Talk:Tonsillitis

MCOTM November
Starting point. Sandy Georgia (Talk)  00:35, 21 November 2020 (UTC)

Citation format
Looking back in time, the article was established with the Diberri/Boghog citation style (which we used to use on all articles). But now it is all over the map. Before we start work, we should decide on a citation style, and how we are going to provide page numbers. We know my preference :) If people want to drop citations in according to their familiar style, I am happy to standardize to one style, if we decide what that will be. Sandy Georgia  (Talk)  21:32, 1 November 2020 (UTC)
 * Erm... as we are not heading towards FAC (at least at this stage), I prefer Dave Iberri's gadget. Until the issue with citation bot is resolved, we can keep a note of the individual page numbers (if necessary). Graham Beards (talk) 21:42, 1 November 2020 (UTC)
 * We could always use Template:Rp temporarily for pages, and fix them all to one method when we're done. Sandy Georgia  (Talk)  22:26, 1 November 2020 (UTC)
 * Is that template still active? It's older than my nephew, Charlie. Sandy, you have an enviable memory, but I think not. Graham Beards (talk) 22:43, 1 November 2020 (UTC)
 * Maybe just stuck in the past :) If you check with the younger-than-us, I think we are headed to sfns ;). Also, the template thing seems resolved at wt:fac ... seems it is page vs. pages. Sandy Georgia (Talk)  22:45, 1 November 2020 (UTC)
 * Bedtime in the UK. I will follow up in the morning. Graham Beards (talk) 22:49, 1 November 2020 (UTC)

To-do
Feel free to add to this list, either with normal separate posts or in-line if you'd prefer to keep it all in one place. Looking forward to making some progress together. Ajpolino (talk) 01:15, 2 November 2020 (UTC)
 * Signs & symptoms - prosify and update reference (the newest ref in that section is from 2014. Certainly not a disaster, but a newer one would be nice if available)
 * Resolve the reference piles - for reasons unclear to me some uncontroversial-looking sentences carry long strings of citations. I assume there's one that could take the place of the pile.
 * Add material - MEDMOS-suggested sections not currently in the article are Classification, Mechanism, Prevention/Screening, Epidemiology, History, Society & culture, Research, and Special populations, and Other animals. My guess is we could write up Mechanism, Epidemiology, and History sections at least? We'll see if sources justify the others.
 * Images - are any other images desired? I'm not in love with File:Tonsillitis_cause.jpg in the causes section...


 * I have flagged primary sources, and mentioned with inline comments in the Books cited section some problems with some of those. Stopping for now.  Sandy Georgia  (Talk)  00:19, 21 November 2020 (UTC)

Random stuff
Reading all about tonsils. Didn't know you had four kinds in different parts of your nose/throat. Didn't know they got bigger in childhood and shrunk in adulthood. Didn't know about peritonsillar abscess aka quinsy. Never heard of "quinsy". Thought it might be archaic but then I saw the NHS used that term so perhaps that's actually the common term, and should be in our lead. Either way "peritonsillar abscess" or "quinsy" probably don't mean anything to many people, so might need explained. Didn't know about tonsil stones. I knew tonsillectomy was performed more often in the 70s and less so now, but didn't know that it was REALLY common early 20th century and is an ancient procedure. I'm seeing "tonsillotomy" mentioned on some websites/papers (is this a partial tonsillectomy?) but isn't mentioned here (it is mentioned at tonsillectomy but there isn't even a tonsillotomy redirect). We probably should have a bit more about tonsillectomy here, even though there is a dedicated article.

I think the statement "as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils" is probably bollocks. They do seem to be involved in an immune response (is that only a local response, or can it generate immune response elsewhere such as in the lungs?) but the idea they are a kind of face mask is a bit silly. Since they shrink in adulthood, and are relatively large in childhood vs throat size, I can see very physical reasons why tonsillitis is a childhood disease. But is there more to it than that and can we give more on the age-related epidemiology. Is there any more epidemiology? If the tonsils are part of your immune system, why is it that they are the ones to suffer when you get the infection? Wouldn't those bits be best at fighting it off? If you don't have much tonsil as an adult, how does that change your incidence or severity of sore throat? -- Colin°Talk 21:59, 3 November 2020 (UTC)

In several sections (symptoms, causes, treatment) there are statements sourced to 4..7 sources. Looking at the archive, this seems to date from User:BSW-RMH's external review in 2010, and they were perhaps unfamiliar with how best to add citations. I think we need to trim that back to just one source if possible, as it is a barrier to editing and verification -- the reader/editor needs to check all the sources to verify if the list is all sourced. Some of the sources are books, which also makes it harder for us to check.

