ACUTE AND CHRONIC TONSILLOPHARYNGITIS AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY SCOPE OF THE PRACTICE GUIDELINE This clinical practice guideline is for use by the Philippine Society of Otolaryngology-Head and Neck Surgery. It covers the diagnosis and management of acute and chronic tonsillopharyngitis and obstructive adenoidal hypertrophy in adults and children. OBJECTIVES The objectives of the guideline are (1) to describe clinical and epidemiologic features of tonsillitis in children and adults including socioeconomic burden of disease; (2) to enumerate current diagnostic techniques, and (3) to describe treatment options. LITERATURE SEARCH This guideline is based on the Clinical Practice Guidelines of the Philippine Society of Otorhinolaryngology Head and Neck Surgery (1996) on Acute and Chronic Tonsillitis. This was updated using available articles published in the past 10 years as found in The National Library of Medicine s PubMed database using the keyword tonsillitis. The search was limited to English language articles involving humans. The search yielded 161 articles which were carefully screened for relevance to the guideline. Of these, ninety-two (92) abstracts were selected and full text journals were obtained whenever possible. In addition, several guidelines on sore throat/pharyngitis and indications for tonsillectomy were included. These are the: Clinical Practice Guideline on Tonsillitis by the American Academy of Otolaryngology-Head and Neck Surgery; Clinical Practice Guidelines on the Management of Sore Throat of the Academy of Medicine Malaysia (2003); National Clinical Guideline on the Management of Sore Throat and Indications for Tonsillectomy of the Scottish Intercollegiate Guidelines Network (1999); Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis of the Infectious Disease Society of America (2002); Practice Guidelines on the Diagnosis and Management of Group A Streptococcal Pharyngitis of the American Family Physician (2003); Guideline on Sore Throat and Tonsillitis of the Finnish Medical Society Duodecim (2004). The chosen articles were divided as follows: Meta-analysis 24 Randomized controlled trial 17 Non-randomized controlled study 7 Descriptive study 33 Committee report 12 Guidelines 6 DEFINITIONS Acute Tonsillopharyngitis the presence of erythematous and/or exudative tonsils with any one of the following symptoms: sore throat, dysphagia, odynophagia, fever and accompanying tender, enlarged cervical lymph nodes. The panel further deliberated on whether tonsillitis with signs but without symptoms or conversely with symptoms but without signs should be admitted in the definition. However, neither the situation can be reliably taken to mean proof of tonsillar inflammation and the criteria was considered broad enough to include much of the clinical spectrum of acute tonsillar infection. Imposing a time frame for the development of symptoms as an additional diagnostic criterion was also considered but disregarded since available evidence does not support a definite clinically recognizable period beyond which acute tonsillitis can be justifiably labeled chronic or persistent in the oropharynx, oral cavity or systemically. (comment: separate definitions for Acute Pharyngitis and Acute Tonsillitis Panel consensus was that both terms can be integrated into one and that recommendations for either are the same)
Viral tonsillopharyngitis inflammatory condition of the tonsils caused by respiratory viruses such as adenovirus, influenza, parainfluenza, and respiratory syncitial virus. Other viral agents include coxsackie, echoviruses, herpes simplex and Epstein Barr Virus (EBV). 1,22 Bacterial tonsillopharyngitis inflammatory condition of the pharynx and or tonsils caused by Group A beta-hemolytic streptococci (GABHS), Hemophilus influenza and Moraxella catarrhalis. 22 Streptococcal tonsillopharyngitis inflammatory condition of the pharynx caused by caused by Group A beta-hemolytic streptococci (strep throat). It has an incubation period of two to five days and is most common in children 5-12 years of age. The risk of acute rheumatic fever complicating untreated streptococcal pharyngitis is 1%. This is associated with complications such as glomerulonephritis and rheumatic heart disease. Chronic Tonsillopharyngitis tonsillar inflammation resulting from recurrent clinically documented attacks of acute tonsillitis occurring 4 times per year. This definition was adapted from the textbooks of otolaryngology by Cummings and Paparella as well as Brodsky s review. The study by Paradise et. al. (1993) demonstrated that patient recall of the number of sore throat episodes grossly overestimates the frequency of subsequent episodes. While the study may be prone to maturation bias (i.e., the patients really got better with time) it does question the validity of patients (or parental) recall