Tonsillitis and Tonsillectomy

Acute tonsillitis: usually self-limiting. Airway compromise, sepsis and deep-neck infection require resuscitation, antibiotics and assessment for drainage. Exudate and a high clinical score do not establish a bacterial diagnosis. ^{NICE NG84 NICE NG84}

Tonsillectomy for recurrent infection: based on documented disabling attacks, their effect on daily life and surgical morbidity.

• Obstructive disease, suspected malignancy and recurrent quinsy have separate indications.

Sore-throat scores: FeverPAIN and Centor guide antibiotic prescribing in uncomplicated sore throat. Airway compromise, sepsis, trismus and deep-neck swelling indicate obstruction or abscess and override the score.

Recurrent tonsillitis: Tonsillectomy is considered for 7 disabling attacks in one year, 5 per year for two years or 3 per year for three years, after documenting the burden and discussing benefit and harm.

Intracapsular surgery: The retained capsule reduces exposure of the pharyngeal muscle; residual lymphoid tissue can regrow, remain symptomatic and require revision.

Postoperative haemorrhage: A fresh bleed that has stopped still requires admission and observation: bleeding can recur and swallowed blood conceals the volume lost.

Postoperative healing: White fibrinous slough in the tonsillar fossae and referred otalgia are expected after tonsillectomy. Fever, deterioration, bleeding or inadequate intake requires review.

Codeine: CYP2D6 converts codeine to morphine; ultra-rapid metabolisers risk respiratory depression. Contraindicated under 18 after tonsil or adenoid surgery for OSA. ^{MHRA codeine safety advice, July 2013}

Palatine tonsils: Paired mucosa-associated lymphoid organs in the tonsillar fossa between palatoglossus (anterior pillar) and palatopharyngeus (posterior pillar). Waldeyer's ring also includes the adenoid, tubal and lingual tonsils and pharyngeal lymphoid tissue.

Blood supply: Tonsillar branch of the facial artery (main supply) and its ascending palatine branch; also the ascending pharyngeal, dorsal lingual and lesser palatine arteries, the last arising from the descending palatine branch of the maxillary artery.

Pathogens: viral EBV, CMV, adenovirus and parainfluenza; bacterial group A, B and C streptococci and anaerobes including Bacteroides and Fusobacterium, with group A streptococcus the routine prescribing target. Mixed infection occurs and exudate does not distinguish viral from bacterial infection.

Complications: suppurative (peritonsillar, parapharyngeal or retropharyngeal abscess, septic thrombophlebitis of the internal jugular vein as Lemierre syndrome, airway obstruction) and non-suppurative streptococcal (scarlet fever, rheumatic fever, glomerulonephritis), the latter presenting as new rash, joint or cardiac symptoms, haematuria or oedema.

Airway obstruction and sepsis: respiratory distress, stridor or stertor, drooling, inability to handle secretions, rapidly worsening swelling, marked trismus, neck stiffness, toxicity or circulatory compromise. Assess airway patency, give oxygen and arrange controlled airway management with the anaesthetist (paediatric anaesthesia for a child) if intubation or ventilation is needed. Resuscitate, start IV antibiotics and stabilise before imaging. ^{NICE NG84}

Current illness: onset, fever, swallowing, oral intake/urine output, cough/coryza, unilateral pain, referred otalgia, voice change, rash, neck swelling and treatment response. Assess dehydration and analgesic requirements.

Recurrent attacks: document dates, clinical features, treatment, GP/emergency visits, admissions, quinsy and days lost from school/work. Distinguish separate acute attacks from persistent nonspecific throat discomfort.

Obstruction: snoring, witnessed apnoeas or gasping, restless sleep, daytime symptoms, poor growth and swallowing difficulty. Tonsil size does not diagnose or grade OSA; assess through the paediatric sleep-disordered breathing pathway.

Context: immunosuppression, previous malignancy, bleeding tendency, anticoagulants, drug allergies and relevant exposure/travel/sexual history. Prolonged fatigue and generalised or posterior cervical nodes suggest EBV or another systemic illness.