1. Introduction

Tonsillitis is a throat disease that is characterized by the inflammation of the tonsils secondary to different types of infection [1,2]. The tonsils, palatine tonsils is one of the major lymphoid tissue in the lateral wall of the oropharynx. They help in the immune system which protects the body against various forms of infections that may enter through the upper aerodigestive tract [3].

It is major caused by various type viral or bacterial infection others were fungal and tuberculosis [4,5] Infected mucous from the patient are contagious and spread by contact with the mouth, throat or air droplet from sneezing. Infected tonsils are inflamed, enlarged, engorged, red, with or without yellow or white coating [6-11]. Post-treatment, the majority of the patient may recover completely or progress to recurrent tonsillitis or chronic tonsillitis [12]. Untreated or poorly treated cases may develop peritonsillitis, peritonsillar abscess, parapharyngeal abscess, retropharyngeal abscess, and other forms of systemic complications.

There are different types of tonsillitis in clinical practice [11-14]. Acute tonsillitis occurred when the disease duration is less than three weeks. Subacute tonsillitis is when symptoms last between three weeks to three months. Recurrent tonsillitis is frequent attacks of acute tonsillitis over a year or two. Chronic tonsillitis is characterized by symptoms of tonsillitis last more than three months. Peritonsillar abscess when there is an accumulation of purulent suppuration in the peritonsillar capsule.

Patterns of clinical manifestations of tonsillitis depend on the type of tonsillitis. Common symptoms include a sore throat with associated referred otalgia, neck pain, and trismus in acute and recurrent tonsillitis [15]. Also, sore throat is associated with dysphagia and odynophagia in acute or recurrent tonsillitis. Chronic tonsillitis is associated with difficulty breathing, cough, snoring, halitosis, sleep apnoea, reduced appetite, and weight loss. Acute symptoms include fever, chills, and malaise. Associated constitutional symptoms are loss of appetite, nausea, vomiting, stomach ache, and furry tongue which may mimic other febrile illnesses. Clinical findings are enlarged cervical lymph node, swollen tonsils, pus on tonsils crypts [16-19].

There are only a few studies on tonsillitis in developing countries particularly in Nigeria in the literature. In this study, we aimed to evaluate the prevalence, sociodemographic features, clinicoepidemiological survey, and bacteriology of tonsillitis among patients in our practice.

2. Materials and Methods

This was a prospective hospital-based study of all patients with a diagnosis of tonsillitis at Ekiti state university teaching hospital, Ado Ekiti, Nigeria. This study was carried out over one year between July 2018 and June 2019.

Data was collected using a pretested interviewer-assisted questionnaire. Data were obtained on sociodemographic features. Others were presenting complaints such as sore throat, painful swallowing, difficulty breathing, cough, snoring, halitosis, sleep apnoea, fever, and malaise on the onset, duration, frequency, severity, relieving factor, and treatment. Ear, nose, and systemic symptoms were obtained and documented.

Detailed oropharyngeal, neck, ear, and nose examinations were done and findings were also documented.

Bacteriological investigations by tonsils swab were taken for microscopic, culture, and sensitivity tests. Results were obtained and findings were recorded.

Data obtained were collated and analyzed using SPSS version 18.0. The data were expressed with descriptive statistics by frequency distribution table, percentage, bar chart, and pie chart.

Ethical clearance for this study was sought and obtained from the ethical committee of the hospital. Informed consent was obtained from the enrolled patient, parent, or guardian.

3. Results

The total number of patients seen in the ear, nose, and throat department over the studied period was 1,296 out of which 164 patients had tonsillitis. The prevalence of tonsillitis was 12.7%.

All the studied age groups were involved with a peak age value of 81 (49.4%) at the first decade of life and the least age value of 1 (0.6%) at the extreme age group of ≥61 years. As illustrated in table 1.

