What is the recommended treatment for unilateral tonsillitis?

Treatment of Unilateral Tonsillitis

The recommended first-line treatment for unilateral tonsillitis is antibiotics targeting Group A Streptococcus, specifically penicillin or amoxicillin, combined with appropriate pain management using NSAIDs or acetaminophen.

Diagnosis and Assessment

When evaluating unilateral tonsillitis, it's important to:

• Distinguish between viral (70-95% of cases) and bacterial causes (5-30% of cases) 1
• Use validated scoring systems like Centor or McIsaac scores to estimate probability of bacterial infection 2
• Consider point-of-care rapid antigen detection testing for Group A Streptococcus in ambiguous cases 2
• Document each episode carefully, including symptoms, physical findings, test results, and impact on quality of life 3

Treatment Algorithm

1. Antimicrobial Therapy

For bacterial tonsillitis (particularly Group A Streptococcus):

• First-line: Penicillin or amoxicillin for 10 days

  • Children with pharyngitis/tonsillitis: Azithromycin 12 mg/kg once daily for 5 days if penicillin-allergic 4
  • Adults: Penicillin V remains the treatment of choice 5

• Second-line (for penicillin-allergic patients):

  • Azithromycin (shorter course of 5 days)
  • Clarithromycin
  • Cephalosporins (if no anaphylactic reaction to penicillin)

2. Pain Management

• NSAIDs (e.g., ibuprofen) and/or acetaminophen for pain relief 3, 5
• Topical agents (sprays, lozenges with local anesthetics) may provide temporary symptomatic relief 3
• Warm salt water gargles for patients old enough to gargle 3
• Avoid corticosteroids as they are not recommended for routine use in tonsillitis 3

Special Considerations

Recurrent Tonsillitis

• Watchful waiting is strongly recommended if there have been <7 episodes in the past year, <5 episodes per year for 2 years, or <3 episodes per year for 3 years 3
• Tonsillectomy may be considered only if frequency criteria are met: ≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 3, 6
• Each episode should be documented with at least one of: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A Streptococcus 6

Unilateral vs. Bilateral Presentation

• Unilateral presentation warrants careful evaluation to rule out:
  • Peritonsillar abscess
  • Malignancy (especially in adults with asymmetric tonsils)
  • Infectious mononucleosis (EBV or CMV) which can present with unilateral findings 7

Monitoring and Follow-up

• Follow-up is not routinely required after clinical improvement 3
• Consider reassessment if symptoms persist beyond expected timeframe (7-10 days)
• Watch for complications such as peritonsillar abscess, rheumatic fever, or glomerulonephritis 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most cases of tonsillitis (70-95%) are viral in origin and do not require antibiotics 1, 7
2. Inadequate pain management: Pain control is essential for recovery and maintaining hydration
3. Premature consideration of tonsillectomy: Surgery should only be considered after meeting strict frequency criteria 3, 6
4. Missing serious underlying causes: Persistent unilateral tonsillitis may indicate peritonsillar abscess or rarely malignancy, requiring further investigation
5. Incomplete antibiotic course: Emphasize the importance of completing the full course of antibiotics to prevent complications and recurrence

By following this evidence-based approach, clinicians can effectively manage unilateral tonsillitis while minimizing unnecessary antibiotic use and avoiding complications.