Management of Tonsillitis

Diagnosis and Initial Assessment

Determining the etiology of tonsillitis is the first critical step in management. Bacterial tonsillitis (particularly Group A Streptococcus) should be distinguished from viral causes through clinical features and appropriate testing 1.
Bacterial tonsillitis typically presents with sudden onset of sore throat, fever >38.3°C (101°F), tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 1.
Rapid antigen detection testing (RADT) and/or throat culture should be performed to confirm Group A Streptococcus (GAS) before initiating antibiotics 1.

First-line treatment for confirmed GAS tonsillitis is penicillin V for 10 days, with amoxicillin as an acceptable alternative 1, 2.
For penicillin-allergic patients, appropriate alternatives include:
- Cephalexin (20 mg/kg/dose twice daily, max 500 mg/dose) for 10 days 2
- Clindamycin (7 mg/kg/dose three times daily, max 300 mg/dose) for 10 days 2
- Azithromycin (12 mg/kg once daily, max 500 mg) for 5 days 2, 3

Ibuprofen and/or acetaminophen are recommended for pain control 2.
A single dose of dexamethasone may be beneficial for pain relief in severe cases 1.

Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years 2, 4.
Watchful waiting does not mean inaction - patients should be closely monitored with regular clinic visits and accurate documentation of episodes 2.

Tonsillectomy may be considered when episodes meet Paradise criteria:
- ≥7 well-documented episodes in the preceding year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years 2
Each episode should be documented with: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for GAS 2.

Clinicians should assess for modifying factors that may favor tonsillectomy even when Paradise criteria aren't met, including:
- Multiple antibiotic allergies/intolerance
- PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis)
- History of >1 peritonsillar abscess 2

GAS carriers (those with GAS present in the pharynx but no active immune response) generally do not require antimicrobial therapy 2.
Carriers are unlikely to spread GAS pharyngitis to close contacts and are at little to no risk for developing complications 2.
Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis in carriers 2.

Initiating antibiotic therapy without confirming GAS infection through testing 1.
Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1.
Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure and complications like rheumatic fever 1, 5.
Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 2, 1.
Failing to distinguish between true recurrent infections and a chronic GAS carrier with intercurrent viral infections 2.

Follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy are not recommended 1.
If symptoms persist despite appropriate antibiotic therapy, consider medication compliance issues, possibility of chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 1.