What is the treatment for tonsillar swelling?

Treatment of Tonsillar Swelling

The treatment of tonsillar swelling should be determined based on the underlying cause, with watchful waiting recommended for most cases of recurrent throat infection, while antibiotics, pain management, and in select cases, tonsillectomy are appropriate interventions depending on severity and frequency of symptoms.

Diagnostic Approach

When evaluating tonsillar swelling, it's important to determine the underlying cause:

• Acute tonsillitis: Look for fever, sore throat, difficulty swallowing, tonsillar erythema, exudate, and cervical adenopathy
• Recurrent tonsillitis: Document frequency and severity of episodes
• Tonsil stones (tonsilloliths): Check for calcified debris in tonsillar crypts
• Tonsillar hypertrophy with sleep-disordered breathing: Assess for snoring, apnea, and daytime symptoms

Treatment Algorithm

1. Acute Tonsillitis

• Viral tonsillitis (70-95% of cases) 1:

  • Supportive care with adequate hydration
  • Pain management with ibuprofen and/or acetaminophen 2
  • Single dose of dexamethasone to reduce inflammation 2

• Bacterial tonsillitis (particularly Group A Streptococcus):

  • Antibiotics: Penicillin or amoxicillin as first-line therapy 3, 4
  • For penicillin allergy: Consider macrolides or cephalosporins
  • Complete at least 10 days of antibiotics for Group A streptococcal infections to prevent rheumatic fever 3, 4
  • Pain management with ibuprofen and/or acetaminophen 2

2. Recurrent Tonsillitis

• Conservative management for cases with:

  • <7 episodes in past year, OR
  • <5 episodes per year in past 2 years, OR
  • <3 episodes per year in past 3 years 2

• Consider tonsillectomy for:

  • ≥7 documented episodes in past year, OR
  • ≥5 documented episodes per year for 2 years, OR
  • ≥3 documented episodes per year for 3 years 2

  Each documented episode should include sore throat plus one of: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A streptococcus 2

3. Tonsil Stones (Tonsilloliths)

• Conservative management 5:

  • Salt water gargles
  • Gentle removal with cotton swabs
  • Good oral hygiene
  • Antibacterial mouthwashes
  • Water flossers to flush out debris

• Tonsillectomy only for:

  • Large tonsilloliths causing significant symptoms
  • Failed conservative management
  • Significant impact on quality of life 5

4. Tonsillar Hypertrophy with Sleep-Disordered Breathing

• Evaluate for comorbid conditions that may improve after tonsillectomy:

  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 2

• Consider polysomnography before tonsillectomy if:

  • Child is <2 years old
  • Child has obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 2

• Recommend tonsillectomy for children with obstructive sleep apnea documented by polysomnography 2

Perioperative Management for Tonsillectomy

If tonsillectomy is performed:

1. Preoperative:

   • Counsel patients/caregivers about pain management 2
   • Screen for bleeding disorders using standardized questionnaire 4

2. Intraoperative:

   • Administer single dose of intravenous dexamethasone 2
   • Do not administer perioperative antibiotics 2

3. Postoperative:

   • Use ibuprofen and/or acetaminophen for pain control 2
   • Avoid codeine in children younger than 12 years 2
   • Arrange overnight monitoring for children who are <3 years old or have severe obstructive sleep apnea 2
   • Document any bleeding within 24 hours (primary) and beyond 24 hours (secondary) 2

Important Considerations

• Watchful waiting is strongly recommended for less severe cases of recurrent tonsillitis 2
• Tonsillectomy benefits are modest and generally limited to the first year after surgery 2
• Peritonsillar abscess is a potential complication of tonsillitis requiring prompt recognition and treatment 6
• Counsel patients that obstructive sleep-disordered breathing may persist or recur after tonsillectomy 2

By following this algorithm, clinicians can provide appropriate treatment for tonsillar swelling while minimizing unnecessary interventions and optimizing patient outcomes.