Tonsillitis in Children — Symptoms, Causes and Treatment

What is tonsillitis?

Tonsillitis (angina, tonsilitis) is the inflammation of the palatine tonsils, lymphoid tissue formations located in the oropharynx, on both sides of the pharynx. The tonsils play a role in immune defense, especially in the first years of life.

It is an extremely common condition in children between 3 and 10 years of age. It can present as an isolated acute episode or as chronic and recurrent tonsillitis, with a significant impact on the child's quality of life.

Symptoms

The manifestations of tonsillitis include:

• Severe sore throat — with radiation to the ear (reflex otalgia), worsened by swallowing
• Difficulty swallowing (odynophagia) — the child refuses food
• Fever — usually 38-40°C, more pronounced in bacterial forms
• Enlarged, red tonsils — sometimes with white-yellowish deposits (pus)
• Enlarged cervical lymph nodes — painful cervical lymphadenopathy
• Halitosis — foul-smelling breath
• Voice changes — "hot potato voice," as if the child had a potato in their mouth
• Loss of appetite and poor general condition
• Abdominal pain and vomiting — more common in young children

Causes

Viral tonsillitis (70-80% of cases)

This is the most common form, caused by:

• Adenoviruses
• Epstein-Barr virus (infectious mononucleosis)
• Enteroviruses (herpangina)
• Influenza and parainfluenza viruses

Bacterial tonsillitis (20-30% of cases)

• Group A beta-hemolytic streptococcus (GABHS) — the most important bacterial pathogen
• Staphylococcus aureus
• Haemophilus influenzae

Differentiating between viral and streptococcal tonsillitis is essential for proper treatment.

Diagnosis

• ENT clinical examination — appearance of the tonsils, presence of deposits, size
• Rapid streptococcal detection test (RADT) — result in 5-10 minutes, sensitivity 85-95%
• Pharyngeal exudate culture — the gold standard for diagnosing streptococcal infection
• Complete blood count — can guide the etiological diagnosis
• ASO titer — for monitoring post-streptococcal complications

The rapid streptococcal test is recommended for any child with suspected bacterial tonsillitis. A positive result requires antibiotic treatment to prevent rheumatic complications.

Treatment

Viral tonsillitis

• Symptomatic treatment — analgesics (paracetamol, ibuprofen), hydration, rest
• Antiseptic gargles — in children who are cooperative
• Antibiotics are NOT indicated in viral forms

Streptococcal tonsillitis

• Penicillin V or amoxicillin — 10 days, first-line treatment
• Macrolides (azithromycin, clarithromycin) — for penicillin-allergic patients
• Analgesics-antipyretics
• Adequate hydration and soft diet

Recurrent tonsillitis — Tonsillectomy

Tonsillectomy is indicated in:

• 7 or more episodes of tonsillitis in the past year
• 5 or more episodes per year in the past 2 consecutive years
• 3 or more episodes per year in the past 3 consecutive years
• Peritonsillar abscess
• Obstructive tonsillar hypertrophy with sleep apnea

When to see a doctor

• The sore throat is severe and the child cannot swallow liquids
• Fever exceeds 39°C and does not respond to antipyretics
• Difficulty breathing or voice changes
• Trismus (difficulty opening the mouth) — suspicion of peritonsillar abscess
• Symptoms do not improve after 48 hours of antibiotic treatment
• Tonsillitis episodes recur frequently

Complications

• Peritonsillar abscess (quinsy) — a serious local complication requiring surgical drainage
• Parapharyngeal and retropharyngeal abscess
• Acute rheumatic fever (ARF) — a post-streptococcal complication with cardiac involvement
• Post-streptococcal glomerulonephritis — renal involvement
• PFAPA syndrome — periodic fever with aphthous stomatitis, pharyngitis, and adenitis
• Obstructive sleep apnea — due to marked tonsillar hypertrophy