What is the proper intervention for a 3-year-old child with persistent hyperplastic tonsillitis (swollen tonsils) for 3 months, who is afebrile (without fever) and has a negative streptococcal (strep) test?

From the Guidelines

For a 3-year-old child with persistently swollen tonsils (3+ enlargement) for 3 months who is afebrile and has a negative strep test, referral to an otolaryngologist (ENT specialist) is recommended for evaluation. The current clinical practice guideline for tonsillectomy in children, updated in 2019 1, does not support surgical intervention for this specific scenario, as the child does not meet the criteria for recurrent throat infection with documentation of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years. While waiting for the specialist appointment, supportive care can include:

• Acetaminophen or ibuprofen for any discomfort
• Adequate hydration
• Soft foods if swallowing is difficult The ENT specialist will likely perform a thorough examination and may consider additional testing such as:
• Complete blood count
• EBV testing
• Throat culture to rule out other infectious causes They may also evaluate for potential obstructive sleep apnea by asking about snoring, breathing pauses during sleep, or daytime sleepiness. Persistent tonsillar enlargement without acute infection could indicate lymphoid hyperplasia (normal immune tissue growth in children), but other possibilities include chronic infection, allergies, or rarely, lymphoma. The specialist might recommend watchful waiting with periodic follow-up if the child is otherwise well and not experiencing significant symptoms like difficulty breathing or swallowing. Surgical intervention (tonsillectomy) would only be considered if there are significant functional issues like obstructive sleep apnea, recurrent infections despite medical management, or if there are concerns about a more serious underlying condition, as suggested by the guideline 1.

From the FDA Drug Label

The recommended dose of azithromycin for children with pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days. The proper intervention for an afebrile 3-year-old with 3+ swollen tonsils for 3 months and a negative strep test is azithromycin 12 mg/kg once daily for 5 days 2.

• Key points:
  • The child's age is 3 years, which is above the recommended age of 2 years for this dosage guideline.
  • The child's weight is not provided, so the dose cannot be calculated exactly, but it would be 12 mg/kg once daily for 5 days.

From the Research

Intervention for Afebrile 3-Year-Old with Swollen Tonsils

• The patient's condition of having 3+ swollen tonsils for 3 months with a negative strep test suggests a need for careful consideration of the cause and appropriate treatment 3, 4.
• Given the patient's age (3 years) and the fact that streptococcal pharyngitis is rare in children under 3 years, the diagnosis and treatment approach may differ from those for older children 4.
• For streptococcal tonsillitis, antibiotic treatment is recommended to prevent complications such as acute rheumatic fever and glomerulonephritis 3, 5.
• However, the choice of antibiotic and duration of treatment can vary, with options including penicillin V, amoxicillin, and cefuroxime axetil 5, 6, 7.
• A 5-day course of cefuroxime axetil or a daily dose of amoxicillin may be as effective as a 10-day course of penicillin V in treating streptococcal tonsillitis, especially in young children 5, 6.
• The treatment outcomes, including the number of additional primary physician visits and the development of complications, can be influenced by the type of antibiotic used, with penicillin-V and amoxicillin showing favorable results in some studies 7.

Considerations for Treatment

• The patient's negative strep test result suggests that the swollen tonsils may not be due to a streptococcal infection, and other causes should be considered 3, 4.
• The duration of the patient's symptoms (3 months) and the absence of fever suggest a possible chronic or recurrent condition, which may require a different treatment approach 4, 5.
• Further evaluation and diagnostic testing may be necessary to determine the underlying cause of the patient's swollen tonsils and to guide appropriate treatment 3, 4.