Etiology and pathogenesis of tonsillitis

Anatomical substrate and core process

Acute tonsillopharyngitis (ATP) represents a combined inflammation. Isolated involvement is extremely rare, so in clinical outpatient practice for children and adults, it is advisable to use the umbrella term (synonym — pharyngotonsillitis).

• Tonsillitis is an inflammatory process directly affecting the palatine tonsils.
• Pharyngitis is inflammation of the pharyngeal mucosa.

Making a specific diagnosis depends on the predominance of inflammation severity in one or another region.

The anatomical substrate for the development of the inflammatory reaction is Waldeyer's pharyngeal lymphoid ring. This is a vital barrier immune organ, which includes the palatine, lingual, pharyngeal, and tubal tonsils. In the pathogenesis of the disease, a key role is played by the fact that while the palatine tonsils bear the main brunt, the inflammatory process always elicits a concurrent reaction of the entire lymphoid ring, as well as regional lymph nodes (submandibular and cervical).

Historically established terminology is quite symbolic: the word "angina" originates from the Latin ango, which translates as "to choke" or "to squeeze." This word very accurately describes the characteristic symptom of constriction and severe pain when swallowing associated with the disease. The term "tonsillitis" comes from the Latin tonsilla — tonsil.

Etiological factors and treatment selection

From the perspective of etiology, which is of paramount clinical importance for determining treatment tactics, two main groups of pathogens are distinguished:

1. Streptococcal process. Associated with group A beta-hemolytic Streptococcus (GAS, S. pyogenes). This condition requires the mandatory prescription of antibacterial drugs. The drugs of choice remain beta-lactams (penicillins) due to the preserved 100% sensitivity of all pathogen strains. If they cannot be used, lincosamides (clindamycin) are prescribed, as they show a low level of resistance (3–4%). The prescription of macrolides and tetracyclines requires caution due to the significant level of GAS resistance to these groups (about 20% and 13–22%, respectively).
2. Non-streptococcal (viral) process. In viral etiology, antibacterial therapy is not indicated, as the disease tends to resolve spontaneously within 1–2 weeks.

A crucial rule is that the detection of colonizing microflora on the oropharyngeal mucosa (such as S. aureus or S. pneumoniae) against the background of acute tonsillopharyngitis symptoms is not an indication for antibiotic therapy. This is a fundamental point that helps avoid unjustified medical intervention.

Pathogenesis and clinical presentation

The development of inflammation in the lymphoid apparatus of the pharynx causes a vivid clinical picture. The following manifestations are typical for tonsillopharyngitis of any etiology:

• Acute onset of the disease;
• Fever, most often febrile (above 38°C), less frequently the temperature may remain normal or subfebrile;
• Discomfort and severe sore throat, which significantly worsen during swallowing (pain syndrome may radiate to the ear);
• Possible bilateral enlargement and tenderness upon palpation of regional lymph nodes;
• In early childhood, refusal of any food, including liquid food, is frequently noted.

The general condition of the patient is usually assessed as satisfactory or of moderate severity. The presence of concomitant catarrhal symptoms (such as cough, rhinorrhea, conjunctivitis, hoarseness) in patients over three years of age is a reliable clinical marker specifically of the viral nature of the disease.

Classification

Several classification options for the disease are used in clinical practice.

By localization of the inflammatory process:

• Acute tonsillitis (predominant involvement of the palatine tonsils);
• Acute pharyngitis (predominant involvement of the pharyngeal mucosa);
• Acute tonsillopharyngitis (combined involvement).

By etiology:

• Streptococcal (GAS-associated);
• Non-streptococcal (viral).

By course:

• Acute;
• Chronic (chronic tonsillitis is considered an independent nosology, separate from the acute episode).

According to ICD-10, the pathology is coded under categories J02 (pharyngitis) and J03 (tonsillitis) depending on the specified pathogen. For example, J02.0 and J03.0 denote streptococcal etiology, J02.8 and J03.8 — caused by other specified pathogens, and J02.9 and J03.9 — unspecified process.

Class and exam questions

What else to study on this topic

• Acute post-streptococcal glomerulonephritis as a complication of infection
• The issue of antibiotic resistance of GAS to macrolides and tetracyclines
• Laboratory diagnostics and monitoring of tonsillopharyngitis
• Alternative treatment regimens for beta-lactam intolerance

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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.