsillitis that impaired their ability to swallow safely.
10035808
b
IV co-amoxiclav
QuestionChoice
This patient has a Centor score of 2 and therefore, does not warrant antibiotics. Oral penicillin V would be used if they had a Centor score of 3 or more.
10035809
c
Oral penicillin V
QuestionComment
the one thing medicine gave me was teaching me how to finesse the system with a telephone call to get abx for my recurrent tonsillitis
47375
User
subscriber
CT everyone 
QuestionComment
Isnt the centor score 3 because of the age as well??? 
+1 age between 3-14, +1 exudate, +1 no cough
48872
QuestionComment
Only modified Centor includes age which NICE doesn't use :(
49831
User
subscriber
Gelert
User
subscriber
Power Jargon
QuestionComment
If you use FEVERPAIN score then is score = 4...consider abx
49630
QuestionComment
Exactly :’)
52075
User
subscriber
Hypertension Juice
QuestionComment
Need to spend more time in GP
53430
User
subscriber
Juice Suture
QuestionComment
its just 3 (purulent tonsils, inflamed tonsils, no cough) 2-3 is apparently a delayed abx prescription so giving PenV now is wrong i guess?
60143
User
subscriber
Serotonin Myopathy
User
subscriber
Womb Syndrome
QuestionComment
I work in OOH...
53452
User
subscriber
Womb Syndrome
QuestionComment
fever, tonsilar exudate, no cough - I count 3..
58824
QuestionComment
Temp is 37.4 so not considered a fever
59428
User
subscriber
Axillary RNA
User
subscriber
Abscess Transplant
Concept
Chapter
# Summary
 
Tonsillitis is an acute inflammation of the tonsils, often with a purulent exudate in bacterial cases. The most common cause of tonsillitis are viruses, however, the most common bacterium causing tonsillitis is Streptococcus pyogenes (group A streptococcus). The CENTOR criteria can be used to determine the likelihood of a bacterial infection, and management of bacterial tonsillitis often involves antibiotic treatment. Key signs and symptoms can include tonsillar exudate, tender anterior cervical lymphadenopathy, fever over 38 degrees Celsius, and absence of a cough. 
  
# Definition
 

Tonsillitis is a form of pharyngitis characterised by acute inflammation of the tonsils, often with a purulent exudate present in bacterial tonsillitis.
 

# Epidemiology
 

In the UK, tonsillitis is a common condition that predominantly affects children and adolescents, with an estimated 7.4% of GP consultations for children under 15 years involving a sore throat or tonsillitis as the primary reason for the visit.
 

# Aetiology
 

The most common causative organism of tonsillitis is Streptococcus pyogenes (group A streptococcus). Epstein-Barr virus (EBV) is another common cause.
 
Risk factors for tonsillitis include:
 
 - Age 5-15 years
 - Immunodeficiency 
 - Family history of tonsillitis 
 - Close contact with an infected individual 
 

# Signs and Symptoms 
 
 - Sore throat 
       - The child may also complain of referred pain in the ears or a headache 
 - Changes to the sound of the child's voice or cry 
 - Purulent and inflamed tonsils
 - Lymphadenopathy 
 

# Differential Diagnosis
 

Differential diagnoses for tonsillitis include the following:
 

 - **Bacterial Tonsillitis**: Main signs and symptoms include cervical lymphadenopathy, tonsillar exudate, and fever.
 - **Viral Tonsillitis**: Symptoms are often milder, and accompanied by coryzal symptoms (i.e. cough, rhinorrhoea). 
 - **Infectious Mononucleosis**: Also known as glandular fever, this is more common in teenagers. This presents with enlarged tonsils, fatigue and occasionally with splenomegaly. 
 - **Hand, foot and mouth disease**: This is caused by the Coxsackie virus, and will feature blisters on the tonsils and roof of the child's mouth. Blisters may also be found on the feet and hands.
 

