Pharyngitis

Repeated discrete episodes of acute tonsillitis with complete resolution between episodes. It is defined by frequency and severity thresholds because these determine whether tonsillectomy delivers benefit that exceeds its risk.

Why recurrence happens

• Bacterial biofilms within the tonsillar crypts, which resist antibiotic penetration and host clearance and reactivate with each viral trigger.
• Beta lactamase producing organisms in the crypts, principally Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis and anaerobes, which inactivate penicillin locally even when the pathogen is a susceptible Streptococcus pyogenes. This is the mechanism of apparent penicillin failure in a patient with a penicillin sensitive organism.
• Streptococcal carriage, in which the organism colonises without invading, with viral illnesses producing symptoms that are then attributed to the streptococcus.
• Impaired local immunity and, occasionally, systemic immunodeficiency.
• High exposure settings: young children, day care, teachers, healthcare workers, large households.

Threshold criteria, commonly known as the Paradise criteria, which define the group in whom tonsillectomy has demonstrated benefit:

• Seven or more adequately documented episodes in the preceding year, or
• Five or more episodes per year in each of the preceding 2 years, or
• Three or more episodes per year in each of the preceding 3 years.

Each episode must have been clinically significant, with sore throat plus at least one of temperature above 38.3 degrees Celsius, cervical lymphadenopathy, tonsillar exudate, or a positive test for group A streptococcus, and each must have been treated appropriately and documented at the time.

The evidence position, stated honestly

Tonsillectomy in children meeting the strict criteria reduces episodes by around three per year in the first year, with the difference narrowing thereafter. In adults, the reduction in days with sore throat is smaller but still meaningful. Many children improve spontaneously with time regardless of surgery. The decision is therefore a genuine balance of a modest, temporary benefit against a real risk of haemorrhage and a painful recovery, and it belongs to the informed patient or family.

• Repeated well demarcated episodes, each with sore throat, fever, odynophagia and lymphadenopathy, resolving completely.
• Complete wellness between episodes, which distinguishes this from chronic tonsillitis.
• Repeated courses of antibiotics with initial response and subsequent recurrence.
• Days lost from school or work, which is a legitimate part of the surgical indication and should be quantified.
• Family disruption and, in adults, occupational consequences.

Assessment that determines the decision

• Document the number of episodes, with dates and treatments, from records rather than from memory. Patient and parental recall substantially overestimates frequency, and a proportion of reported episodes were viral upper respiratory infections or self limiting sore throats.
• Where the history is uncertain, a period of prospective documentation over 6 to 12 months using a symptom diary and clinical confirmation of each episode is a legitimate and often decisive approach.
• Assess for the alternative explanations: PFAPA syndrome with strikingly regular episodes and complete wellness between, tonsilloliths causing halitosis and discomfort mistaken for infection, chronic tonsillitis with persistent symptoms, and recurrent viral pharyngitis.

Red flags requiring investigation beyond the throat

• Unilateral tonsillar enlargement, ulceration, induration or a neck mass in an adult, indicating malignancy.
• Recurrent infections at multiple sites, chronic diarrhoea, failure to thrive, indicating immunodeficiency.
• Pallor, bruising and lymphadenopathy, indicating haematological malignancy.
• Recurrent oral ulceration with cyclical fever in a young child, indicating PFAPA syndrome.
• Recurrent oral ulceration with genital ulceration and uveitis, indicating Behçet disease.

• Documented episode history, which is the diagnosis.
• Throat swab culture during an episode to establish the pathogen and its sensitivities, which guides antibiotic choice for subsequent episodes and identifies beta lactamase producing organisms.
• Full blood count with differential.
• Immunoglobulin G, A and M with subclasses, and specific antibody responses to pneumococcal and tetanus vaccination, where the pattern suggests immunodeficiency or where infections occur at other sites.
• HIV testing in the appropriate context.
• Anti streptolysin O and anti DNase B titres, which are of limited value acutely but which distinguish true recurrent infection with a rising titre from carriage with a static titre.
• Consider PFAPA in a child under 5 years with regular episodes; a trial of a single dose of prednisolone 1 to 2 mg/kg at episode onset, which aborts the episode within hours, is both diagnostic and therapeutic.
• Examination under anaesthesia with biopsy or tonsillectomy for unilateral disease in an adult.

Non surgical management, which should be exhausted first in patients not meeting criteria

• Treat each episode adequately with a full 10 day course of phenoxymethylpenicillin where streptococcal, since incomplete courses contribute to recurrence.
• Where episodes recur despite penicillin, use an agent stable to beta lactamase: co amoxiclav 625 mg three times daily for 10 days, or clindamycin 300 mg four times daily for 10 days, which penetrates the tonsil well, is active against anaerobes and biofilm associated organisms, and has the best evidence for eradication in recurrent disease.
• Analgesia, hydration and symptomatic care as for acute tonsillitis.
• Address modifiable factors: smoking cessation including passive exposure, treatment of reflux, management of allergic rhinitis and mouth breathing, and dental hygiene.
• Watchful waiting for 6 to 12 months in children not clearly meeting criteria, since spontaneous improvement is common and the difference between surgical and non surgical groups narrows over time.
• Long term antibiotic prophylaxis is not recommended for recurrent tonsillitis.

