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by Warren P. Silberstein, M.D.
05/19/97
The term tonsillitis means that the tonsils are inflamed. Usually this refers to enlarged, pussy tonsils. The diagram shows where the tonsils are. Tonsillitis can occur with many causes of sore throat. Pus on the tonsils is not a sign of bacterial infection. Mononucleosis can cause a severe tonsillitis.
Pharyngitis means that the pharynx (the medical term for throat) is inflamed. Tonsillitis occurs as part of pharyngitis, usually when the throat is more inflamed; however, tonsillitis is not a more serious illness than pharyngitis.
Most scratchy throats associated with colds don't require medical attention. Strep throat (see below) does not cause any cold symptoms such as runny nose or cough; however, a person with a cold who is exposed to Strep will be more susceptible. Put another way, the presence of cold symptoms doesn't rule out Strep, so a patient who is very ill with a sore throat should seek medical attention whether or not he has cold symptoms.
Strep throat usually starts with fever, swollen glands, and sore throat. Many children experience abdominal pain with Strep throat. The throat appears very red. There may be pus on the tonsils but this is not at all diagnostic of Strep since many viruses can cause pus on the tonsils. The lymph nodes (glands) at the angle of the jaw and the back of the neck may be large, firm, and tender. While this is a typical appearance for Strep throat, not all children with Strep are very sick or have a very red throat. The only way to accurately diagnose Strep throat is to do a Rapid Strep Test or a throat culture. It is preferable not to treat with antibiotics just because a throat "looks bad." It is just as important not to dismiss a sore throat without culturing it just because it doesn't look very inflamed.
Strep throat can be successfully treated with plain penicillin or erythromycin for penicillin allergic patients. Newer, more exotic, more expensive, broad spectrum antibiotics offer no advantage over penicillin or erythromycin for treating Strep and should not be used. Most patients feel much better after two to three days of antibiotics; however, it is extremely important to take the full 10 day course of medication and not to miss any doses. The more doses the patient misses or the less of the 10 day course the patient completes, the greater the risk that the patient will have a relapse. Strep throat can also be treated with a single injection of long acting penicillin. This is useful for children to whom it is difficult to give medicine or in situations where the patients don't remember to take their medication.
Even though patients generally get better with treatment, children still sometimes have relapses even with full treatment . This occurs because as the throat gets less inflamed the amount of antibiotic getting into the tissue decreases. After completion of treatment there may still be some Strep living in the throat but not invading the tissue. People can carry Strep in their throats for a long time without getting sick. Most carriers will become non-carriers within a few months without treatment. Treatment for carriers is rarely successful since antibiotic levels in the non-inflamed tissues are low, and the Strep is not living in the tissue. A carrier is only slightly contagious. Carriers can also develop Strep throat from the Strep they are carrying in their throats. Most patients who relapse become sick again within 48 hours after stopping antibiotics.
Relapses should be treated with penicillin or erythromycin just like the original infection. In situations where a child has multiple relapses a course of Rifampin for the last 4 days of treatment can sometimes eliminate the carrier state. My favorite treatment for recurrent Strep is a 10 day course of Duricef. In some cases a prolonged course of penicillin twice daily may be necessary. In refractory cases, especially with large, diseased tonsil, it may be necessary to remove the tonsils.
Strep throat may cause Scarlet Fever. The rash of Scarlet Fever is a fine red rash which covers most of the body and feels like sandpaper. The rash is most intense in the groin and under the arms. The area around the mouth is not red and so looks pale. For many children, Scarlet Fever is nothing more than Strep throat with a rash; however, we are currently seeing an upswing in the severity of Strep infections and some children with Scarlet Fever may be significantly sicker.
The diagnosis is obvious when a patient has all the classical findings of mononucleosis, but in less obvious cases the diagnosis can be made or confirmed with a blood test. The blood test may not be diagnostic until at least a week of illness.
Since Mononucleosis is caused by a virus, there is no curative medicine available. The main treatment is bed rest and adequate fluids. If a patient has such severe tonsillitis that he can't swallow, steroids can be used to reduce the inflammation of the tonsils. In extreme cases, hospitalization for IV fluids could be required to prevent dehydration.
After recovery from the acute illness most patients will have a prolonged period of fatigue. When those patients wake up in the morning they may have energy, but after some activity they may become severely fatigued. That fatigue is not a relapse. It simply tells the patient that he has reached the limit for the amount of activity that he can tolerate.
Herpangina is diagnosed by the characteristic blisters and canker sores that appear on the anterior pillars, the skin folds that come down from the palate in front of the tonsils. Sometimes the cankers may appear on the tongue and in the cheeks as well.
The illness starts abruptly with fever, headache, sore throat, difficulty swallowing, and sometimes stiff neck. The throat is often sore out of proportion to the degree of redness. Fever may persist up to five days. As with most other viruses, there is no specific treatment, so treatment is aimed at symptomatic relief. Most children recover without complications, but since coxsackie viruses can cause a whole host of different illnesses, any child who has worrisome symptoms should be evaluated by a doctor.
Herpangina is primarily a summer illness. The virus can be found in stool, so presumably it can spread from stool to mouth on someone's hands and through swimming pools.
Hand-foot-and-mouth disease is a variation of herpangina in which characteristic blisters occur on the palms and soles and sometimes extend up the extremities. Occasionally the bumps and blisters may be found on the buttocks. The course of the illness is the same as herpangina.
Children who get a primary herpes infection may develop herpes gingivostomatitis. The illness may begin with fever that may last several days before the gingivostomatitis begins. With gingivostomatitis children have sore throat, sore mouth, swollen red gums that bleed easily, canker sores primarily in the front of the mouth, and extension of the sores to the outside of the lips as groups of blisters. Sometimes herpes may be hard to tell apart from coxsackie. The similarities between herpes and coxsackie resulted in the name, herpangina, for the illness caused by coxsackie. Coxsackie involves primarily the throat and sometimes the tongue whereas herpes involves primarily the lips and gums.
Herpes is one of the few viruses for which there is an antiviral drug; however, the medication, Zovirax, has only been approved for treatment of genital herpes. At this time, as with most other viruses, the treatment is supportive and for symptomatic relief only. Most cases of gingivostomatitis recover within a week, but I have seen severe cases last up to two weeks. If the amount of inflamed tissue is sufficient to prevent drinking, IV fluids may be necessary to prevent dehydration.
Rarely, the inflammation in the throat from a virus infection may result in a secondary bacterial infection around the tonsil called a peritonsillar abscess or peritonsillitis. Patients with peritonsillitis may have such severe dysphagia (difficulty swallowing) that they drool. The abscess around the tonsil causes a swelling in the palate which bulges forward and causes the position of the uvula to shift and the palate to be asymmetrical as seen in the diagram. Even though the original infection may have been viral, this complication requires antibiotic treatment. Severely ill patients may require intravenous antibiotics and drainage of the abscess by a surgeon.
Any patient whose course is not as expected or who seems very ill should seek medical attention.
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