Differential diagnosis of tonsillitis

Acute tonsillitis

It can be caused by a diverse range of agents. It most often occurs in children and young adults. The etiology can be guessed by clinical presentation: intensity, extent, involvement of the neck and soft palate, the presence of exudation, blisters, and the presence of petechiae or enanthema. Out of all the bacterial etiologies, Streptococcus pyogenes is the most common cause of tonsillitis. In children under the age of three, it is usually of viral origin.

Clinical picture

Locally, in tonsillitis there is redness and swelling of the tonsils, they may be covered with pins. Sore throat, accompanied by difficulty swallowing (odynophagia), develops rapidly. The submandibular nodes are swollen and painful. To the local manifestations is worsened by a general feeling of illness - malaise, fatigue, fever, and lethargy.

According to the clinical picture, it is usually not possible to identify the causative agent.

Diagnosis	Clinical picture, and diagnostics (DG)
Acute inflammation of the tonsils	clinical picture: redness and edema of the tonsils, purulent pins, fibrin coatings, necrosis (angina catarrhalis, folicularis, lacunaris, pseudomembranacea)
Infectious mononucleosis	clinical picture: tonsillitis with severe lymphadenopathy (generalized), Holzel's sign, Bass's symptom clinical picture+diff: leukocytosis (initially leukopenia) monocytosis, atypical leukocytes, DG: serology
Herpangina	clinical picture: vesicular tonsillitis, vesicular efflorescence on storey arches, clinical picture+diff: leukopenia
Streptococcal tonsillitis	clinical picture: most often lacunar tonsillitis, clinical picture+diff: left-shifted neutrophilia, DG: cultivation, ASLO
Scarlet fever	clinical picture: fever, most commonly lacunar tonsillitis, raspberry tongue, spinal skin rash, Filatov and Šrámek symptoms, DG: clinical picture, FW, cultivation, ASLO
Tonsillitis in oropharyngeal tularemia	clinical picture: necrotizing tonsillitis, often unilateral, marked regional lymphadenopathy, DG: clinical picture, FW, serology
Diphtheria	clinical picture: špinavě šedé povlaky přesahující okraje tonzil, pevně lpící, foetor, DG: nátěr na sklíčko, bakteriologie
Ulceromembranous tonsillitis (Plaut–Vincent angina)	clinical picture: necrotizing tonsillitis with a tendency to ulceration, dirty coatings, immunologically compromised individuals, severe general condition, unilateral finding, rare occurrence
Tonsillitis in agranulocytosis (in acute leukemia)	clinical picture: bilateral necrotizing tonsillitis, ulceration of the pharyngeal mucosa, no evidence of lymphadenopathy, while hepatosplenomegaly is usually present, tonsillitis may be the first manifestation of the overall underlying disease DG: clinical picture, FW
Syphilitic tonsillitis (Stage II syphilis)	clinical picture: mucosal plaques DG: serology

Clinical units

Streptococcal tonsillopharyngitis

 For more information see Streptococcal tonsillitis.

Diphtheria

 For more information see Diphtheria.

Plaut-Vincent angina

• rare, caused by a mixed flora of anaerobes and spirochetes
• the disability is one-sided - a disgusting odor (feator ex ore) is typical
• Lemierre's syndrome - a rare but fatal, infection by fusobacterium necrophorum, which spreads to the mediastinum.

Infectious mononucleosis

 For more information see Infectious mononucleosis.

• significant swelling of the tonsils with thickening
• Holtzel's sign - small petechias on the soft palate
• Bass symptom - swelling of the eyelids

Herpangina

• coxsackie viruses, mostly in children
• fever, headache
• redness of the oropharynx with small blisters (2-10) that do not coalesce
• pain during swallowing
• within 2-4 days the fever subsides and the ulcers heal
• dif. dg. - herpetic stomatitis - anterior ulcers in the oral cavity

Other forms

• less common
• gonococcal pharyngitis, secondary syphilis

Diagnosis

• from the clinical picture
• laboratory examination - viral - normal sedimentation, leukopenia, predominance of mononuclear cells
• Infectious mononucleosis (IM)- atypical lymphocytes

Therapy

• viral - only symptomatic
• streptococcal - penicillin (erythromycin), cephalosporins I.g., abscess - lincosamides;
• gonococcus, syphilis - also penicillin
• corynebacterium diphtheriae - also penicillin
• In IM, on the other hand, aminopenicillins are completely inappropriate!

References

Source

• BENEŠ, Jiří. Studijní materiály [online]. ©2007. [cit. 2009]. <http://jirben2.chytrak.cz/materialy/orl_jb.doc>.

Used literature

• KLOZAR, Jan, et al. Speciální otorinolaryngologie. 1. vydání. Praha : Galén, 2005. 224 s. ISBN 80-7262-346-X.

• HAVLÍK, Jiří, et al. Infektologie. 2. vydání. Praha : Avicenum, 1990. 393 s. ISBN 80-201-0062-8.

• LOBOVSKÁ, Alena. Infekční nemoci. 1. vydání. Praha : Karolinum, 2001. 263 s. ISBN 80-246-0116-8.