Tonsillar swelling

Tonsillar swelling is enlargement of one or both palatine tonsils, noted by the patient or at examination. Bilateral symmetrical enlargement is usually physiological, infective or obstructive. Unilateral or asymmetric enlargement needs exclusion of lymphoma and squamous carcinoma.

Anatomy. The palatine tonsils lie in the tonsillar fossae of the oropharynx, within Waldeyer ring with the adenoids and lingual tonsil. They are largest in early childhood and regress after puberty.

Grading. Brodsky scale: grade 0 (tonsils within the fossa), 1 (under 25 percent of the oropharyngeal width), 2 (25 to 50 percent), 3 (50 to 75 percent), 4 (over 75 percent, kissing tonsils).

Classification. Symmetrical (physiological hypertrophy, acute and recurrent tonsillitis, chronic tonsillar hypertrophy, infectious mononucleosis) and asymmetrical (peritonsillar abscess, tumour, lymphoma, deep neck infection, tonsillolith, cyst).

Key distinctions. Rapid unilateral swelling with trismus, uvular deviation and fever is peritonsillar abscess. Painless unilateral firm enlargement in an adult, with a non-tender node, suggests lymphoma or carcinoma.

History.

• Onset, duration, side, pain, fever, trismus, voice change, drooling and dysphagia.
• Snoring, witnessed apnoea, daytime sleepiness, mouth breathing, and behaviour or school problems in children.
• Recurrent sore throat (number of episodes each year), halitosis, tonsilloliths and ear pain.
• Weight loss, night sweats, neck lumps, tobacco and alcohol use, HIV and sexual history, and immunisation status.

Examination. Airway (stridor, drooling), tonsil size (Brodsky grade), symmetry, surface (exudate, ulcer, membrane, crypts, tonsilloliths), consistency (palpate firmness with a gloved finger when safe), uvular deviation, trismus, palate, tongue base, cervical nodes (size, tenderness, fixity), hepatosplenomegaly, nasal airway, adenoidal facies, and height and weight in children.

Red flags

• Stridor, drooling, trismus or inability to swallow
• Unilateral enlargement, firmness or ulceration, particularly in adults over 40 or in smokers
• Persistent unilateral enlargement over 3 weeks
• Hard or fixed neck nodes, night sweats, weight loss or fever
• Hepatosplenomegaly and pancytopenia
• Grey membrane (diphtheria)
• Obstructive sleep apnoea with failure to thrive or cardiopulmonary complications in a child
• Immunosuppression
• Bleeding from the tonsil

Special groups. Children: physiological hypertrophy and obstructive sleep apnoea. Adults: lymphoma and human papillomavirus related oropharyngeal carcinoma. Pregnancy: avoid tetracyclines. Region specific: Burkitt lymphoma in sub-Saharan Africa and diphtheria where immunisation is incomplete.

Symmetrical

• Physiological tonsillar hypertrophy
• Acute viral and bacterial tonsillitis (group A streptococcus), recurrent tonsillitis
• Infectious mononucleosis, cytomegalovirus, acute HIV infection
• Chronic tonsillar hypertrophy with obstructive sleep apnoea
• Diphtheria, candidiasis
• Leukaemia, bilateral lymphoma

Asymmetrical

• Peritonsillar abscess and cellulitis
• Parapharyngeal abscess, retropharyngeal abscess
• Lymphoma (Hodgkin, non-Hodgkin, Burkitt), squamous cell carcinoma of the tonsil
• Salivary gland neoplasm, minor salivary gland tumour
• Tonsillolith, tonsillar cyst, tonsillar papilloma
• Tuberculous tonsillitis, actinomycosis, syphilis (primary chancre), sarcoidosis
• Parapharyngeal tumour, vascular anomaly including aberrant carotid artery
• Tonsillar haematoma, foreign body

Reasoning. Decide whether the swelling is infective, obstructive or neoplastic from the history and examination. Biopsy asymmetric or suspicious tonsils.

First line. Airway assessment, oropharyngeal examination, throat swab for streptococci when features of infection, full blood count and film, and monospot or Epstein Barr virus serology when mononucleosis is suspected.

Targeted tests.