Tonsillectomy

Indications:

• Meeting the frequency and severity thresholds above with documented episodes.
• Recurrent peritonsillar abscess, or a single abscess in a patient with a history of recurrent tonsillitis.
• Obstructive sleep apnoea from tonsillar hypertrophy, which is a separate and stronger indication.
• Suspected malignancy, unilateral enlargement, or the need for tissue diagnosis.
• PFAPA syndrome, where tonsillectomy is curative in the majority.
• Recurrent tonsillitis with a documented complication such as rheumatic fever or streptococcal glomerulonephritis.
• Chronic tonsillitis with persistent symptoms and halitosis unresponsive to conservative measures.
• Tonsillitis causing febrile convulsions.

Preoperative assessment

• Full blood count and, where there is a bleeding history or family history, a coagulation screen and von Willebrand studies. Routine coagulation screening in all patients has low yield; a structured bleeding history is more informative.
• Sickle cell screening where relevant.
• Assess for obstructive sleep apnoea, which changes the anaesthetic and postoperative plan and may require overnight monitoring.
• Defer surgery for at least 3 to 4 weeks after an acute episode, since operating on an acutely inflamed tonsil increases bleeding and pain, though a hot tonsillectomy is occasionally performed for recurrent abscess.

Surgical technique

• Cold steel dissection with ligature or bipolar haemostasis has the lowest rate of secondary haemorrhage and remains the technique against which others are compared.
• Bipolar diathermy dissection is faster with less primary bleeding but higher secondary haemorrhage rates and more postoperative pain.
• Coblation, using bipolar radiofrequency in a saline field at 60 to 70 degrees Celsius, produces less thermal injury, less pain and faster recovery than diathermy, with haemorrhage rates that are technique and operator dependent.
• Intracapsular tonsillectomy, or tonsillotomy, removing tonsil tissue while leaving a rim of capsule, produces markedly less pain and lower haemorrhage rates and is well established for obstructive hypertrophy. Its role in recurrent infection is more limited, since residual tissue may become reinfected, and it should be used with that caveat explained.
• Ensure meticulous haemostasis, particularly at the inferior pole.
• Avoid excessive diathermy in the tonsil bed, which increases pain and delays healing.

Postoperative care

• Regular analgesia for at least 7 to 10 days, prescribed as a scheduled regimen rather than as required, since pain peaks around days 4 to 7 as the slough separates. Undertreated pain leads to poor oral intake and readmission.
• Paracetamol 1 g every 6 hours in adults, or 15 mg/kg every 6 hours in children.
• Ibuprofen 400 mg every 8 hours in adults, 10 mg/kg every 8 hours in children. Nonsteroidal anti inflammatory drugs do not increase the risk of post tonsillectomy bleeding requiring intervention and should be used, since withholding them causes worse pain and worse intake.
• Avoid codeine entirely in children after tonsillectomy, given deaths in ultrarapid metabolisers, particularly those with obstructive sleep apnoea. Where a stronger opioid is required in a child, use morphine at a carefully calculated dose with appropriate monitoring.
• Encourage normal diet and normal activity, since eating promotes separation of slough and reduces infection.
• Adequate hydration.
• Chewing gum and normal oral hygiene.
• Advise 2 weeks off school or work and avoidance of crowded places, since infection precipitates secondary haemorrhage.

Haemorrhage

• Primary haemorrhage, within 24 hours, occurs in around 0.5 to 1 percent and requires return to theatre for haemostasis in most cases.
• Secondary haemorrhage, typically days 5 to 10, occurs in 2 to 5 percent overall and is associated with infection and slough separation.
• Any bleeding after tonsillectomy requires assessment in hospital. A small herald bleed frequently precedes a major one, and patients discharged after a minor bleed sometimes return exsanguinating.
• Management: admit, intravenous access, bloods including full blood count and crossmatch, intravenous fluids, and antibiotics with co amoxiclav 1.2 g every 8 hours since infection is usually the driver. Tranexamic acid 1 g intravenously three times daily.
• Hydrogen peroxide gargles for minor ooze.
• Return to theatre for bleeding that is active, recurrent or significant, or where the patient is unstable. In a child, the threshold should be low, since children compensate and then decompensate abruptly.
• Airway management in an actively bleeding patient is hazardous. Anticipate a full stomach of swallowed blood, prepare suction and a difficult airway trolley, involve the most experienced anaesthetist available, and consider a rapid sequence induction with the patient in the head down lateral position.

Other complications

• Dehydration and readmission for pain and poor intake, which is the commonest reason for readmission.
• Velopharyngeal insufficiency, particularly where adenoidectomy is performed simultaneously in a patient with a submucous cleft.
• Taste disturbance from lingual nerve or glossopharyngeal branch injury.
• Dental and lip injury from the mouth gag.
• Temporomandibular joint pain.
• Cervical spine injury with atlantoaxial subluxation, particularly in Down syndrome, and Grisel syndrome, that is non traumatic atlantoaxial rotatory subluxation presenting with torticollis and neck pain after pharyngeal surgery or infection.
• Catastrophic haemorrhage from injury to an aberrant internal carotid artery, which is rare but which is the reason for careful dissection in the correct plane.

Follow up

Routine follow up is not required after uncomplicated tonsillectomy. Review histology in every adult specimen and in any unilateral or suspicious tonsil. Advise the patient that sore throats will still occur but should be less frequent and less severe, and that pharyngitis without tonsils remains possible.