What is the treatment for persistent tonsillitis?

Treatment of Persistent Tonsillitis

For persistent tonsillitis, watchful waiting is strongly recommended for cases with <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year for the past 3 years, with tonsillectomy considered only when meeting specific frequency and severity criteria. 1

Initial Assessment and Diagnosis

• Determine the etiology of tonsillitis by distinguishing bacterial from viral causes through clinical features and appropriate testing 2
• Bacterial tonsillitis typically presents with sudden onset of sore throat, fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 2
• Perform rapid antigen detection testing (RADT) and/or throat culture to confirm Group A Streptococcus (GAS) before initiating antibiotics 2, 3

Acute Treatment Options

For Confirmed GAS Tonsillitis:

• First-line treatment: Penicillin V for 10 days, with amoxicillin as an acceptable alternative 2, 4
• For penicillin-allergic patients: Use cephalexin, clindamycin, or azithromycin 2, 5
• Pain management: Ibuprofen and/or acetaminophen 2
• For severe cases: Consider a single dose of dexamethasone for pain relief 2

For Viral Tonsillitis:

• Supportive care including adequate hydration, rest, and pain management 3, 6

Management of Persistent/Recurrent Tonsillitis

Watchful Waiting Approach:

• Strongly recommended for patients with <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year for the past 3 years 1
• Watchful waiting does not mean inaction—patients should be closely monitored with regular clinic visits and episodes accurately documented 1

Tonsillectomy Consideration:

• May be recommended when episodes meet Paradise criteria: ≥7 documented episodes in the past year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years 1, 2
• Each episode should be documented with at least one of the following: temperature ≥38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for GAS 1

Modifying Factors That May Favor Tonsillectomy:

• Multiple antibiotic allergies/intolerance 1
• PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1
• History of >1 peritonsillar abscess 1

Special Considerations

Biofilm-Related Persistent Tonsillitis:

• Microorganisms often create biofilms in the tonsils, serving as a repository for recurrent infection 7
• Standard antimicrobials may provide temporary relief but often fail to eradicate biofilms, leading to recurrence 7

Management of GAS Carriers:

• GAS carriers generally do not require antimicrobial therapy and are unlikely to spread GAS pharyngitis to close contacts 2
• Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis in carriers 2

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 2
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 4
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 2, 8
• Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1, 2
• Failing to distinguish between true recurrent infections and a chronic GAS carrier with intercurrent viral infections 2

Follow-up Recommendations

• Follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy are not recommended 2
• 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 2