when unverified by medical consultation. Even medical validation is no guarantee of true tonsillitis because of the lack of a widely accepted clinical definition among general practitioners, pediatricians and otolaryngologists. Obstructive Tonsillar Hypertrophy presence of enlarged tonsils enough to cause symptoms of functional obstruction of the air and food passages such as snoring and dysphagia. The degree of obstruction may be expressed in terms of Clinically Assessed Size (CAS) scale in which the distance between the tonsils and the distance between the anterior tonsillar pillars are measured while the tongue is gently depressed. The ratio between the two is a measure of tonsillar encroachment on oropharyngeal space. While the scale lacks clinical validity at present the panel recognized its potential for standardizing tonsillar examination findings. Obstructive adenoidal hypertrophy presence of enlarged adenoids enough to cause symptoms of chronic mouth breathing, snoring, hyponasal speech and eustachian tube dysfunction. Hyponasal speech can be detected by a lack of change in voice nasality whether the nose is pinched shut or not. The test words recommended are mama, mana, nina, nganga, mga, mani and mano. PREVALENCE AND BURDEN OF ILLNESS In an analysis of the health situation in Vietnam for children under 5 years, the World Health Organization Regional Office for the Western Pacific (2005) cited the incidence of acute pharyngitis and acute tonsillitis as 251.39 rate per 100,000 population (0.25%) in 2002 and was ranked as 2 nd leading cause of morbidity. It is estimated that approximately 50% of cases of acute pharyngotonsillitis have a viral etiology. In 15 20% of cases, a primary bacterial pathogen, most commonly a streptococcal organism is recovered (Discolo 2003). Epidemiological data from western countries, in general, as specifically GABHS infections, both community and hospital based are more readily available. However, there is considerable variation in the prevalence of GABHS sore throats from one country to another. In Dhaka, Bangladesh, 22% of 601 children studied had a positive culture but only 2.2% was due to GABHS (Faruq 1995). In Israel, the prevalence is 15% among 152 symptomatic children aged 3 months to 5 years of age (Amir 1994). In the Italian French study, 26% of 865 children from 5 months to 14 years had GABHS pharyngitis (Cauwenberge 1999). Overall, he
figure is less than 30% in most countries. In the adult population GABHS is responsible for 5-10% of cases of acute pharyngitis (Bisno 2001). In our local setting, the Philippine General Hospital Out Patient Department ORL Clinic had 10 consults for Acute Tonsillitis, 4 consults for Acute Pharyngitis, and 21 consults for Acute Tonsillopharyngitis and 76 consults for Chronic Hypertrophic Tonsils out of 13,517 patients during the period of January to May of 2005. The prevalence rate is 7 out of 1000 patients for Acute Tonsillitis, 3 out of 1000 patients for Acute Pharyngitis, 15 out of 1000 patients for Acute Tonsillopharyngitis, and 56 out of 1000 patients for Chronic Hypertrophic Tonsils from January to May of 2005 (Table 1). Table 1-Philippine General Hospital Out Patient Department ORL Clinic (January to May 2005) Acute Tonsillitis Acute Pharyngitis Acute Tonsillopharyngitis Chronic Hypertrophic Tonsils Total OPD consults Consults 10 4 21 76 13,517 Prevalence 7 / 1000 3 / 1000 15 / 1000 56 / 1000 ---------- In the University of Perpetual Help Binan and Rizal and Sta. Rosa Polyclinic and Community Hospital 4,080 patients with ages ranging from 1 to 18 years old, and 680 age >19 years old were referred to the Out Patient Department of these institutions for tonsillitis in 2004. They admitted 148 patients from these for peritonsillar abscess. For the University of Sto. Tomas (UST)-Out Patient Department, they had 3,456 consults for tonsillitis in 2004 for both pediatric and adult patients. 85 of these patients subsequently underwent surgery. The economic impact of tonsillitis locally is not known due to paucity of studies. Research from other countries may provide insight into the socioeconomic impact of this condition. In the adult population, about 6.7 million visits annually were for sore throat (Barlet 1997). In the UK, it is estimated that visits for consultation for sore throat alone cost the NHS 60 million pounds per annum (National Ambulatory Medical Care Survey 1989-1999). RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE AND CHRONIC TONSILLOPHARYNGITIS AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY 1. The diagnosis of acute tonsillopharyngitis may be made clinically for both children and adults. It is important to differentiate whether the infection is viral or bacterial in etiology. Approximately 30 to 60% have a viral etiology (rhinovirus, adenovirus, and others) only 5 to 10% are caused by bacteria, with Group A beta-hemolytic streptococci being the most common bacterial etiology. In Hongkong, 2.65% of those more than 14 years of age have GABHS pharyngitis. In the US, the 1988 prevalence rates of recurrent tonsillitis was 14.9% among white non-hispanics, 6.5% among black non-hispanics and 10.2% among Hispanics (1988 National Health Survey on Child Health, US) 2. There are several reasonable approaches to the diagnosis of GABHS in an otherwise healthy adult, such as use of clinical criteria alone or use of rapid antigen testing as an adjunct to
