What treatment is recommended for enlarged tonsils, sore throat, constant cough, and production of yellow phlegm lasting two months?

Management of Prolonged Upper Respiratory Symptoms with Productive Cough

You need immediate evaluation to determine if this represents bacterial infection requiring antibiotics, particularly given the two-month duration with yellow phlegm production, which suggests possible bacterial superinfection or chronic bronchitis rather than simple viral tonsillitis.

Initial Diagnostic Approach

Test for Group A Streptococcus

• Perform rapid antigen detection test and/or throat culture for group A beta-hemolytic streptococcus (GABHS) if you have symptoms suggestive of bacterial pharyngitis (persistent fever, anterior cervical adenopathy, tonsillopharyngeal exudates) 1
• Testing is essential because only confirmed streptococcal pharyngitis warrants antibiotic treatment 1
• Clinical symptoms alone cannot reliably differentiate bacterial from viral tonsillitis 2

Evaluate the Chronic Cough Component

The two-month duration of productive cough with yellow phlegm suggests this extends beyond simple acute tonsillitis and requires evaluation for:

• Chronic bronchitis or bacterial bronchitis - yellow/purulent sputum production for 2 months indicates possible bacterial involvement 1
• Upper airway cough syndrome (post-nasal drip) - enlarged tonsils and throat symptoms can contribute to chronic cough through post-nasal drainage 1
• Gastroesophageal reflux disease (GORD) - can cause chronic cough and throat symptoms lasting months 1

Treatment Based on Findings

If GABHS Positive

• First-line: Penicillin for 10 days to eradicate streptococcus from the pharynx 1
• Alternative if penicillin allergy: Azithromycin 12 mg/kg once daily for 5 days (for pharyngitis/tonsillitis in appropriate age groups) 3
• Amoxicillin-clavulanate may be superior if previous penicillin treatment failed, as it covers beta-lactamase producing bacteria that can "shield" GABHS 4, 5

For the Chronic Productive Cough (2 months duration)

This requires treatment beyond simple tonsillitis management:

• Consider empiric antibiotic therapy if you have purulent sputum with at least 2 of 3 Anthonisen criteria (increased dyspnea, increased sputum volume, increased sputum purulence) 1
• First-line antibiotics for chronic bronchitis: amoxicillin, first-generation cephalosporins, macrolides, or doxycycline 1
• Second-line antibiotics (amoxicillin-clavulanate, cefuroxime-axetil, or respiratory fluoroquinolones) if first-line fails or if you have frequent exacerbations 1

For Upper Airway Contribution to Cough

• Trial of intranasal corticosteroids for 1 month if prominent upper airway symptoms (nasal congestion, post-nasal drip sensation) are present 1
• Topical nasal steroids for 2-8 weeks have shown effectiveness for cough with post-nasal drip 1

For Possible Reflux-Related Cough

• Proton pump inhibitors (PPIs) such as omeprazole 20-40 mg twice daily before meals for at least 8 weeks if reflux symptoms are present or suspected 1
• GORD-related cough is reported in 5-41% of chronic cough cases 1

Tonsillectomy Consideration

Watchful waiting is strongly recommended unless you meet specific criteria 1, 6, 7, 8:

Criteria for Tonsillectomy

You would need documented episodes meeting ALL of the following for each episode 1:

• Sore throat PLUS
• Temperature >38.3°C (>100.9°F), OR cervical adenopathy, OR tonsillar exudate, OR positive GABHS test

AND frequency of:

• ≥7 documented episodes in the past year, OR
• ≥5 documented episodes per year for 2 years, OR
• ≥3 documented episodes per year for 3 years 1, 7, 8

You do not meet tonsillectomy criteria based on current presentation alone - this requires prospective documentation of recurrent episodes 1

Critical Pitfalls to Avoid

• Do not assume viral infection and withhold evaluation - two months of symptoms with purulent sputum warrants bacterial workup 1, 2
• Do not treat with antibiotics without confirming bacterial infection for the throat component - only treat strep pharyngitis if confirmed by testing 1
• Do not ignore the chronic cough component - this is not typical of simple tonsillitis and requires separate evaluation for chronic bronchitis, upper airway disease, or reflux 1
• Antibiotics provide modest benefit even for confirmed strep throat (number needed to treat = 6 at 3 days), so confirmation is essential before treatment 1