What is the treatment for a patient with a sore throat, swollen tonsils, and bleeding tonsils?

Management of Sore Throat with Swollen and Bleeding Tonsils

This patient requires immediate evaluation for serious complications such as peritonsillar abscess, parapharyngeal abscess, or other life-threatening throat infections, given the presence of bleeding tonsils, which is an atypical and concerning feature. 1, 2

Immediate Assessment

Urgent evaluation is mandatory because bleeding tonsils with severe symptoms warrant assessment for rare but serious conditions including:

• Peritonsillar abscess
• Parapharyngeal abscess
• Epiglottitis
• Lemierre syndrome 1, 2

Look specifically for these red flag features:

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Trismus (inability to open mouth)
• Muffled "hot potato" voice
• Asymmetric tonsillar swelling 1, 3

Diagnostic Approach

Test for Group A Streptococcus before initiating antibiotics using rapid antigen detection test (RADT) and/or throat culture. 1, 2, 4

Apply the Centor criteria to assess likelihood of bacterial infection:

• Fever ≥38.3°C (101°F)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough 1, 2

If the patient meets fewer than 3 Centor criteria, testing is not needed and antibiotics should not be prescribed. 1 However, the presence of bleeding tonsils supersedes typical algorithms and warrants further investigation regardless of score.

Treatment Algorithm

If Group A Streptococcus is Confirmed:

First-line therapy: Penicillin V or amoxicillin for 10 days 2, 4

For penicillin-allergic patients:

• Non-anaphylactic allergy: First-generation cephalosporins (cefuroxime, cefpodoxime, or cefdinir) for 10 days 2, 4
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 2, 5

The full 10-day course is essential to eradicate Group A Streptococcus and prevent complications including acute rheumatic fever, glomerulonephritis, and peritonsillar abscess. 2, 4, 6 Shorter courses are less effective despite some studies suggesting comparable symptom resolution. 6

If Testing is Negative or Viral Etiology:

Supportive care only:

• Analgesics: Acetaminophen or NSAIDs (ibuprofen) 4, 6
• Adequate hydration 3, 7
• Throat lozenges and salt water gargles 4
• Corticosteroids (dexamethasone) may reduce symptom duration 6

Do not prescribe antibiotics for viral tonsillitis. 1, 7

Special Considerations for Bleeding Tonsils

Tonsillar bleeding is not a typical feature of uncomplicated acute tonsillitis and raises concern for:

1. Peritonsillar abscess - requires urgent drainage and IV antibiotics 1, 3
2. Severe infection with tissue necrosis - may require hospitalization 3
3. Underlying coagulopathy - though this would typically present with other bleeding manifestations 6

If bleeding persists or recurs, or if the patient appears toxic, immediate ENT consultation and possible hospital admission are indicated. 3, 6

Monitoring and Follow-Up

Reassess clinical response after 72 hours of antibiotic therapy. 4 If no improvement or worsening occurs:

• Switch to broader-spectrum antibiotic (amoxicillin-clavulanate, clindamycin, or second/third-generation cephalosporin) 2, 4
• Re-evaluate for complications or alternative diagnoses 3

Do not perform follow-up throat cultures in asymptomatic patients who completed appropriate therapy. 2

When to Consider Tonsillectomy

Tonsillectomy is not indicated for a single episode, even if severe. 1

Watchful waiting is strongly recommended unless the patient meets Paradise criteria:

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

Each documented episode must include sore throat plus at least one of: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive Group A Streptococcus test. 1

Modifying factors that may favor earlier tonsillectomy include:

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

Critical Pitfalls to Avoid

• Never prescribe antibiotics without confirming bacterial infection through testing - this contributes to antibiotic resistance and unnecessary adverse effects 1, 2, 4
• Never dismiss bleeding tonsils as routine tonsillitis - this requires urgent evaluation for serious complications 1, 3
• Never use inadequate antibiotic duration (<10 days for confirmed Group A Streptococcus) - this increases treatment failure and complication risk 2, 4, 6
• Never use codeine in children <12 years for post-tonsillectomy pain if surgery becomes necessary 1