Table 1. Age group distribution of the patients

There were 91 (55.5%) males and 73 (44.5%) females. Male to female ratio was 1.2:1. In this study, 69 (42.1%) were rural dwellers while 95 (57.9%) were urban dwellers. The majority 153 (93.3%) of the studied patients were Christian faith and 11 (6.7%) were Muslim faith. The common patients' educational level was 67 (40.9%) primary, 53 (32.3%) secondary, and 26 (15.9%) nil formal education. On parent/patient occupation status, majority 52 (31.7%) were civil servant followed by 45 (27.4%) students/ apprentice and 27 (16.5%) artisan. Patients with a family history of tonsillitis were commoner than a family without tonsillitis as in 108 (65.9%) and 56 (34.1%) respectively. As demonstrated in table 2.

Table 2. Sociodemographic features of the patients

The commonest types of tonsillitis in this study were 97 (59.1%) recurrent tonsillitis. Others were 43 (26.2%) acute tonsillitis and 24 (14.6%) chronic tonsillitis. This is showed in figure 1.

Figure 1. Types of tonsillitis among patients

The majority of 63 (38.4%) of the patients were referred by paediatrician. This was followed by 54 (32.9%) family physicians and 32 (19.5%) casualty officer. As in figure 2.

Figure 2. Sources of referral among patients

Emergency presentations were less common in this study. The majority of 116 (70.7%) of the patients were seen in the ear, nose, and throat outpatient clinic. This was followed by an emergency ward and hospital ward in 47 (28.7%) and 1 (0.6%) respectively. As demonstrated in figure 3.

Figure 3. Pattern of presentation among patients

Most of the patients with tonsillitis presented with fever, sore throat, odynophagia, and otalgia in 119 (72.6%), 117 (71.3%), 99 (60.4%), and 92 (56.1%) respectively. Frequent findings on clinical examination were 90 (54.9%) enlarged tonsils, 86 (52.4%) neck pain/cervical lymphadenopathy, and 63 (63.4%) exudate on the tonsils. As illustrated in table 3.

Table 3. Clinical features among patients

Throat swab was taken from 93 (56.7%) inflamed tonsils. No bacteria were isolated from 41 (25.0%) patients throat swab while bacteria growth were isolated in 52 (31.7%) patients throat swab. Common isolated bacteria were 19 (11.6%) Staphyloccocus aureus, 14 (8.5%) Streptococcus species, 7 (4.3%) Pseudomonas aeroginosa, 6 (3.7%) Proteus species and 4 (2.4%) Klebsiella species. This is showed in table 4.

Table 4. Microscopic of cultured organisms among patients

In this study, Streptococcus species and Staphylococcus aureus from the different swabs showed 100% sensitivity to cefuroxime, gentamicin, azithromycin, and ceftazidime while Staphylococcus aureus further had 100% sensitivity to Amoxicillin and Streptomycin. Both showed some sensitivity to ampicillin and co-trimoxazole. As shown in table 5.

Table 5. Antibiotic sensitivity among the patients

In this study, the commonest associated complication of tonsillitis was otitis media in 31 (18.9%). Others were 17 (10.4%) peritonsillitis and 6 (3.7%) peritonsillar abscess. As illustrated in figure 4.

Figure 4. Complication of tonsillitis among patients (bar)

4. Discussion

Tonsillitis is a common throat disorder with poor epidemiological studies in developing countries including Nigeria. In this hospital-based study, the prevalence of tonsillitis was 12.7%. This prevalence was lower than findings from other studies [20,21]. The lower patient presented in this study center may be due to our peculiar sociocultural practice of treatment of sore throat with jin and spicy local concussion by the sufferer.

On sociodemographic features, tonsillitis is commoner in children and younger age groups compared to adults. A study conducted in Scotland also found tonsillitis to be commoner in children compared to adults [22]. This may be due to cross-infection among school children with the habit of sharing utensils and cups. Another contributing factor is the high incidence of family history of tonsillitis in this study [23]. The order of prevalence of families with tonsillitis were siblings, mother, father, and other relatives, and this is further determined by their closeness and family ties. Most patients with tonsillitis believed it is a minor illness and was not a communicable disease.

