What is the treatment for a tonsil ulcer?

Treatment of Tonsil Ulcers

The treatment of tonsil ulcers should begin with antibiotics, specifically penicillin V (250 mg 2-3 times daily for children, 500 mg 2-3 times daily for adolescents/adults) for 10 days, particularly when Group A Streptococcus is the suspected cause. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Assess for streptococcal infection:

   • Apply Centor Criteria (tonsillar exudates, tender anterior cervical lymph nodes, lack of cough, fever) 1
   • Patients with score ≥3 should undergo rapid antigen detection test (RADT) and/or throat culture 2

2. Rule out other causes:

   • Consider other etiologies such as aphthous ulcers 3, tuberculosis 4, or syphilis 5 if presentation is atypical
   • Biopsy may be necessary for persistent ulcers to exclude malignancy 3

Treatment Algorithm

1. Antibiotic Therapy (for bacterial causes)

• First-line: Penicillin V for 10 days 1, 2

  • Children: 250 mg 2-3 times daily
  • Adults: 500 mg 2-3 times daily

• Alternatives for penicillin allergy: 1, 2

  • Non-anaphylactic allergy: First-generation cephalosporins (e.g., cephalexin)
  • Anaphylactic allergy: Clindamycin (300-450 mg three times daily) or azithromycin (12 mg/kg once daily, max 500 mg for 5 days)

• For treatment failures or recurrent infections: 6

  • Clindamycin: 20-30 mg/kg/day in 2-4 divided doses for 10 days (children)
  • Adults: 600 mg/day in 2-4 divided doses for 10 days
  • Amoxicillin/clavulanate: 40 mg/kg/day in 3 divided doses for 10 days

2. Supportive Care

• Pain management: 1

  • NSAIDs (ibuprofen) or acetaminophen for pain and inflammation
  • Throat lozenges for symptomatic relief
  • Warm salt water gargles

• Hydration and nutrition: 1

  • Cold liquids or ice chips
  • Avoid hot, spicy, or hard foods that may irritate the throat

3. Management of Recurrent Cases

• For frequent recurrent episodes: 6

  • Consider tonsillectomy if meeting criteria: ≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years with proper documentation
  • Each episode should have documented sore throat plus one of: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A beta-hemolytic streptococcus

• For persistent ulcers: 3

  • Consider systemic steroids (e.g., prednisone 60 mg) for major aphthous ulcers
  • Referral to otolaryngology if no improvement after appropriate therapy

Special Considerations

• Bleeding: For ulcers with bleeding, assess severity - minor bleeding can be managed conservatively while severe bleeding requires immediate medical attention 1

• Complications to monitor: 1

  • Worsening infection
  • Increased bleeding
  • Difficulty breathing
  • Dehydration

• Follow-up: Patients with persistent symptoms after 48-72 hours of antibiotic therapy should be reevaluated 1

Pitfalls and Caveats

1. Avoid unnecessary antibiotics: Do not prescribe antibiotics for likely viral causes (Centor score <3) 1, 2

2. Complete the full course: Failure to complete the full antibiotic course increases risk of treatment failure and complications like acute rheumatic fever 1

3. Avoid routine follow-up cultures: After adequate treatment of streptococcal tonsillitis, repeat pharyngeal swabs are not indicated 6

4. Consider carrier state: For recurrent positive cultures without significant symptoms, consider streptococcal carrier state rather than true infection 6

5. Surgical consideration: Tonsillectomy should be reserved for cases meeting specific criteria and not used routinely for isolated tonsil ulcers 6