Acute Infection

Most episodes of acute pharyngotonsillitis are caused by viruses (Chapter 373). Group A β-hemolytic streptococcus (GABHS) is the most common cause of bacterial infection in the pharynx (Chapter 176).

Chronic Infection

The tonsils and adenoids can be chronically infected by multiple microbes, which can include a high incidence of β-lactamase–producing organisms. Both aerobic species, such as streptococci and Haemophilus influenzae, and anaerobic species, such as Peptostreptococcus, Prevotella, and Fusobacterium, predominate. The tonsillar crypts can accumulate desquamated epithelial cells, lymphocytes, bacteria, and other debris, causing cryptic tonsillitis. With time, these cryptic plugs can calcify into tonsillar concretions or tonsillolith. There is growing evidence that biofilms might also play a role in chronic inflammation of the tonsils.

Airway Obstruction

Both the tonsils and adenoids are a major cause of upper airway obstruction in children. Airway obstruction in children is typically manifested in sleep-disordered breathing, including obstructive sleep apnea, obstructive sleep hypopnea, and upper airway resistance syndrome (Chapter 17). Sleep-disordered breathing secondary to adenotonsillar breathing is a cause of growth failure (Chapter 38).

Tonsillar Neoplasm

Rapid enlargement of one tonsil is highly suggestive of a tonsillar malignancy, typically lymphoma in children.

Acute Infection

Symptoms of GABHS infection include odynophagia, dry throat, malaise, fever and chills, dysphagia, referred otalgia, headache, muscular aches, and enlarged cervical nodes. Signs include dry tongue, erythematous enlarged tonsils, tonsillar or pharyngeal exudate, palatine petechiae, and enlargement and tenderness of the jugulodigastric lymph nodes (Fig. 375–1; Chapters 176 and 373).

Figure 375–1 Pharyngotonsillitis. This common syndrome has a number of causative pathogens and a wide spectrum of severity. A, The diffuse tonsillar and pharyngeal erythema seen here is a nonspecific finding that can be produced by a variety of pathogens. B, This intense erythema, seen in association with acute tonsillar enlargement and palatal petechiae, is highly suggestive of group A β-streptococcal infection, though other pathogens can produce these findings. C, This picture of exudative tonsillitis is most commonly seen with either group A streptococcal or Epstein-Barr virus infection. (B, Courtesy of Michael Sherlock, MD, Lutherville, MD.)

(From Yellon RF, McBride TP, Davis HW: Otolaryngology. In Zitelli BJ, Davis HW, editors: Atlas of pediatric physical diagnosis, ed 4, Philadelphia, 2002, Mosby, p 852.)

Chronic Infection

Children with chronic or cryptic tonsillitis often present with halitosis, chronic sore throats, foreign body sensation, or a history of expelling foul-tasting and foul-smelling cheesy lumps. Examination can reveal tonsils of almost any size and often they contain copious debris within the crypts. Because the offending organism is not usually GABHS, streptococcal culture is usually negative.

Airway Obstruction

In many children, the diagnosis of airway obstruction (Chapters 17 and 365) can be made by history and physical examination. Daytime symptoms of airway obstruction, secondary to adenotonsillar hypertrophy, include chronic mouth breathing, nasal obstruction, hyponasal speech, hyposmia, decreased appetite, poor school performance, and, rarely, symptoms of right-sided heart failure. Nighttime symptoms consist of loud snoring, choking, gasping, frank apneas, restless sleep, abnormal sleep positions, somnambulism, night terrors, diaphoresis, enuresis, and sleep talking. Large tonsils are typically seen on examination, although the absolute size might not indicate the degree of obstruction. The size of the adenoid tissue can be demonstrated on a lateral neck radiograph or with flexible endoscopy. Other signs that can contribute to airway obstruction include the presence of a craniofacial syndrome or hypotonia.

Tonsillar Neoplasm