From the Guidelines
For a 17-year-old with 3+ enlarged tonsils, I recommend a comprehensive evaluation starting with a thorough history and physical examination, as outlined in the clinical practice guideline: tonsillectomy in children (update) 1. The workup should include:
- A complete blood count to assess for infection or mononucleosis
- A rapid strep test if symptoms suggest streptococcal pharyngitis
- Possibly a monospot test to rule out Epstein-Barr virus infection If the patient has recurrent tonsillitis (defined as 7+ episodes in one year, 5+ episodes per year for two consecutive years, or 3+ episodes per year for three consecutive years), persistent symptoms despite appropriate antibiotic therapy, or complications such as peritonsillar abscess, referral to an otolaryngologist (ENT) for consideration of tonsillectomy is appropriate, as stated in the guideline 1. For acute tonsillitis, treatment typically includes:
- Analgesics such as acetaminophen (10-15 mg/kg/dose every 4-6 hours, maximum 3,000 mg daily) or ibuprofen (10 mg/kg/dose every 6-8 hours, maximum 3,200 mg daily)
- Adequate hydration
- Antibiotics if bacterial infection is confirmed, with Penicillin V (250-500 mg orally twice daily for 10 days) or amoxicillin (50 mg/kg/day divided twice daily for 10 days, maximum 1,000 mg/day) being first-line treatments for streptococcal pharyngitis 1. Enlarged tonsils without infection may require sleep study evaluation if there are concerns for obstructive sleep apnea, particularly if the patient exhibits symptoms like snoring, witnessed apneas, or daytime somnolence, as recommended in the guideline 1. It is essential to note that the decision to perform a tonsillectomy should be based on the individual patient's needs and medical history, and should be made in consultation with an otolaryngologist (ENT) 1.
From the Research
Work-up for a 17-year-old with 3+ tonsils
- The patient's symptoms and physical examination findings, such as sore throat, fever, and tonsillar exudate, should be evaluated to determine the likelihood of streptococcal pharyngitis 2, 3, 4, 5, 6
- Clinical scoring systems, such as the modified Centor score, can be used to predict the risk of streptococcal infection and guide further testing 2, 3, 4
- Rapid antigen detection tests or throat culture can be used to diagnose streptococcal pharyngitis, with throat culture being the gold standard 2, 3, 4, 5
- The presence of cough, coryza, and diarrhea suggests a viral cause, while fever, tonsillar exudate, and cervical lymphadenitis increase the suspicion of streptococcal pharyngitis 2, 3, 4
Diagnostic Considerations
- The patient's age, symptoms, and physical examination findings should be considered when deciding which diagnostic tests to use 3, 5
- Rapid antigen detection tests are useful for quickly diagnosing streptococcal pharyngitis, but may not be as sensitive as throat culture 2, 3, 4, 5
- Throat culture is recommended in children and adolescents with a negative rapid antigen test result 3
Treatment Considerations
- Penicillin and amoxicillin are first-line antibiotics for the treatment of streptococcal pharyngitis, with a recommended course of 10 days 2, 3, 4, 5
- First-generation cephalosporins can be used as an alternative in patients with penicillin allergy, but macrolides may not be effective due to resistance 2, 3, 4, 5
- Tonsillectomy is rarely recommended as a preventive measure, and is typically considered only in cases of recurrent streptococcal pharyngitis 3, 4