The Merk aka MSD manual entry is for "tonsillopharyngitis" and overlaps infection of the pharynx. The BMJ Best Practice: Tonsillitis entry (which I can only read the summary) has a definition: "Acute tonsillitis is an acute infection of the parenchyma of the palatine tonsils. This definition does not include tonsillitis as part of infectious mononucleosis, although tonsillitis may occur in isolation or as part of a generalised pharyngitis. The clinical distinction between tonsillitis and pharyngitis is unclear in the literature, and the condition is often referred to simply as 'acute sore throat'." That definition excludes infectious mononucleosis, i.e. Epstein-Barr virus that our article says counts for between 1 and 10% of cases. It also claims the literature is unclear wrt pharyngitis. I do note that it is explicitly saying "palatine tonsils" vs the other tonsils. It seems that, if unqualified, then "tonsils" means "palatine tonsils" but our article could perhaps be clearer if this is the appropriate restriction. Another issue is our definition at NCIthesaurus is for "acute tonsillitis", which is also what the BMJ is for. But there is also "chronic" and/or "recurrent" tonsillitis. Is it ever genuinely chronic or does the recurrent one just feel that way? I assume some causes would be more typically "acute" and only some lead to chronic/recurrent cases.

I had a look at Centor criteria to find out how it got its name. There is a rather dubious and unsourced mnemonic on the page. I see an alternative mnemonic at this page, though am still unconvinced it would help anyone. Looking at the sources, I note that the paper from 1981 lead author was an "RM Centor" so I guess they are the source of the name. Perhaps we should consider if this or any mnemonic is WP:WEIGHT sufficient to mention on that wiki article, or if Wikipedia is simply perpetuating what one guy made up one day. -- Colin°Talk 18:44, 4 November 2020 (UTC)


 * I'm also wondering whether tonsillopharyngitis/pharyngotonsilitis should be covered primarily in this article or in Pharyngitis. WhatamIdoing (talk) 19:41, 4 November 2020 (UTC)


 * I've had much more trouble than I expected finding good sources on "tonsillitis" rather than tonsillopharyngitis/sore throat. This review (in the "Terminology and ICD10 Classification" section) gives a nice breakdown of the ways people reference tonsillitis in the literature that I found somewhat understandable. To WAID's question, it seems like tonsillitis is nearly always associated with pharyngitis, but I haven't found any source that comes out and says it in those words... Ajpolino (talk) 23:14, 8 November 2020 (UTC)

Above is a lot to process, so I'll make some comments and see whether these lead to more specific questions/clarifications. The tonsils are in the pharynx, so (as an internist, infectious diseases specialist, and research immunologist) I'm not sure what distinction is desired - tonsillitis is a specific location/type of pharyngitis, but the former could be part of the latter. Tonsils are part of Waldeyer's ring, a component of gut-associated lymphoid tissue or the more inclusive mucosa-associated lymphoid tissues (MALT), and therefore a component of the system of secondary lymphoid organs (which almost uniquely contain resident naive lymphocytes, lymphoid follicles, and other specialized structures/functions of the immune system). The immune system supports a degree of compartmentalization, such that naive lymphocytes recognizing antigens in MALT for the first time tend to remain localized to tissues of the same type (e.g. tissue-resident memory T cells). Happy to discuss further (life - especially pandemic life - is very busy, but I'll try to keep an eye on this page and my email notifications are turned on). &mdash; soupvector (talk) 00:00, 9 November 2020 (UTC)
 * BTW, "tonsillotomy" is a debulking procedure more commonly called "intracapsular tonsillectomy", used to treat obstructive symptoms from bulky tonsils. &mdash; soupvector (talk) 01:27, 9 November 2020 (UTC)
 * @Soupvector, thanks for this. I think the 'audience' I have in mind is someone who gets an e-mail message saying something like "little Johnny has tonsillitis again, and we hope he won't end up needing surgery".  The recipient of this e-mail message heads to Wikipedia to learn a little more.  Is it reasonably safe to assume that sources talking about pharyngotonsillitis are relevant to that subject? WhatamIdoing (talk) 02:07, 10 November 2020 (UTC)
 * In practice, inflammation of the pharynx (generally) and tonsils (specifically) is on a continuum, and there certainly appears to be overlap in the etiologies. So, I think the answer to your question is yes. &mdash; soupvector (talk) 02:23, 10 November 2020 (UTC)

