Definition

Tonsillopharyngitis refers to an acute infection of the throat and tonsils. The tonsils, composed of lymphoid tissue, play a role in the body's immune system. Consequently, pathogens entering the nose or throat frequently infect the tonsils and the surrounding throat tissues. This condition is particularly common, especially in children.

Causes

Tonsillopharyngitis is predominantly caused by viral infections, with common culprits including adenovirus, rhinovirus, influenza virus, coronavirus, and respiratory syncytial virus (RSV). Other viruses that can cause this condition include the Epstein-Barr virus (which causes mononucleosis), herpes simplex virus, cytomegalovirus, and HIV.

In approximately 30% of cases, the infection is caused by bacteria. The most frequent bacteria that cause tonsillopharyngitis is Group A beta-hemolytic streptococcus (GABHS). Other bacteria that can cause this condition include Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia pneumoniae. Less common bacterial causes are Bordetella pertussis (pertussis), Fusobacterium, Corynebacterium diphtheriae (diphtheria), Treponema pallidum (syphilis), and Neisseria gonorrhoeae (gonorrhea).

Risk factor

GABHS bacterial infection primarily affects children aged 5-15 years and is uncommon in children under 3 years. Parents of school-aged children and adults in close contact with infected individuals are also at higher risk.

People working in child care centers, schools, or shelters are at increased risk of infection transmission.

Symptoms

The main symptom of tonsillopharyngitis is a sore throat, especially when swallowing. Young children may refuse to eat due to this pain. Other common symptoms include:

• High fever is more common with GABHS bacterial infections
• Cough and runny nose
• Decreased appetite
• Fatigue
• Headache
• Digestive problems
• Bad breath
• Muffled voice
• Sometimes, the pain radiates to the ear
• Red, swollen tonsils with white spots on the surface

Symptoms particularly indicative of GABHS bacterial infections include:

• Fever
• Enlarged, painful lymph nodes in the neck
• Body rash

GABHS infections generally resolve within 7 days. Recurrent tonsil infections can lead to the formation of small holes in the tonsils, which can harbor hardened white saliva resembling small stones. This environment is good for bacterial growth, causing chronic bad breath and increased susceptibility to recurrent tonsillitis.

Diagnosis

Diagnosis of tonsillopharyngitis is typically established through a combination of consultation and examination. While the inflammation of the pharynx and tonsils is easily identified, distinguishing between viral and bacterial infections can be challenging. In certain cases, additional tests may be required, such as a culture procedure or rapid antigen test:

• Throat culture involves growing germs from throat samples in laboratory media. This test is useful for identifying the causative agent of infection, particularly GABHS, and finding the right treatment.
• Rapid antigen test. A throat swab is tested with a reagent to determine the presence of GABHS quickly.

Given the necessity of antibiotic treatment for GABHS infections, rapid diagnosis is crucial. Many facilities recommend rapid antigen testing or culture for all children with symptoms of tonsillopharyngitis. Adults with tonsillopharyngitis symptoms such as white spots on the tonsils, enlarged neck lymph nodes, fever with no cough may also be tested. The need for these tests remains a topic of debate, and doctors will decide on a case-by-case basis.

Management 

Treatment for tonsillopharyngitis involves addressing both the symptoms and underlying causes. Symptomatic therapy includes:

• Analgesic medications to help relieve sore throat. Paracetamol/acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to alleviate pain.
• Throat lozenges or sprays containing benzocaine, phenol, or lidocaine can be used to alleviate pain, though they may not be as effective as NSAIDs.

• Short-term corticosteroids can help speed up the healing process.

• Gargling with warm salt water can provide some relief, although limited evidence supports its effectiveness in reducing symptoms.

Tonsillopharyngitis must be treated. If the cause is Group A beta-hemolytic streptococcus (GABHS), antibiotics are necessary to treat the infection. The doctor will determine the choice of antibiotic and dosage. Repeat laboratory tests after treatment are generally not needed.

Tonsillectomy or surgical procedure to remove the tonsils may be considered in cases of recurrent tonsillitis, especially in children. Criteria for surgery include:

• More than 6 episodes per year.
• More than 4 episodes per year for 2 consecutive years.
• More than 3 episodes per year for 3 consecutive years.

Other indications for surgery in children also include: 

• Severe, persistent infections despite antibiotic treatments
• Sleep disorders due to airway obstruction by enlarged tonsils
• Recurrent peritonsillar abscess
• Suspected cancer

Surgery may be recommended for chronic bad breath and tonsil stones in adults without strictly following the same criteria used for children. The doctor will evaluate the need for tonsil removal surgery based on the individual's age, risk factors, and history of recurrent infections. However, even after removing their tonsils, people may still experience throat infections or pharyngitis.

Significant bleeding occurs in less than 2% of patients, usually within 24 hours or 7 days post-surgery. Immediate medical attention is necessary if bleeding occurs.

Complications

Untreated bacterial tonsillopharyngitis can lead to:

• Peritonsillar abscess, which is pus accumulation around the tonsils, potentially obstructing the airway and causing breathing difficulties.
• Rheumatic fever, this can lead to rheumatic heart disease, damaging the heart valves.
• Glomerulonephritis or inflammation of the kidneys.

Prevention

You can do these to prevent tonsillopharyngitis:

• Wash hands frequently, especially before touching your nose and mouth.
• Do not share food, drinks, or eating utensils with sick individuals.
• Change your toothbrush regularly.

When to see a doctor?

You should consult a doctor if you experience: 

• Prolonged sore throat that lasts more than 2 days.
• High fever with a temperature above 38.3 degrees Celsius.
• Painful or difficult swallowing.
• Breathing issues
• Significant pain and swelling of the tonsils.

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