8.10 Diseases of the Adenoids and Palatine Tonsils
8.10.1 Adenotonsillitis
Key Features
Adenotonsillitis is most commonly viral in etiology.
Bacterial etiology is similar to acute otitis media (OM):
Group A β-hemolytic Streptococcus pneumoniae
Moraxella catarrhalis
Haemophilus influenzae
Chronic infection is typically polymicrobial.
There is growing evidence for the role of biofilm.
Acute adenotonsillitis most commonly presents in children 5 to 10 years of age and young adults 15 to 25 years of age. The primary consideration in its accurate diagnosis and treatment is prevention of secondary complications particularly associated with group A β-hemolytic Streptococcus pneumoniae, including rheumatic fever and poststreptococcal glomerulonephritis. Suppurative complications avoided by early and appropriate management include peritonsillar abscess and deep neck space infection.
Epidemiology
The average incidence of all acute upper respiratory infections is five to seven per child per year. It is estimated that children have one streptococcal infection every 4 to 5 years. Group A Streptococcus is isolated in 30.0 to 36.8% of children with pharyngitis, and asymptomatic carriage of group A Streptococcus is ~ 10.9% for children aged 14 or younger.
Clinical
Signs
Erythremic, exudative palatine tonsils
Tonsilloliths
Trismus
Cervical adenopathy
Palatal petechiae (infectious mononucleosis)
Symptoms
Halitosis
Sore throat
Odynophagia
Purulent rhinorrhea
Postnasal drip
Nasal obstruction
Fever
Differential Diagnosis
Adenotonsillar hypertrophy
Acute pharyngitis (bacterial or viral)
Peritonsillar abscess
Infectious mononucleosis
Lymphoma, leukemia, or other neoplasm (unilateral/asymmetric tonsillar enlargement)
Evaluation
Physical Exam
In the head and neck exam, focus on examination of the oral cavity, inspection of palatine tonsils looking for enlargement, erythema, peritonsillar cellulitis, abscess, and exudates. Palpation of the neck is performed to assess for cervical adenopathy.
Imaging
Contrast-enhanced computed tomography (CT) if concerned about retropharyngeal or deep neck space infection.
Labs
Complete blood count (CBC) with differential; monospot, if clinically indicated.
Other Tests
Do a throat swab for culture and sensitivity and latex agglutination tests for group A β-hemolytic Streptococcus.
Treatment Options
Medical
Analgesics and antipyretics are prescribed.
Relevant Pharmacology
Antibiotic therapies include:
Amoxicillin: Penicillin-based β-lactam antibiotic with bactericidal action due to interference with bacterial cell wall synthesis
45 mg/kg per day divided every 8 hours for 7 to 10 days
Amoxicillin + Clavulanate: Clavulanate has itself little antibacterial action, but it is a potent β-lactamase inhibitor, protecting the penicillin-based antibacterial action.
45 mg/kg per day (amoxicillin component) divided every 12 hours for 7 to 10 days
Azithromycin: Macrolide, semisynthetic derivative of erythromycin. Bactericidal action is through inhibition of protein synthesis via binding to the 50S ribosomal RNA subunit.
10 mg/kg for 1 dose, then 5 mg/kg per day for 5 days
Cefuroxime axetil: Second-generation cephalosporins’ bactericidal action is due to the inhibition of peptidoglycan synthesis interfering with cell wall synthesis, similar to penicillin′s.
30 mg/kg per day divided every 12 hours for 7 to 10 days
Surgical
Surgery entails a delayed tonsillectomy and/or adenoidectomy for recurrent disease ( Table 8.5 ). Currently, it is rare to perform a tonsillectomy in the setting of an acute infection (quinsy tonsillectomy). The presence of a peritonsillar abscess requires acute incision and drainage; removal of the tonsil to allow drainage is rarely needed.
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