# Investigations
 

The CENTOR criteria can be used to indicate the likelihood of a sore throat being due to a bacterial infection. The criteria are as follows:
 

 1. Tonsillar exudate
 2. Tender anterior cervical lymphadenopathy
 3. Fever over 38 degrees Celsius
 4. Absence of a cough
 

 [lightgallery]
 

Each of the CENTOR criteria scores 1 point, with a maximum score of 4. A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating Streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating Streptococcus.

Alternatively, the FeverPAIN score can be used. The criteria for this include:

- **Fever**
- **P**us on tonsils
- **A**ttended within 3 days of symptom onset
- **I**nflamed tonsils
- **N**o cough or coryza 

Diagnosis is usually clinical, however, in some cases, further investigations may include:

- Throat swab for microscopy and culture
- Monospot (heterophile antibody) test for glandular fever 
 

# Management
 

Bacterial tonsillitis with a CENTOR criteria score of 3/4, FeverPAIN score of 4 or 5, or evidence of systemic upset/immunosuppression warrants prescribing antibiotics:
 

-  1st line: Penicillin V PO QDS for 5-10 days
    -  Dose is dependent on age, see BNFc for dosing 
-  Alternative in penicillin allergy: Clarithromycin/Erythromycin PO BD for 5 days
    -  Dose is dependent on age, see BNFc for dosing 

For patients with a CENTOR score of 0-2 or FeverPAIN score of 0 or 1:

- Advise that antibiotics are not needed as they do not tend to alter how long symptoms last and may cause side effects such as diarrhoea and nausea.
- Conservative management including paracetamol for analgesia and ensuring adequate fluid intake. 

If the child is systemically very unwell or has severe complications, consider referring the child to the hospital. 

# Complications

- Quinsy (peritonsillar abscess)
- Acute otitis media 
- If tonsillitis is due to Group A beta haemolytic step:
    - Rheumatic fever
    - Syndenham's chorea 
    - Glomerulonephritis 
    - Scarlet fever 

# Prognosis 

Tonsillitis is usually self-resolving within 3-4 days. Some children will have recurrent tonsillitis, and this recurrence may be reduced by smoking cessation for the parents or through tonsillectomy. 

Tonsillectomy may be indicated for severe recurrent tonsillitis (more than 7 episodes/year for one year, more than 5 episodes/year for two years and more than 3 episodes per year for 3 years). This may be done via diathermy or coblation. 


# NICE Guidelines

[NICE Guidelines Sore Throat (acute)](https://www.nice.org.uk/guidance/ng84) 

[NICE Flowsheet on Antimicrobial Prescribing](https://www.nice.org.uk/guidance/ng84/resources/sore-throat-acute-in-adults-antimicrobial-prescribing-visual-summary-pdf-11315864557) 
 

# References
 
[NHS Information on Tonsillitis](https://www.nhs.uk/conditions/tonsillitis/)

[Patient Info Tonsillitis](https://patient.info/doctor/tonsillitis-pro) 

[Great Ormond Street Hospital Tonsillectomy](https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/your-child-having-his-or-her-tonsils-andor-adenoids-removed/)
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Picture
An example of a right sided quinsy.
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Peritonsilar abscess.jpeg
images/n2yy75x31665036171698.jpg
images/n2yy75x31665036171698_256.jpg
images/n2yy75x31665036171698_512.jpg
IYkODgR6iAiWeHh4d3l1ZXiIo49L9To=
543
Tonsillitis
Topic
29
Paediatrics
Condition
670
Tonsillitis
UkmlaTopic
5
Child health
19565
In cases of tonsillitis with a Centor score of 2, supportive care with analgesia and hydration is the primary management approach.
A 13-year-old boy presents to General Practice complaining of a sore throat for the last four days with no cough. He is able to eat and drink. He has no past medical history, is not taking any medications and has no allergies. Examination reveals no lymphadenopathy but there is swelling of the tonsils bilaterally with exudate. His observations are:

- Temperature 37.4 degrees Celsius
- Pulse 78 bpm
- Respiratory rate 15
- Oxygen saturation 98% on room air.

What is most appropriate management plan?
a