clinical screening. Either of these strategies is associated with reasonable diagnostic accuracy (approximate sensitivity > 70%, specificity > 70% and allows treatment decisions to be made early in the course of illness, when patients can receive symptomatic benefit 3. (refer to Table 2) Table 2. Clinical features of acute tonsillopharyngitis 1,16 2.The diagnosis of acute group A streptococcal infection should be suspected on clinical grounds and may be supported by performance of a laboratory test. 1 Features suggestive of bacterial etiology Sudden onset Sore throat /Dysphagia Fever Petechiae Headache Nausea, vomiting, and abdominal pain Inflammation of pharynx and tonsils Patchy discrete exudates Tender, enlarged anterior cervical nodes Patients aged 5-15 years History of exposure Features suggestive of viral etiology Conjunctivitis Coryza Cough Hoarseness Diarrhea Muscle and Joint pains Highlighted features are adapted from the Centor Criteria 2.1. Throat culture remains to be the gold standard for the diagnosis of streptococcal pharyngitis with a sensitivity of 90-95%. 9 2.2. A positive rapid antigen detection test (RADT) may be considered definitive evidence for treatment of streptococcal pharyngitis, with specificity of 95% and sensitivity of 89.1%. These values are similar to those of throat culture which has a 99% specificity and 83.4% sensitivity. RADT, however, is not widely available locally and cannot be considered part of routine diagnostic assessment. 1 2.3.Either a positive throat culture or RADT provides adequate confirmation of GABHS in the pharynx, but a negative RADT result should be confirmed with a throat culture whenever possible. 23 2.4. However, the value of early diagnosis in the minority of cases when streptococcus is present should be weighed against the higher cost incurred in testing the majority of cases seen. Selective use of diagnostic studies is suggested. 8 Consequent to the risk of complications developing from untreated GABHS infection, early diagnosis and appropriate antimicrobial treatment is warranted.
Attempts to study the predictive value of the various signs and symptoms have not been particularly reliable. 19 3. The diagnosis of chronic tonsillitis can be made by a history of medically documented episodes of acute tonsillitis for at least 4 times a year. There are four randomized controlled trials (RCT) on tonsillectomy versus non-surgical intervention studies in children but no RCT in adults. Scottish Intercollegiate Guidelines Network advised more than 5 episodes and American Academy of Otolaryngology-Head and Neck Surgery more than 3 episodes as indication for tonsillectomy. Non-controlled studies demonstrated reduction in number of sore throats and improved general health with tonsillectomy. The panel concensus for this CPG is at least 4 episodes a year. 4. The diagnosis of obstructive adenoidal hypertrophy should be made on the basis of enlarged adenoids and a persistent difficult in breathing and/or swallowing. The following may be used in the diagnosis of obstructive adenoidal hypertrophy: Anterior rhinoscopy Posterior rhinoscopy Intraoral palpation (palpation can be done in children intraoperatively) Soft tissue lateral films of the nasopharynx may be used to determine the adenoid enlargement but its low sensitivity and the need for proper radiologic techniques is emphasized RECOMMENDATIONS ON THE MANAGEMENT OF ACUTE AND CHRONIC TONSILITIS AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY Management includes symptomatic treatment, antibiotic therapy for GABHS pharyngitis and, if clinically indicated, surgical treatment. 1. Symptomatic treatment is an integral part in the management of children and adults with sore throat. This includes maintaining adequate fluid intake, warm saline gargle, bed rest, use of analgesics and antipyretics, maintaining good oral hygiene. 23,24,25 1.1. Paracetamol or Ibuprofen is effective in treatment (in the first 48 hours) of associated with sore throat. 26 2. Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis based on clinical and epidemiological findings with/without supported by laboratory examinations. 27
