Tonsillitis

Acute tonsillitis is common in two to eight year olds and uncommon in infants.

Lymphoid tissue in the tonsils and adenoids is very small in infants and undergoes rapid growth from one to five years, reaching maximum size relative to body size between four to seven years.

Thus the body is clever enough to provide the biggest proportion of lymphoid tissue in the peak years of childhood infections.

Complications of tonsillitis, such as peri-tonsillar or cervical abscess are very rare.

Of more concern, are the delayed complications of rheumatic fever or glomerulonephritis resulting from Group A streptococcal infection;  the infamous ‘Strep throat’.

In developing countries, rheumatic fever remains an endemic disease with an annual incidence of 100 to 200 cases per 100,000 school age children.

In developed countries, incidence has decreased since the 1950's and is now 0.5 cases per 100,000.

Group A streptococcus is cultured in less than 5% of cases but despite this low incidence, antibiotics are prescribed in more than 70% of cases of tonsillitis.

Antimicrob Chemother 2000 France reported that, because late diagnosis can have serious consequences and because acute rheumatic fever is a hospital emergency, most European doctors have a tacit agreement that all cases of pharyngitis and tonsillitis should be treated with antibiotics despite the fact that only a minority of cases is caused by Group A streptococcus.

B.M.J. report stated that, in tonsillitis, antibiotics had  little effect on duration of symptoms,  nil effect on the rate of early return for medical advice,  nil effect on the rate of complications and  nil effect on the rate of relapse

Med.J.Aus 1992 study assessed the justification for the use of antibiotics in the management of sore throat in general practice and reported that ‘In Australia, with the exception of socio-economically deprived Aboriginal communities, the incidence of acute rheumatic fever is probably not high enough to justify the use of antibiotics for sore throat.  Protection against suppurative infection seems to be slight and it is difficult to establish the benefit of antibiotic treatment for reducing the symptoms of sore throat.  Until more benefits for antibiotic management of sore throat can be demonstrated, it is recommended that infrequent use be adopted.’

Cochrane Data System Review 2000 looked at a number of studies of the prescription of antibiotics for tonsillitis and reported that ‘Sore throat is a very common reason for people to seek medical care.  Sore throat is a disease that remits spontaneously; that is, 'cure' is not dependent on treatment.  Nonetheless primary care doctors commonly prescribe antibiotics for sore throat and other upper respiratory tract infections.  Antibiotics confer relative benefits in the treatment of sore throat.  However, the absolute benefits are modest.  Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics who will derive no benefit.’

B.M.J. 1995. This study of antibiotics for sore throats recommended that patient and doctor should reach decision together.

W.H.O. guidelines for tonsillitis recommend a waiting time of four days, followed by a throat swab if sore throat persists.  Results are available in forty-eight hours.  This is still time enough to prescribe antibiotics for prevention of complications if Group A Streptococcus is present.