When Tonsillitis Requires Hospitalization
Hospitalize patients with tonsillitis when they have severe infections requiring intravenous therapy, complications such as peritonsillar abscess or Lemierre syndrome, inability to maintain oral hydration, or systemic signs of sepsis. 1
Absolute Indications for Hospitalization
The American Academy of Otolaryngology-Head and Neck Surgery identifies specific scenarios where hospitalization is necessary:
- Severe infections requiring hospitalization - This represents an exclusion from watchful waiting protocols and mandates immediate admission 1
- Peritonsillar abscess (>1 episode) - Requires surgical drainage and close monitoring 1
- Lemierre syndrome (thrombophlebitis of the internal jugular vein) - A life-threatening complication requiring urgent intervention 1
- Descending mediastinitis - Infection spreading through cervical spaces into the mediastinum, causing widespread cellulitis, necrosis, and sepsis 2
Clinical Features Suggesting Need for Hospitalization
Systemic Signs of Severe Infection
- Fever with hemodynamic instability - Hypotension, confusion, or volume depletion indicating sepsis 3, 4
- Inability to maintain oral hydration - Dehydration requiring intravenous fluid resuscitation 3, 5
- Respiratory compromise - Airway obstruction from severe tonsillar hypertrophy or associated edema 3
Local Complications
- Deep space neck infections - Parapharyngeal or retropharyngeal abscess formation requiring surgical drainage 3, 2
- Rapidly progressive cellulitis - Extensive inflammation spreading beyond the tonsillar region 3
Patients Who Can Be Managed Outpatient
Most cases of acute tonsillitis do not require hospitalization. Simple viral or bacterial pharyngitis can be managed with supportive care including analgesia and adequate hydration 3, 5, 4
- Uncomplicated bacterial tonsillitis - Even group A streptococcal infections can be treated with oral antibiotics as an outpatient 5, 4
- Recurrent tonsillitis without complications - These patients are candidates for watchful waiting or elective tonsillectomy, not emergency admission 1
Common Pitfalls to Avoid
- Do not hospitalize solely based on frequency of infections - The Paradise criteria (≥7 episodes/year, ≥5/year for 2 years, or ≥3/year for 3 years) are indications for elective tonsillectomy, not hospitalization 1
- Recognize warning signs early - Life-threatening complications like mediastinitis can develop even in previously healthy young adults from their first episode of tonsillitis 2
- Consider imaging when appropriate - CT scanning is essential for early diagnosis of deep space infections and mediastinitis 2