Prevalence of tonsillitis was higher in males than females in this study. This is contradictory to findings from the previous study in other parts of the world which revealed higher female prevalence [24]. This may be secondary to a higher incidence of outdoor activities in males than females. More males feed outside the home in the eatery, cafeteria, and local food vendor sharing poorly treated cups and utensils after use. This habit was commoner among urban dwellers, businessmen, students, and apprentices in this study.

In this study majority of the patients were diagnosed with recurrent tonsillitis. Many patients and their relatives believe tonsillitis is a minor illness that can be cured with a homemade herbal concussion as a remedy. Also, some believe that it is a self-limiting disease. The second most common type of tonsillitis is acute tonsillitis followed by chronic tonsillitis they present early and late respectively. Both acute and recurrent tonsillitis mainly presented due to odynophagia which may be severe enough to cause total dysphagia or limit the patient to a liquid diet. The majority of chronic tonsillitis seek expert opinion due to persistent throat discomfort or obstructive symptoms.

The patients first approach to the treatment of tonsillitis was home care followed by over the counter drugs or pharmacy. Failure of all these cares usually the prompt patient or their relatives to contact a family physician for definitive treatment. Referral of the patient to specialist was mainly from the family physician or paediatrician if treatment failed. Unfortunately, the majority of the patient presents in ear, nose, and throat outpatient clinic in the subacute state. Few cases presented in casualty with complicated tonsillitis.

Majority of our patients presented with fever and sore throat. Many of the patients were treated as a case of either Malaria or Typhoid fever. Which are common causes of fever in the Malaria endemic zone. Unfortunately, the majority of the primary health care officer does not consider tonsillitis as one of their differentials in their diagnosis. Clinical examination of the oropharynx revealed enlarged inflammation of the tonsils. Oropharyngeal examinations are not routinely done and these findings are often omitted by the primary health care officer. This finding is contrary to the report from other studies [25,26].

In this study, no growth of bacterial was reported in about half of the throat swab sent for microscopy, culture, and sensitivity test. This is most likely due to wrong diagnosed Malaria or Typhoid fever and inappropriate antibiotics with another form of treatment. The most common isolated bacteria were Staphylococcus aureus which is followed by Streptococcus spices and Pseudomonas aureginosa. All these bacteria were found in acute tonsillitis and recurrent tonsillitis. Similar results were recorded from other studies on the most common isolated bacteria [27,28]. A contrary result was reported from another study [29]. These different findings may be due to different population studies, sociocultural practices, and types of abused antibiotics.

Staphylococcus aureus and Streptococcus spices in this study were found to be sensitive to Cefuroxime, Gentamicin, Azithromycin, Ceftazidime, Amoxicillin, Streptomycin, Ampicillin, Cephalexin, Floxapen, and Cotrimoxazole as in other studies [27,29]. Slight different results of some antibiotics resistance were reported in other studies [21]. The observed differences in antibiotics sensitivity maybe after the wrong diagnosis and inappropriate antimicrobial administration. This practice leads to the waste of scarce resources, waste of precious time, exposure to toxic effects of drugs and promotes the emergence of resistant bacteria.

Wrong diagnosis and poor treatment were the main causes of complicated tonsillitis in this study. The main encountered complications were otitis media, peritonsillitis, and peritonsillar abscess. These are avoidable if accurate diagnosis and prompt treatment were instituted.

5. Conclusions

In this study, tonsillitis was found to be common in all age groups and presents mainly with fever, sore throat, and tonsil enlargement. The condition is commonly misdiagnosed for other causes of fever and wrongly treated. The majority had recurrent tonsillitis and Staphylococcus aureus with Streptococcus species were isolated and sensitive to common antimicrobials. There were associated avoidable complications at presentation. Differentials of tonsillitis should be considered in patients with febrile illnesses.

Funding

There was no financial support. It is a self-sponsored research study.