Early antibiotic therapy will suppress rapidly infection and lower the risk of transmission within 24 hours allowing children to return to school. Untreated patients usually will improve in 3 5 days unless a complication develops 28. The majority of the studies and guidelines mostly involved patients with acute tonsillopharyngitis. 2.1. Penicillin is the drug of choice for the treatment of streptococcal pharyngitis. The antibiotic has proven efficacy and safety, a narrow spectrum of activity and low cost. Amoxicillin (Pediatric dose: 50mg/kg/day in 3 divided doses, Adult dose: 250-500 mg capsule every 8 hours) is often used in place of Penicillin V (Pediatric dose: 50-100 mg/kg/day in 3-4 divided doses, Adult dose: 1-4 g/day in 3-4 divided doses) as oral therapy for young children, the efficacy seems equal. This choice is primarily related to acceptance of the taste of suspension. Intramuscular Benzathine Penicillin G therapy (Pediatric dose: 100,000 250,000 units/kg/day in 4-6 divided doses, Adult dose: 600,000-1.2 M units IM) is preferred for those patients unlikely to complete full 10 day course of oral therapy. 30 2.2.First Generation Cephalosporins may be used instead of penicillin but may be more expensive. 2 nd Generation Cephalosporins are as effective as 1 st Geneneration Cephalosporin but may be more expensive than both Penicillins and 1 st Generation Cephalosporin deleted phrase(are therefore not recommended). 31 2.3. A 10 day course of First Generation Cephalosporin (Cefadroxil with Pediatric dose: 25-50 mg/kg/day once daily, Adult dose: 500mg-2g once daily and Cefalexin with Pediatric dose: 25-50 mg/kg/day in 4 divided doses, Adult dose: 4-6g/day in 4 divided doses) has been shown to be superior to penicillin in eradicating GABHS. 2 2.4. Erythromycin (Pediatric dose: 30-50 mg/kg/day in 4 divided doses, Adult dose: 1-2 g/day in 4 divided doses) is a suitable alternative for patients allergic to penicillin who manifest hypersensitivity to beta lactam antibiotics. For patients allergic to Penicillin and Erythromycin-intolerant Clindamycin (Pediatric dose: 20-30mg/kg/day in 3 or 4 divided doses, Adult dose: 150-300 mg in 3 or 4 divided doses) is recommended as an alternate antibiotic 1. 2.5. Failure to resolve the infection within 3-4 days justifies shifting to augmented penicillins, clindamycin, 3 rd generation cephalosporins or higher generation macrolides. Higher generation macrolides may be used for 3-5 days. 3. Surgical treatment (Tonsillectomy with or without Adenoidectomy) Tonsillectomy may be recommended in patients with the following conditions:
3.1. Tonsillar hyperplasia accompanied by any of the following: upper airway obstruction, dysphagia, speech impairment or halitosis 3.2. Recurrent or chronic tonsillitis - majority of the panel voted 4 episodes of tonsillitis in a year is the indication for Tonsillectomy instead of 5 episodes (SIGN Recommendation is 5 episodes and AAO-HNS is more than 3 episodes). 3.3. Peritonsillar abscess occurring in the background of chronic tonsillitis. 31 3.4 Panel: Comment on ASO Titier as an indicator for Tonsillectomy: Cases with high ASO, both IgG- and IgM-subclasses, were considered to have an indicative factor for tonsillectomy The significance of antibody for streptolysin-o concerning tonsillectomy was studied. The results obtained were as follows. 1. The upper limit of ASO titer in 5,121 school children was 250 u and a value of more than 333 u was considered abnormal. But the level of the normal limit was different from year to year. 2. Among 143 cases with a high ASO titer of more than 833 u, only 12 cases had recurrent tonsillitis. There was no correlation between the tonsillar hypertrophy and the height of streptococcal antibodies. 3. There was a correlation between the titers determined by ELISA IgG-ASO and ASO in Todd units (r = 0.69), but there was no agreement between the titers determined by ELISA IgM-ASO and ASO in Todd units. 4. IgM-ASO determined by ELISA showed high levels in cases with early stages of streptococcal infection, focal infection and streptococcal carriers. Tonsillectomy resulted in yearly mean decreases in number of weeks on antibiotics by 5.9 weeks, number of workdays missed by 8.7 days, and physician visits by 5.3 visits. Tonsillectomy results in significant improvement in quality of life, decreases health care utilization, and diminish the economic burden of chronic tonsillitis in the adult population. 32 3.4. Patients with the following conditions may benefit from adenoidectomy Obstructive adenoidal hypertrophy 3.5. New surgical modalities for tonsillectomy may be available but are not recommended as routine procedures because of higher expense deleted phrase(unproven effectiveness). These include coblation, radiofrequency and ultrasonic harmonic scalpel. 11,13,14,15,16 4.Vaccinations against pneumococcus may be used in children to prevent future episodes of sore throat. 18 Grade C recommendation Review of vaccination record of children is warranted. (A panelist suggested deletion of this guideline)