Disagreeing numbers
Hi all, I'm sure this will pop up a few times but the article currently attributes 50 to 80% of tonsillitis to viruses, sourced to a 2014 review in Clinical Otolaryngology. A 2018 review in Surgery gives a bit less to viruses (sorry Graham), claiming 40-60%. Anyone see other numbers to break the tie, or have a reason to prefer one source over the other? Ajpolino (talk) 03:42, 6 November 2020 (UTC)
 * Hi, I did some low-level clean up. I also noticed that the lead says "Tonsillitis is most commonly caused by a viral infection and about 5% to 40% of cases are caused by a bacterial infection.  " while later on under Causes (as  has shared above), it says "The most common causes are viral infections; these account for 50 to 80% of tonsillitis cases. " JenOttawa (talk) 01:35, 10 November 2020 (UTC)

PANDAS
I am working on what to do about the PANDAS fraud ummm ... statement. That controversy now involves PANDAS, PANS and CANS, and has moved well beyond strep, but we still have to say something. Tourette syndrome Sandy Georgia (Talk)  14:55, 10 November 2020 (UTC)

Dale 2017
 * The PANDAS hypothesis states that streptococcal infections trigger immune responses that interact with the brain
 * The PANDAS hypothesis has evolved to now include PANS, which removes the necessity of streptococcal infection and broadens the definition to an acute and sudden onset of tics and OCD
 * Although PANDAS and PANS remain controversial
 * Patients with the PANDAS/PANS phenotype have a high rate of familial (particularly maternal) autoimmune disorders, suggesting a potential genetic vulnerability to immune dysregulation

 Marazziti 2018
 * In the childhood, much emphasis has been given to the relationship between group A Streptococcus (GAS) infection and the development of a group of clinical syndromes characterized by neuropsychiatric symptoms known as "pediatric autoimmune neuropsychiatric disorders associated with streptococcus" (PANDAS). However, more recently, PANDAS has been reconsidered and evolved towards pediatric acute-onset neuropsychiatric syndrome (PANS) and/or Childhood Acute Neuropsychiatric Syndrome (CANS) all characterized by the presence of typical of OCD symptoms and tics.
 * ... the available data cast doubts about the role of GAS: Therefore new categories have been described, the so-called PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) and CANS (Childhood Acute Neuropsychiatric Syndrome). This is supported by the results of a recent nationwide survey carried out in Sweden indicating a familial link between autoimmune disorders, not limited to streptococcus-related conditions and both OCD and Tourette/chronic tics disorders.
 * It should be immediately noted that this field is rapidly evolving, e.g., if the PANDAS concept has been a sort of paradigm for more than decade, now it is put into question and included in the broader concept of PANS. PANS do not exclude GAS infections, but underlies the association with other causative factors.

Zibordi 2018
 * The terms Pediatric Autoimmune Neuropsychiatric disorders associated with streptococcal infections (PANDAS), Pediatric acute-onset neuropsychiatric Syndrome (PANS), and Childhood Acute Neuropsychiatric Symptoms (CANS) have been used to describe certain acute onset neuropsychiatric pediatric disorders. This clinical characteristic was unusually abrupt onset of obsessive compulsive symptoms and/or severe eating restrictions and concomitant cognitive, behavioral or neurological symptoms. Because the CANS/PANS criteria define a broad spectrum of neuropsychiatric conditions, the syndrome is presumed to result from a variety of disease mechanisms and to have multiple etiologies, ranging from postinfectious autoimmune and neuroinflammatory disorders to toxic, endocrine or metabolic disorders.
 * subset of cases triggered by infections with group A Streptococcus (GAS)
 * The criteria for PANDAS had been developed to define an etiologically homogeneous group of patients for research studies, and purposely excluded acute-onset cases not triggered by GAS infections, which inadvertently and unfortunately diverted attention from children with acute onset OCD not related to GAS infections ... These difficulties have led two groups of investigators on a independent basis to postulate a revision of the diagnostic criteria and to propose of a new clinical definition ... CANS (Childhood Acute Neuropsychiatric Syndrome) and PANS (Pediatric Acute-Onset Neuropsychiatric Syndrome).
 * PANDAS identified a subgroup of patients with abrupt onset of OCD clinically related to GAS and accompanied by neuropsycological (sic) and motor symptoms. While PANDAS has found no confirmation of a distinct syndrome, new criteria for pediatric acute onset neuropsichiatric (sic) syndrome (PANS/CANS) have been remplaced (sic) it highlighting the fact that several agents rather than only Straptococcus (sic) might be involved.
 * Because the CANS/PANS criteria define a broad spectrum of neuropsychiatric conditions, the syndrome is presumed to result from a variety of disease mechanisms and to have multiple etiologies, ranging from postinfectious autoimmune and neuroinflammatory disorders to toxic, endocrine or metabolic disorders.

