Treatment of Tonsillitis in a 17-Year-Old
For acute tonsillitis in a 17-year-old, treatment should include supportive care with NSAIDs (e.g., ibuprofen) and steroids (e.g., dexamethasone), along with antibiotics (penicillin or cefuroxime for 10 days) if bacterial infection is confirmed. 1
Diagnosis of Tonsillitis
First, determine if the tonsillitis is viral or bacterial:
Viral tonsillitis (70-95% of cases) 2:
- Symptoms: sore throat, mild fever, cough, rhinorrhea
- Physical exam: mild to moderate tonsillar enlargement, erythema without exudate
- No specific testing needed
Bacterial tonsillitis (5-30% of cases) 2, 1:
- Symptoms: severe sore throat, difficulty swallowing, fever >38°C
- Physical exam: tonsillar exudate, enlarged/tender cervical lymph nodes
- Testing: rapid antigen detection test or throat culture for Group A Streptococcus
Treatment Algorithm
1. Supportive Care (for all types of tonsillitis)
- Pain management:
- NSAIDs (ibuprofen) for pain and inflammation 1
- Adequate hydration
- Soft diet
- Saltwater gargles
2. Pharmacological Treatment
For Viral Tonsillitis:
- Supportive care only
- Dexamethasone (single dose) to reduce inflammation and pain 1
For Bacterial Tonsillitis:
- First-line antibiotic: Penicillin for 10 days 1
- For penicillin allergy: Cephalosporins (if no anaphylaxis history) or macrolides
- Adjunctive therapy: Single dose of dexamethasone to reduce inflammation 3
Note: While shorter courses (3-5 days) of antibiotics may provide similar symptom relief, the full 10-day course is recommended to prevent complications like rheumatic fever and glomerulonephritis 1.
3. Monitoring and Follow-up
- Improvement should occur within 48-72 hours of starting appropriate treatment
- If symptoms worsen or don't improve, reevaluate for complications:
- Peritonsillar abscess
- Retropharyngeal abscess
- Systemic spread of infection
Indications for Surgical Management
For recurrent tonsillitis, the American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend tonsillectomy only if the following Paradise criteria are met 3:
- ≥7 episodes in the past year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years
If these criteria are not met, watchful waiting is strongly recommended 3.
Common Pitfalls to Avoid
Overuse of antibiotics for viral tonsillitis: Most cases (70-95%) are viral and don't require antibiotics 2.
Inadequate duration of antibiotic therapy: A full 10-day course is necessary to prevent complications like rheumatic fever, even if symptoms improve earlier 1.
Premature consideration of tonsillectomy: Surgery should only be considered after meeting specific frequency criteria for recurrent infections 3.
Failure to recognize complications: Watch for signs of peritonsillar abscess (severe, asymmetric pain, "hot potato" voice, trismus) which requires immediate referral.
Inadequate pain management: Pain can lead to poor oral intake and dehydration, especially in adolescents.
By following this evidence-based approach, most cases of tonsillitis in adolescents can be effectively managed with excellent outcomes for morbidity, mortality, and quality of life.