What are the treatment options for tonsillitis?

Treatment Options for Tonsillitis

For acute bacterial tonsillitis confirmed by testing, treat with penicillin V for 10 days; for viral tonsillitis, provide supportive care only with analgesics and avoid antibiotics. 1, 2

Diagnostic Approach Before Treatment

Test before treating - perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating any antibiotic therapy. 3, 1, 2 This prevents unnecessary antibiotic use in the majority of cases, which are viral in origin. 4

• Bacterial tonsillitis presents with sudden onset sore throat, fever ≥38.3°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 1, 2
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy. 1, 2
• Use the modified Centor/McIsaac score ≥3 as an indication for testing and potential antibiotic therapy. 5

Medical Treatment Algorithm

For Confirmed Bacterial (GAS) Tonsillitis:

First-line antibiotic therapy:

• Penicillin V for 10 days is the gold standard treatment. 1, 2, 6
• Amoxicillin is an acceptable alternative to penicillin V. 2
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though shorter courses may resolve symptoms. 1, 2, 7

For penicillin-allergic patients:

• Non-anaphylactic allergy: use first-generation cephalosporins. 1
• Anaphylactic allergy: use clindamycin, azithromycin, or clarithromycin. 1
• Azithromycin (12 mg/kg once daily for 5 days in children) is clinically and microbiologically superior to penicillin V at Days 14 and 30. 6

For treatment failures:

• Consider amoxicillin-clavulanate, clindamycin, or second/third-generation cephalosporins. 1
• Alternative regimens for documented recurrent GAS within 2 weeks include clindamycin (20-30 mg/kg/day in 3 doses for 10 days), penicillin with rifampin, or amoxicillin-clavulanate. 3, 1

For Viral Tonsillitis:

Supportive care only:

• Analgesics: acetaminophen, NSAIDs (ibuprofen), aspirin (adults), or throat lozenges for pain relief. 3, 7
• Topical agents containing benzocaine, lidocaine, or ambroxol may provide temporary symptomatic relief. 3
• Warm salt water gargles (for patients old enough to gargle). 3
• Hydration and rest. 4
• Do not prescribe antibiotics - viral tonsillitis is self-limited and resolves within one week. 3, 4

Adjunctive Therapy:

• A single intraoperative dose of dexamethasone is recommended for surgical cases to reduce pain. 3, 2
• Steroids (dexamethasone) and NSAIDs (ibuprofen) can be used for acute symptom relief in bacterial cases. 8, 7
• Corticosteroids are not routinely recommended for acute GAS pharyngitis due to potential adverse effects and the self-limited nature of the disease. 3

Surgical Treatment: Tonsillectomy

Indications for Tonsillectomy in Recurrent Tonsillitis:

Watchful waiting is strongly recommended if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years. 3, 2

Tonsillectomy may be considered when meeting Paradise criteria with proper documentation: 3, 2

• ≥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

Each documented episode must include:

• Temperature ≥38.3°C (101°F)
• Cervical adenopathy
• Tonsillar exudate, OR
• Positive test for GAS 3

Modifying factors that may favor tonsillectomy despite not meeting Paradise criteria: 3

• Multiple antibiotic allergies/intolerance
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of >1 peritonsillar abscess
• Obstructive sleep-disordered breathing with tonsillar hypertrophy

Important Surgical Considerations:

• Tonsillectomy solely to reduce frequency of GAS pharyngitis is not recommended in adults or children. 3
• In children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis; for tonsillar hyperplasia, partial tonsillectomy (tonsillotomy) should be first-line therapy due to lower pain and hemorrhage risk. 8, 7

Follow-Up and Monitoring

• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy. 1, 2
• If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics. 3, 2
• Chronic GAS carriers (positive culture without active infection) do not require antimicrobial therapy as they are unlikely to spread infection or develop complications. 3

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing - this is the most common error leading to unnecessary antibiotic use. 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS, as this contributes to antibiotic resistance. 1, 2
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis - only the full 10-day course prevents rheumatic fever and glomerulonephritis. 1, 2, 7
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria - watchful waiting is preferred for most cases. 3
• Never ignore severe warning signs requiring urgent evaluation: difficulty swallowing, drooling, neck tenderness/swelling, or trismus, which may indicate peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome. 1