Overview
Definition:
Recurrent tonsillitis refers to a pattern of frequent, symptomatic episodes of tonsillar inflammation, typically characterized by sore throat, fever, and tonsillar exudates, occurring multiple times within a defined period
Tonsillectomy is the surgical removal of the palatine tonsils and is a common surgical procedure in pediatric otolaryngology.
Epidemiology:
Recurrent tonsillitis is a common condition in children and adolescents, with a peak incidence between 5 and 15 years of age
The exact incidence of recurrent tonsillitis leading to tonsillectomy varies geographically and depends on the criteria used for intervention.
Clinical Significance:
Recurrent tonsillitis significantly impacts a child's quality of life, leading to missed school days, parental work absenteeism, and discomfort
Understanding the criteria for tonsillectomy is crucial for appropriate patient selection, balancing symptom relief with surgical risks and resource utilization for DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
Severe sore throat, often unilateral or bilateral
Difficulty swallowing (dysphagia) and pain with swallowing (odynophagia)
Fever, typically high-grade
Headache
Malaise
Halitosis (bad breath)
Neck pain or stiffness due to cervical lymphadenopathy
Parental concern regarding frequency and severity of episodes.
Signs:
Enlarged, erythematous tonsils with or without exudates (white or yellow patches)
Palpable, tender anterior cervical lymph nodes
Palatal petechiae may be present
Uvular edema or deviation in severe cases
Assessment of tonsillar size and presence of crypts.
Diagnostic Criteria:
The Paradise Criteria, developed in 1981, are widely used to identify children likely to benefit from tonsillectomy for recurrent tonsillitis
The criteria assess the frequency of documented tonsillitis episodes: 7 episodes in the past year
OR 5 episodes per year in the past 2 years
OR 3 episodes per year in the past 3 years
Each episode must be characterized by a temperature of >100.4°F (38°C), cervical lymphadenopathy (>2 cm or tender), or tonsillar exudates.
Diagnostic Approach
History Taking:
Detailed history of sore throat episodes: frequency, duration, severity, and documented symptoms (fever, exudates, lymphadenopathy)
Previous antibiotic use and response
Rule out mononucleosis or other viral causes
Assess impact on school attendance and quality of life
Inquire about snoring or sleep-disordered breathing, which may also be an indication for tonsillectomy.
Physical Examination:
Thorough oropharyngeal examination to assess tonsillar size, erythema, and exudates
Palpation of cervical lymph nodes for size, tenderness, and mobility
Examination of the nasopharynx and ears to rule out other contributing factors
Assessment of general health and hydration status.
Investigations:
Throat swab for rapid antigen detection tests (RADTs) or culture to identify Group A Streptococcus (GAS) if suspected during an acute episode
Infectious mononucleosis testing (e.g., Monospot, EBV serology) if clinically indicated
Blood counts may reveal leukocytosis or atypical lymphocytes
Sleep study if sleep-disordered breathing is suspected.
Differential Diagnosis:
Acute tonsillitis (viral or bacterial)
Peritonsillar abscess (quinsy)
Infectious mononucleosis
Streptococcal pharyngitis without recurrence
Viral pharyngitis
Diphtheria
Other causes of sore throat like gastroesophageal reflux disease or allergic rhinitis.
Management
Initial Management:
During an acute episode: symptomatic treatment with analgesics (paracetamol, ibuprofen), hydration, and rest
Antibiotics are indicated for confirmed bacterial tonsillitis (e.g., GAS pharyngitis)
The decision for tonsillectomy is based on recurrent patterns and the Paradise criteria, not solely on acute episodes.
Medical Management:
Antibiotics are used to treat acute bacterial tonsillitis
For GAS pharyngitis: Penicillin V 50 mg/kg/day divided into 2-3 doses (max 500 mg/dose) for 10 days, or Amoxicillin 50 mg/kg/day once daily (max 1000 mg/dose) for 10 days
Alternatives include cephalosporins or macrolides for penicillin-allergic patients
Recurrent symptomatic infections unresponsive to antibiotics may prompt surgical consideration.
Surgical Management:
Tonsillectomy is indicated when the Paradise criteria for recurrent tonsillitis are met, or when tonsillar hypertrophy causes significant obstructive symptoms or sleep-disordered breathing
The procedure involves surgical removal of the tonsils, typically using electrocautery, cold dissection, or coblation techniques
Adenoidectomy is often performed concurrently if adenoid hypertrophy is present.
Supportive Care:
Postoperative care is crucial
Pain management is paramount with regular analgesics
Adequate hydration is essential to prevent dehydration and facilitate recovery
Soft, cool diet is recommended
Monitoring for bleeding is critical, with prompt attention to any signs of hemorrhage
Parents should be educated on signs of complications.
Complications
Early Complications:
Hemorrhage (primary or secondary), occurring most commonly within the first 24 hours or 5-10 days post-operatively
Dehydration
Pain
Infection at the surgical site
Anesthesia-related complications
Velopharyngeal insufficiency (rare).
Late Complications:
Chronic pain
Taste disturbances
Scarring leading to altered pharyngeal anatomy
Recurrence of lymphoid tissue (rare)
Persistent snoring or sleep-disordered breathing if adenoids not fully addressed.
Prevention Strategies:
Careful patient selection for tonsillectomy based on well-defined criteria
Meticulous surgical technique to minimize bleeding
Thorough postoperative pain management and hydration
Educating parents on recognizing and reporting signs of bleeding or infection
Ensuring complete tonsillar removal to prevent recurrence.
Prognosis
Factors Affecting Prognosis:
Adherence to postoperative care instructions
Absence of significant comorbidities
Surgical technique and surgeon experience
Management of anesthetic risks
Timely recognition and management of complications, especially bleeding.
Outcomes:
Successful tonsillectomy leads to a significant reduction or elimination of recurrent tonsillitis episodes, improved quality of life, decreased missed school days, and improved sleep if obstruction was present
The Paradise criteria help ensure that those most likely to benefit undergo surgery.
Follow Up:
Typically, a single postoperative follow-up visit within 2-4 weeks is sufficient to assess healing and address any residual concerns
Long-term follow-up is usually not required unless specific complications arise or there is a suspicion of residual lymphoid tissue or recurrence
Annual review of school absence data can provide objective outcome measures.
Key Points
Exam Focus:
Remember the specific numbers and criteria for the Paradise criteria (7-5-3 rule over 1, 2, 3 years)
Understand the antibiotics of choice for GAS pharyngitis and their dosages
Be aware of the timing and management of primary vs
secondary post-tonsillectomy hemorrhage.
Clinical Pearls:
Always inquire about snoring and sleep-disordered breathing, as this can be an independent indication for tonsillectomy, even without recurrent infections
Differentiate between true recurrent tonsillitis and frequent viral pharyngitis
Emphasize parental education on the recovery process and warning signs.
Common Mistakes:
Performing tonsillectomy based solely on parental complaint without objective documentation of recurrent infections meeting established criteria
Underestimating the severity of postoperative pain and dehydration
Failing to consider sleep-disordered breathing as an indication
Inadequate workup for infectious mononucleosis in atypical presentations.