DRG Category: 145
Mean LOS: 2.4 days
Description: Surgical: Other Ear, Nose, Mouth Throat Operating Room Procedures Without Complication or Comorbidity or Major Complication or Comorbidity
Tonsils are the masses of lymphatic tissue located in the depressions of the mucous membranes of the fauces (constricted opening leading from the mouth to the oral pharynx) and pharynx. The tonsils act as a filter to protect the body from bacterial invasion via the oral cavity and also to produce white blood cells. Tonsillitis is generally referred to as an inflammation of a tonsil, particularly a faucial tonsil. Acute tonsillitis is considered acute pharyngitis. When tonsillar involvement is severe, the term tonsillopharyngitis or tonsillitis is used; when the involvement is minor, the term nasopharyngitis is used. Nearly all children have at least one episode of tonsillitis during their childhood. Complications include difficulty or disrupted breathing, abscesses, and sepsis, and if caused by group A beta-hemolytic streptococci (GABHS), rheumatic fever, scarlet fever, septic arthritis, and poststreptococcal glomerulonephritis.
Viral infection is the leading cause of nasopharyngitis. Adenovirus is the most common infecting agent, but other viruses include enteroviruses, herpes virus, and Epstein-Barr virus. A nonviral cause is Mycoplasma pneumoniae. Bacterial causes include GABHS, Neisseria gonorrheae, and Corynebacterium diphtheriae. Risk factors include childhood and frequent exposure to infectious agents such as often found at a school or day-care center.
Heritable immune responses could be protective or could increase susceptibility.
Viral tonsillitis is unusual in infants under age 2 years and is most common in children of both sexes ages 4 to 5 years. Bacterial infections are most common in children ages 5 to 11 years.
Ethnicity, race, and sexual/gender minority status have no known effect on the risk for tonsillitis. Sore throat and swollen lymph nodes (adenopathy) are early signs of HIV infection as well as tonsillitis. The Centers for Disease Control and Prevention (2020) reported in 2018 that 69% of new HIV diagnoses in the United States were in gay and bisexual men. In young people ages 13 to 24 years, young gay and bisexual men account for 83% of all new HIV diagnoses. If persons are at risk for HIV and have signs of tonsillitis, they should have HIV testing.
Children develop tonsillitis in all regions of the world. Recurrent tonsillitis has a prevalence of 10% to 12% in many developed regions; no data are available in developing regions.
PLANNING AND IMPLEMENTATION
Collaborative
The aim of treatment for a viral infection is to provide supportive care. Usually, fever and sore throat pain can be managed with over-the-counter analgesia. Antibiotic therapy is appropriate for bacterial infections. Allow the child to get rest and provide adequate fluid intake. If the child continues to have symptoms in spite of appropriate antibiotic therapy after cultures and sensitivities, the child may represent a “treatment failure” and may need a different antibiotic. If a relapse occurs, a second course of antibiotics may be needed, and a family member may be a carrier.
Chronic tonsillitis occurs in children with recurrent throat infections (seven in the past year or five in each of the past 2 years). Tonsillectomy and adenoidectomy decrease the incidence of these problems during childhood, although those who do not have surgery also have a decreased incidence of infection. Current recommendations generally encourage physicians to avoid surgery in most cases. Watchful waiting, as compared to tonsillectomy, has been shown to have similar outcomes with quality of life. A Cochrane review shows that tonsillectomy and adenoidectomy are most effective with children who are most severely affected with pharyngitis and that some children will get better without surgery. The decision to remove the tonsils relates directly to hypertrophy, obstruction, chronic infection, and parent/child choice.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Non-narcotic analgesia and antipyretics | Varies with drug | Acetaminophen, ibuprofen | Relieve aches and pains and reduce fever |
| Antibiotics | Varies with drug | Benzathine penicillin G, potassium penicillin V, erythromycin, first-generation cephalosporin, amoxicillin, dicloxacillin, cefdinir, cefuroxime | Halt replication of the bacteria in bacterial infections |
| Corticosteroids | Varies with drug | Dexamethasone, prednisone, prednisolone | Reduces inflammation to allow for adequate airway, breathing, and swallowing |
Independent
Children should be allowed to rest as much as possible to conserve their energy; organize interventions to limit disturbances. Provide age-appropriate activities. Crying increases the child's difficulty in breathing and should be limited if possible by comfort measures and the presence of the parents; parents should be allowed to hold and comfort the child as much as possible. Provide adequate hydration to liquefy secretions and to replace fluid loss from increased sensible loss (increased respirations and fever). The child might also have a decreased fluid intake during the illness. Apply lubricant or ointment around the child's mouth and lips to decrease the irritation from secretions and mouth breathing. Instruct parents to provide soft foods for swallowing difficulties. Using saltwater gargles, warm liquids, or cold foods may help with throat soreness.
Evidence-Based Practice and Health Policy
Abdel-Naby Awad, O. (2020). Echinacea can help with Azithromycin in prevention of recurrent tonsillitis in children. American Journal of Otolaryngology. Advance online publication. https://doi.org/10.1016/j.amjoto.2019.102344
- The authors employed a prospective randomized clinical trial design to evaluate children in the Ear, Nose, Throat Clinic with recurrent tonsillitis who were scheduled for a tonsillectomy. Children were divided into three groups: those who did not receive any prophylactic antibiotics, those who received azithromycin daily for 6 days every month for 6 months, and the last group who received the same antibiotic treatment but also added echinacea to their treatment plan three times daily for 10 days every month for 6 months.
- The first group showed no statistically significant difference between number of tonsillitis episodes compared to the pre-study duration. In the group receiving just the antibiotic treatment, there were a smaller number of tonsillitis episodes reported in comparison to the pre-study duration. The group receiving both the antibiotics and supplemental echinacea reported a significantly less number of attacks during the study than those in the second group. The author concluded that the combined use of azithromycin and echinacea produced more favorable outcome than azithromycin alone in patients with recurrent tonsillitis.