• Contrast CT neck for suspected abscess or deep neck infection, and MRI for parapharyngeal extension or tumour.
• Tonsillectomy (diagnostic) with histology for persistent asymmetry in an adult, or incisional biopsy. Immunohistochemistry, p16 and human papillomavirus testing for carcinoma; flow cytometry for lymphoma.
• Staging: CT neck, chest, abdomen and pelvis, or PET CT.
• HIV test, syphilis serology, interferon gamma release assay and chest radiograph when tuberculosis or HIV are suspected.
• Sleep study (polysomnography or overnight oximetry) in children with suspected obstructive sleep apnoea when surgery is considered and the picture is unclear.
• Lactate dehydrogenase, uric acid and bone marrow in suspected lymphoma with systemic features.

Limitations. Needle biopsy of a suspected lymphoma is less reliable than excisional or core biopsy. Tonsil size does not correlate with severity of sleep disordered breathing.

Airway compromise. Upright position, oxygen, urgent anaesthetic and ENT call, dexamethasone 10 mg IV (children 0.15 to 0.6 mg/kg, maximum 10 mg), and intubation or surgical airway if needed.

Acute tonsillitis.

• Analgesia with paracetamol 1 g orally every 4 to 6 hours (maximum 4 g in 24 hours) and ibuprofen 400 mg orally every 6 to 8 hours (maximum 2.4 g in 24 hours).
• Phenoxymethylpenicillin 500 mg orally four times daily for 10 days when streptococcal infection is likely (clarithromycin 500 mg orally twice daily for 5 days in penicillin allergy).

Peritonsillar abscess.

• Needle aspiration or incision and drainage by ENT.
• Benzylpenicillin 1.2 g IV every 6 hours with metronidazole 500 mg IV every 8 hours, then oral phenoxymethylpenicillin 500 mg four times daily with metronidazole 400 mg three times daily to complete 7 to 10 days.
• In penicillin allergy, clindamycin 600 mg IV every 8 hours then 300 to 450 mg orally four times daily.

Infectious mononucleosis. Supportive care and avoidance of contact sports for 4 weeks; prednisolone 40 to 60 mg orally daily for 3 to 5 days for airway compromise.

Chronic hypertrophy and obstructive sleep apnoea in children.

• For mild disease, intranasal corticosteroid (mometasone 50 micrograms, 1 spray to each nostril once daily from age 3 to 11 years) and montelukast 4 mg orally at night (age 2 to 5 years; 5 mg from age 6 to 14 years).
• Adenotonsillectomy for moderate to severe obstructive sleep apnoea or recurrent infection.

Tonsillolith and chronic tonsillitis. Gargles, oral hygiene, manual removal; tonsillectomy for refractory symptoms.

Recurrent tonsillitis. Tonsillectomy for 7 or more well documented, treated, disabling episodes in 1 year, 5 or more each year in 2 years, or 3 or more each year in 3 years.

Tonsillectomy aftercare.

• Paracetamol 1 g every 6 hours with ibuprofen 400 mg every 6 to 8 hours (unless bleeding risk or surgeon preference) for 7 to 10 days. Give fluids and avoid aspirin.
• Secondary haemorrhage (at 5 to 10 days) needs admission, antibiotic (amoxicillin 500 mg orally three times daily for 5 days), tranexamic acid, and theatre if bleeding continues.

Neoplasms. Urgent multidisciplinary oncology care: surgery, radiotherapy, chemotherapy, or immunotherapy by type and stage. Lymphoma: haematology referral and staging; tumour lysis precautions in Burkitt lymphoma (hydration, allopurinol 300 mg orally daily or rasburicase 0.2 mg/kg IV).

Tuberculosis, syphilis and sarcoidosis. Specialist treatment by type (tuberculosis: isoniazid 5 mg/kg, rifampicin 10 mg/kg, pyrazinamide 25 mg/kg and ethambutol 15 mg/kg daily for 2 months, then isoniazid and rifampicin for 4 months, with pyridoxine 10 to 25 mg daily and liver monitoring).

Monitoring. Review at 48 to 72 hours for infection, at 3 weeks for unilateral enlargement, and at 6 weeks after treatment of abscess.

Referral and escalation. Immediate for airway compromise or abscess. ENT within 2 weeks for unilateral or persistent asymmetric enlargement and suspected neoplasm. Paediatric ENT for obstructive sleep apnoea. Haematology and oncology for lymphoma.

Admission criteria. Airway threat, abscess, inability to swallow fluids, tonsillectomy haemorrhage, severe obstructive sleep apnoea in children, or systemic toxicity.

Discharge and safety netting. Return for noisy breathing, drooling, trismus, inability to swallow fluids, fever, neck swelling, bleeding from the throat, weight loss, or persisting unilateral enlargement.