Treatment of Tonsillitis (Inflammation of the Tonsils)
The treatment of tonsillitis should be based on whether the cause is viral or bacterial, with antibiotics prescribed only for confirmed bacterial cases, particularly Group A Streptococcus, while viral tonsillitis requires symptomatic treatment with analgesics and hydration. 1, 2
Diagnosis: Determining the Cause
- Bacterial tonsillitis typically presents with sudden onset of sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1
- Viral tonsillitis usually presents without high fever, tonsillar exudate, and cervical lymphadenopathy 1
- Rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus should be performed to confirm bacterial infection before initiating antibiotics 1
- The Centor clinical scoring system can help identify patients with higher likelihood of streptococcal infections 3
Treatment for Bacterial Tonsillitis
First-line Antibiotic Therapy
- Penicillin V for 10 days is the recommended first-line treatment for confirmed Group A Streptococcal tonsillitis 1, 4
- Amoxicillin can be used as an alternative, especially in younger children due to taste considerations and availability as syrup or suspension 3, 1
- The standard 10-day course of antibiotics is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1
Alternative Antibiotics (for penicillin-allergic patients)
- Erythromycin: 250 mg four times daily or 500 mg twice daily for 10 days in adults; 30-50 mg/kg/day in divided doses for children 5
- Azithromycin: 500 mg once daily for 3 days in adults; 12 mg/kg once daily for 5 days in children 6
Treatment for Viral Tonsillitis
- Symptomatic treatment with analgesics is the mainstay of therapy 2
- Either ibuprofen or paracetamol (acetaminophen) is recommended for relief of acute sore throat symptoms 3
- A single intraoperative dose of dexamethasone is recommended for pain relief in surgical cases 1
- Adequate hydration should be maintained 2
Management of Recurrent Tonsillitis
- Watchful waiting is recommended if there have been fewer than 7 episodes in the past year, fewer than 5 episodes per year for the past 2 years, or fewer than 3 episodes per year for the past 3 years 3, 1
- Tonsillectomy should be considered when episodes meet Paradise criteria: 7 or more well-documented episodes in the preceding year, or 5 or more episodes per year for 2 consecutive years, or 3 or more episodes per year for 3 consecutive years 1
- All episodes should be disabling, adequately treated, and well-documented 1
- Partial tonsillectomy (tonsillotomy) should be the first-line surgical therapy in children under six years with tonsil hyperplasia rather than recurrent infections 7
- Total extracapsular tonsillectomy is indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome, and peritonsillar abscess 7
Adjunctive Treatments
- Mouthwashes, throat sprays, or lozenges may provide symptomatic relief 4
- There is inconsistent evidence supporting herbal treatments or other complementary therapies for sore throat 3
- Bacterial immunotherapy has shown promise in reducing the need for tonsillectomy in adults with recurrent tonsillitis 8
Common Pitfalls to Avoid
- Initiating antibiotic therapy without confirming bacterial infection through testing 1
- Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed Group A Streptococcus 1
- Inadequate duration of antibiotic therapy (less than 10 days) for Group A Streptococcal tonsillitis, which increases risk of treatment failure 1
- Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 1
- Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1
- Ignoring potential complications of tonsillitis such as peritonsillar abscess, rheumatic fever, or post-streptococcal glomerulonephritis 7