Obsessive–compulsive disorder and tic disorders are hypothesized to arise in a subset of children as a result of a post-streptococcal autoimmune process. Its potential effect was described in 1998 by the controversial hypothesis called PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), a condition thought to be triggered by GABHS infections. The PANDAS hypothesis is unconfirmed and unsupported by data, and two new categories have been proposed: PANS (pediatric acute-onset neuropsychiatric syndrome) and CANS (childhood acute neuropsychiatric syndrome). The CANS/PANS hypotheses include different possible mechanisms underlying acute-onset neuropsychiatric conditions, but do not exclude GABHS infections as a cause in a subset of individuals. PANDAS, PANS and CANS are the focus of clinical and laboratory research but remain unproven.
 * Proposed text

Could be shortened? May still give undue emphasis to GABHS, which persist thanks to Susan Swedo? Sandy Georgia (Talk)  17:35, 10 November 2020 (UTC)


 * Why do we have to say anything about this in this article? PANDAS doesn't mention tonsillitis by name, and, at a quick glance, none of those sources do, either.  Group A streptococcal infection gives PANDAS barely a sentence, and Strep throat offers only a link in a list.  Surely PANDAS is much more closely related to those than to tonsillitis, which doesn't necessarily involve GABHS (or any bacteria). WhatamIdoing (talk) 03:44, 13 November 2020 (UTC)
 * So far, I feel the same as WAID on this one. I haven't seen PANDAS mentioned in any of the tonsillitis articles I've looked through (though I haven't been looking for it). Perhaps PANDAS itself would be a good COTM nomination (perhaps everyone should nominate something...). Ajpolino (talk) 05:12, 13 November 2020 (UTC)


 * I am fine with completely deleting the dated sentence that is in the article now ... and hope that the pro-PANDAS crowd does not re-insert. Sandy Georgia (Talk)  09:30, 13 November 2020 (UTC)


 * I deleted the dated statement that was in this article, and updated the GAS article to the text above.  I do not think PANDAS would be a worthy MCOTM because it has finally become passé. |PANDAS Sandy Georgia  (Talk)  09:42, 13 November 2020 (UTC)
 * [off-topic] That's reminded me of a story I read some years ago. Apparently, smartphones are a major tool in convincing parents that their child's autism was not caused by toddler-aged vaccinations.  The key question from the pediatrician is:  "Did you get any video from his one-year-old birthday party, months before this vaccination?" A review of the videos often shows symptoms that are identifiable in hindsight.  I wonder if there's a similar pattern with PANDAS, with "my kid is suddenly OCD" being rebutted by "but you've been posting on Facebook about her quirky behaviors for years" or something like that.
 * [back on topic] Thanks for removing PANDAS from this article. WhatamIdoing (talk) 16:29, 13 November 2020 (UTC)
 * You’ve got the picture with PANDAS ... but for years trying to address the content was like dealing with Morgellons. But in this case, the NIH was on the wrong side. ;) Sandy Georgia  (Talk)  16:40, 13 November 2020 (UTC)

Tonsillitis in old person
Suggestions 2409:4042:4E99:E47E:194E:C4AF:6F19:358E (talk) 20:49, 29 April 2022 (UTC)

slay
i slay 86.22.124.150 (talk) 08:07, 22 November 2022 (UTC)