Necrotizing tonsillitis

What is necrotizing tonsillitis?

This is a tonsillitis that is caused by anaerobic bacteria that are part of the normal flora in our oral cavities.
In certain situations, which we will touch upon below, these bacteria multiply and infect the tonsils.

But tonsillitis means strep throat, no?

Not necessarily.
As I have previously explained in one of my most read posts on this website Group A Strep Throat, there are many different types of throat infections.
Most throat infections are caused by viruses and only a minority of the infections are actually caused by bacteria.
Among the bacteria, the most common one is streptococcus. But there are other bacteria that can cause infections in this region, including anaerobic bacteria.

What are anaerobic bacteria?

Bacteria can be divided into many different types of groups. One of the ways in which we distinguish between the different groups is by the bacteria’s need or capacity to survive in the absence of oxygen.
Anaerobic bacteria are able to (and some of them have to) thrive in the absence of oxygen.
We all have these types of bacteria in our oral cavities, and we live in peace with them as the normal flora in our bodies.

Okay, then why would someone have necrotizing tonsillitis?

Sometimes, we can’t find a good answer to this question. Bacteria tend to thrive and multiply in certain conditions and in some of the cases this type of infection is spontaneous and does not have any preceding signs.
However, in a large portion of the cases, I often see anaerobic infections start secondarily to a different throat infection, usually infectious mononucleosis.

What is the association between infectious mononucleosis and anaerobic tonsillitis?

Infectious mononucleosis, especially when caused by EBV (learn more about EBV here), causes an infection in the throat that manifests in exudates on the tonsils. However, sometimes, a few days following this infection, those same anaerobic bacteria that live in our oral cavity (the ones I just told you about), decide to take over those sick tonsils, and that is how infectious mononucleosis tonsillitis turns into anaerobic / necrotizing tonsillitis.
Do not get confused, in most of the cases of infectious mononucleosis this does not occur, but in certain cases it does happen – I see this once a week on average.

How can we detect necrotizing tonsillitis?

There are certain principles you should be familiar with. Start of by taking a good look at the image attached.
Appearance – necrotizing / anaerobic tonsillitis has a characteristic appearance. The tonsils appear to be covered with a white/grey/green coloured layer. What you see is not the ‘typical’ strep throat or infectious mononucleosis exudates, rather a more ‘cheesy’ appearance.
Odour – anaerobic infections have a characteristic offensive smell. Okay, I know that all of the children suffering from tonsillitis can have bad breath, this is mostly due to the multiplication of anaerobic bacteria in the mouth (and not necessarily anaerobic tonsillitis). However, when a child has necrotizing tonsillitis, it is exceptionally stinky.
Severity of illness – this is a severe and painful illness. The patients feel a strong pain that they describe as “knives”, have high fever and appear sick.
Prodromal symptoms and the typical patient – many times these patients are adolescents (it is less common in infants and young children) with an infection that started off as “simple” but did not improve, and it could present as a clinical deterioration including a new onset of fever a few days after the illness develops.

What should we not miss? What is not in line with necrotizing tonsillitis?

What should we not miss? An abscess in one of the tonsils. Abscesses also involve anaerobic bacteria but are usually one-sided and this causes one of the tonsils to look sick and the other to have a normal size and appearance. In addition, there are some other findings on throat examination that may cause you to suspect that an abscess has developed. The importance in diagnosing an abscess promptly is the need for a different type of treatment as well as drainage.
What is not in line with anaerobic tonsillitis? I was not planning on discussing other anaerobic infections in the oral cavity in this chapter such as ones that originate in the teeth or the floor of the mouth. I wanted to simply discuss the tonsillar tissues.

How can we isolate the bacteria causing the necrotizing tonsillitis?

Theoretically speaking we can try and culture these anaerobic bacteria under special laboratory conditions. We don’t do this in practice. A regular throat swab will obviously not be able to isolate these bacteria.

What is the treatment for anaerobic tonsillitis?

First of all, we have to realize that this is a severe infection, in a patient who hasn’t had any food or drink for several days, and therefore we must consider the need for referral to urgent care for rehydration, bloodwork and intravenous antibiotic treatment.
However, in most of the cases, a correct diagnosis does not necessarily have to lead to urgent care or emergency department referral, but it does have to lead to starting adequate therapy based on the following principles:
Reduction of fever and rehydration (plenty of fluids). This part is easy.
Choosing adequate antibiotic therapy – this is slightly more complex but I will try to simplify it. There are many different antibiotics that work well for anaerobic bacteria, including penicillin. However, since this is usually a severe infection, and if it follows EBV infection, penicillin can cause an unpleasant rash. This is where the idea that choosing penicillin and its derivatives (amoxicillin or amoxicillin-clavulanic acid) is incorrect.
In my opinion the first choice of antibiotics for this infection is Clindamycin. Also, when it comes to the choice of doses there can be disagreements, but I will leave that part to your physician. If you really want to know why – send me an email and I will try to explain.
Let’s make this clear, necrotizing tonsillitis is a severe infection, and if it is not handled correctly, it can cause suffering and complications. For that reason, the physician should detect it correctly and manage it properly.
However, if managed well, the physician will probably receive some chocolates from their patient within 36-48 hours.

In summary, this is a chapter for advanced readers, I know. But somehow, I have a feeling it will really be helpful when it comes to this severe, yet not uncommon infection.
Good luck.