Tonsillitis; The Bacteria and Viral Infection of the Tonsils

When you open your mouth, there are two oval-shaped pads of tissues located at the back of the throat, they are known as the Tonsils also known as the palatine tonsils. There are other types of tonsils which include the Adenoid tonsils, pharyngeal tonsils, and Lingual Tonsils which make up Waldeyer's ring. These tonsils are made up of tissues that are similar to the lymph nodes, and they are part of our immune system acting as a trap for microorganisms that could enter the airway and cause infection they also provide antibodies against those infectious causing microbes. Since they are responsible for trapping microbes, then you should expect that they will be vulnerable to infections. In the early years of life, the lymphoid tissues are exposed to a lot of antigens, so they are hyperplastic this is usually around 6 years of age, and when the child is getting to puberty, the tonsils are already shrunk. They are supplied blood from about 5 vessels which are the dorsal lingual artery, the ascending palatine artery, the tonsillar branch of the facial artery, ascending pharyngeal artery, and the lesser palatine artery, and these cause bleeding excessively during tonsillectomy which is the removal of the tonsils. The tonsils are composed of Crypts which are normally colonized by species of bacteria and can be exposed to viral organisms but then the lymph nodules contain the T-cells, B-cells, and Macrophages which are Immune cells.

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Tonsillitis, the inflammation of the tonsils leading to Tonsillar edema, hypertrophy, pain, and erythema, is caused by Viral and bacterial infection. Although it is the Palatine tonsil that is affected, other tonsils such as the adenoid and lingual tonsils, as well as the pharynx can be affected. The most common cause of tonsilitis is viral infections such as Rhino Virus, Epstein Barr Virus (EBV), Adenovirus, Respiratory syncytial virus, parainfluenza, and Influenza virus. It can also be caused by bacteria which are usually Group A streptococcus bacteria (Streptococcus pyogenes) The inflammation of the tonsils can lead to exudate which can be a yellow, or whitish discharge.

EBV infection is most times asymptomatic but it can be symptomatic in cases such as infectious mononucleosis which usually begins with fatigue, malaise, Sore throat, and pharyngeal tonsilitis, in tough cases, it can lead to splenomegaly. The virus is transmitted via saliva. It targets the B-cells in the oral pharynx and the tonsils have B-cells in them. They replicate and as the body builds an immune response, they conquer them. Identifying the virus includes full blood count which will show results for high lymphocyte count (lymphocytosis) and low platelet. Mono spot test to look at metrophile antibodies, and troat swap to look for differential diagnosis. In cases where it is Streptococcus pyogenes, it can be treated using Penicillin V (Phenoxymethyl Penicillin). Tonsilitis can also be caused by streptococcus pneumonia, Staph. aureus, and Haemophilus influenza.

Patients with Tonsillitis will present with symptoms that include sore throat, fever, pain on swallowing, red inflamed or enlarged tonsils with white patches (exudates), pus, and patients may present with Anterior cervical lymphadenopathy. Since it can be caused by bacteria and viruses, using Centor criteria will help identify which is responsible. If the Centor score is above 3 or more, then there is a 40 to 60% chance that it is caused by bacteria, and antibiotics can be given at this stage. To identify a point, the patient must have a fever over 38^oC, tonsillar exudates, absence of cough, and tender anterior cervical lymphadenopathy. Patients can also be diagnosed using the fever pain score where there if the patient has a fever pain score of 2 to 3, the patient has about a 50% probability that it is a bacterial infection while a 4 to 5 score shows a 60% probability of a bacterial infection. Patients' point is determined by fever within a 24-hour period, purulence, inflamed tonsil, and a short period of time within infection.

Management for Tonsilitis will start with admission to a hospital if the patient is immunocompromised and has high-pitched noise with breathing (Stridor), if the patient is having respiratory distress and cellulitis and peritonsillar abscess. The fever pain score or the centor criteria is calculated. In the case of viral tonsilitis, education, and use of simple analgesias such as paracetamol, and Ibruprofen for pain. Antibiotics should be used for bacteria causes and cases of severe infection. It is important to delay the use of antibiotics so as to ascertain if it is a viral infection, and treatment with antibiotics can begin after 2 to 3 days. Antibiotics such as Penicillin V for Streptococcus pyogenes, Use of Clarithromycin is an antibiotic of choice in cases of penicillin allergy in patients. Tonsillitis can come with complications such as Peritonsillar abscess, Otitis Media, Post streptococcal reactive athritis, Scarlet fever, Post streptococcal glomerulonephritis, and Rheumatic fever.

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Reference
https://www.kenhub.com/en/library/anatomy/waldeyers-ring

https://www.ncbi.nlm.nih.gov/books/NBK538296/

https://www.cdc.gov/epstein-barr/about-mono.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9447300/

https://www.nice.org.uk/guidance/ng84/chapter/terms-used-in-the-guideline

https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/tonsillitis

https://emedicine.medscape.com/article/871977-overview