What are the symptoms and treatment options for tonsillitis?

Symptoms of Tonsillitis

Tonsillitis presents with sore throat accompanied by visible inflammation of the pharynx and tonsils, characterized by erythema and edema with or without exudate, and may include fever, tender cervical lymphadenopathy, and absence of cough in bacterial cases. 1, 2

Clinical Presentation

Bacterial Tonsillitis (Group A Streptococcus)

• Sudden onset of sore throat with temperature >38.3°C (>101°F) 1
• Tonsillar exudate visible on physical examination 1
• Tender anterior cervical lymphadenopathy (tender lymph nodes or >2 cm) 1
• Absence of cough is a distinguishing feature from viral causes 2, 3
• Erythema and edema of the uvula, pharynx, and tonsils 1

Viral Tonsillitis

• Typically lacks high fever, tonsillar exudate, and prominent cervical lymphadenopathy 2, 3
• Sore throat with more generalized upper respiratory symptoms 4
• Accounts for 70% to 95% of tonsillitis cases 5

Diagnostic Approach

Clinical Scoring Systems

• Use validated scoring systems (Centor, McIsaac, or FeverPAIN score) to estimate the probability of bacterial tonsillitis before testing 6
• These scores help determine which patients require microbiologic confirmation 6

Microbiologic Testing

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus before initiating antibiotics 2, 7
• Obtain a single throat swab specimen from the posterior pharynx and uvula prior to antibiotic therapy 1
• At least 10 colonies of group A β-hemolytic streptococci should be present on culture plate for confirmation 1
• Never initiate antibiotics without confirming GAS infection through testing to avoid unnecessary antibiotic use in the majority of viral cases 2, 7

Treatment Options

Medical Management for Confirmed Bacterial Tonsillitis

• Penicillin V for 10 days is the gold standard first-line treatment for confirmed Group A Streptococcus tonsillitis 2, 7
• Amoxicillin for 10 days is an acceptable alternative first-line treatment 2, 7
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though shorter courses may resolve symptoms 2, 8

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: use first-generation cephalosporins 2, 3
• For anaphylactic penicillin allergy: use clindamycin, azithromycin, or clarithromycin 2, 3
• Azithromycin demonstrated 98% clinical success at Day 14 and 94% at Day 30 in pediatric pharyngitis/tonsillitis studies 9

Supportive Care

• Combination of paracetamol and/or non-steroidal anti-inflammatory drugs for symptom relief 6
• Steroids (e.g., dexamethasone) can be used for acute symptom management 10, 8

Surgical Management: Tonsillectomy Indications

Paradise Criteria for Tonsillectomy

Tonsillectomy should be considered only when meeting strict frequency criteria with proper documentation: 1

• ≥7 documented episodes in the preceding year, OR
• ≥5 documented episodes in each of the preceding 2 years, OR
• ≥3 documented episodes in each of the preceding 3 years 1, 6

Documentation Requirements

Each counting episode must include: 1

• Temperature >38.3°C (>101°F), OR
• Cervical lymphadenopathy (tender lymph nodes or >2 cm), OR
• Tonsillar exudate, OR
• Positive test for Group A β-hemolytic streptococcus

Observation Period

• A 12-month period of observation is recommended before tonsillectomy because control groups in randomized trials showed spontaneous improvement, with infection rates dropping to 1.17 episodes in year 1.03 in year 2, and 0.45 in year 3 1
• Benefits of tonsillectomy are modest and primarily limited to the first year after surgery 1

Modifying Factors for Earlier Surgery

Consider tonsillectomy even without meeting Paradise criteria if: 1

• Multiple antibiotic allergies or intolerance
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of >1 peritonsillar abscess
• Complications requiring hospitalization or Lemierre syndrome 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics without microbiologic confirmation of Group A Streptococcus, as 70-95% of cases are viral 2, 5
• Never use antibiotic courses shorter than 10 days for GAS tonsillitis, as this increases treatment failure risk and does not prevent rheumatic fever 2, 7, 8
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria, as spontaneous resolution is common 2, 1
• Do not obtain routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 2, 3
• Rapid antigen testing has very low sensitivity and should be confirmed by culture if used 10, 8
• Ten percent of healthy children carry Streptococcus pyogenes asymptomatically; screening without symptoms does not justify treatment 10, 8