Treatment of Recurrent Tonsillitis
For recurrent tonsillitis, watchful waiting is strongly recommended unless the patient meets Paradise criteria (≥7 episodes in 1 year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years), in which case tonsillectomy becomes an option, though benefits are modest and balanced against surgical risks. 1, 2
Initial Management: Watchful Waiting vs. Surgery
When to Observe (Not Operate)
Watchful waiting is the recommended approach 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 1, 2, 3
The natural history strongly favors spontaneous improvement: untreated children averaged only 1.17 episodes in year one, 1.03 in year two, and 0.45 in year three after observation began 2
Multiple studies demonstrate that control groups showed spontaneous reduction in infection rates, and benefits of surgery did not persist beyond the first year 1
Critical pitfall: Only 17% of patients who reportedly met Paradise criteria actually had adequate documentation when reviewed, often due to overstated histories or natural improvement over time 1
Paradise Criteria for Considering Tonsillectomy
Each episode must be properly documented with all of the following 1, 2:
Frequency threshold: ≥7 episodes in preceding year, OR ≥5 episodes per year in each of preceding 2 years, OR ≥3 episodes per year in each of preceding 3 years 1, 2
Clinical features (sore throat plus ≥1 of the following): temperature >38.3°C (>101°F), cervical lymphadenopathy (tender nodes or >2 cm), tonsillar exudate, OR positive test for group A beta-hemolytic streptococcus 1, 2
Treatment documentation: antibiotics administered in conventional dosage for proven or suspected streptococcal episodes 1
Medical record documentation: each episode substantiated by contemporaneous notation, OR if not fully documented, subsequent observation by clinician of 2 episodes with patterns consistent with initial history 1
Modifying Factors That May Favor Surgery
Even without meeting Paradise criteria, tonsillectomy may be considered for 1, 2, 4:
- Multiple antibiotic allergies or intolerance 1, 2, 4
- PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1, 2, 5
- History of >1 peritonsillar abscess 1, 2
Realistic Expectations About Tonsillectomy
Benefits are modest: even in children meeting Paradise criteria, there is not a clear preponderance of benefit over harm, but rather a balance that favors benefit 1
The Infectious Diseases Society of America does not recommend tonsillectomy solely to reduce frequency of GAS pharyngitis (strong recommendation, high-quality evidence) 4
Surgical risks include postoperative pain, hemorrhage risk, and unknown effects of general anesthesia in children <4 years 1
Medical Management of Acute Episodes
Distinguishing True Recurrent Infection from Carrier State
True recurrent GAS pharyngitis requires aggressive treatment with rising anti-streptococcal antibody titers and active immunologic response 4
Chronic GAS carrier with viral infections: patient colonized with GAS who experiences intercurrent viral pharyngitis that tests positive but doesn't represent true bacterial infection 4
Carriers lack rising antibody titers, are at very low risk for complications, and are unlikely to spread infection 4
If carrier state is identified, antimicrobial therapy is not indicated 4
Treatment for Confirmed Bacterial Tonsillitis
- Penicillin V for 10 days (gold standard) 6
- Amoxicillin is an acceptable alternative 6, 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 6
For penicillin-allergic patients 6, 8:
- Non-anaphylactic allergy: use first-generation cephalosporins 6
- Anaphylactic allergy: use clindamycin, azithromycin, or clarithromycin 6, 8
Treatment for Recurrent Infections That Failed Standard Therapy
For cases failing both azithromycin and amoxicillin-clavulanate, the Infectious Diseases Society of America recommends clindamycin 4:
Cephalosporins, clindamycin, macrolides, and amoxicillin-clavulanate are more effective than penicillin in eradicating infection, especially after penicillin failure 9
Beta-lactamase-producing bacteria were recovered from >75% of tonsils in patients with recurrent infection, potentially "shielding" GABHS by inactivating penicillin 9
Critical Pitfalls to Avoid
Never initiate antibiotics without confirming GAS infection through testing (rapid antigen detection test or throat culture) 6
Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis to prevent rheumatic fever 6, 7
Never perform tonsillectomy without meeting appropriate frequency and documentation criteria 6
Do not routinely test or treat asymptomatic contacts 4
Do not use long-term antibiotic prophylaxis except for patients with history of rheumatic fever 4
Do not perform routine post-treatment cultures in asymptomatic patients who completed appropriate therapy 4, 6
Do not assume all positive tests mean active infection—consider carrier state, especially if episodes are frequent and close together 4
Documentation Requirements
Primary care providers should collate documentation of all visits related to throat infections 2
Each episode must include: symptoms, physical findings, test results, days of school absence, and quality of life issues 2
Use a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) for each episode 10
Consecutive counting of tonsillitis episodes is essential for determining if Paradise criteria are met 10