Recurrent Tonsilopharyngitis: Definition, Diagnosis, Physical Exam, and Management
Definition
Recurrent tonsilopharyngitis is defined as ≥7 documented episodes in the past year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years. 1
Each episode must be documented with:
- Sore throat PLUS at least one of the following: 1
- Temperature ≥38.3°C (101°F)
- Cervical adenopathy
- Tonsillar exudate
- Positive test for Group A beta-hemolytic streptococcus
Diagnosis
Clinical Assessment
Bacterial tonsillitis presents with sudden onset sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 2
Viral tonsillitis typically lacks high fever, tonsillar exudate, and prominent cervical lymphadenopathy. 2
Diagnostic Testing
Always use a clinical scoring system (Centor, McIsaac, or FeverPAIN) to estimate the probability of bacterial infection before testing. 3
- Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus to confirm bacterial infection before prescribing antibiotics. 2, 3
- In ambiguous cases after scoring, a point-of-care GAS swab test is helpful. 3
Critical Distinction: True Infection vs. Carrier State
Distinguish between true recurrent GAS pharyngitis and chronic GAS carrier with intercurrent viral infections. 4
- True recurrent infection: Multiple bona fide bacterial infections with rising anti-streptococcal antibody titers and active immunologic response. 4
- Carrier state: Patient colonized with GAS experiencing viral pharyngitis that tests positive for GAS but lacks rising antibody titers and has no active immunologic response. 4
- Carriers are at very low risk for complications and unlikely to spread infection. 4
Physical Examination
Document the following for each episode: 1
- Temperature measurement (≥38.3°C supports bacterial etiology)
- Tonsillar examination for size, erythema, and presence of exudate
- Cervical lymph node examination for tenderness and enlargement
- Absence or presence of viral symptoms (cough, rhinorrhea, hoarseness suggest viral etiology)
Management
Acute Episode Treatment
For confirmed GAS tonsillitis, prescribe penicillin V for 10 days or amoxicillin as an equivalent alternative. 2, 5
- The full 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever. 2, 5
- For non-anaphylactic penicillin allergy: first-generation cephalosporins (cefalexin, cefadroxil) for 10 days. 5
- For anaphylactic penicillin allergy: clindamycin, azithromycin, or clarithromycin. 5
Treatment of Recurrent Episodes After Initial Therapy Failure
For recurrent tonsillitis that has failed both azithromycin and amoxicillin-clavulanate, use clindamycin 20-30 mg/kg/day divided into 3 doses for 10 days (maximum 300 mg/dose) in children, or 600 mg/day divided into 2-4 doses for 10 days in adults. 4, 1
Alternative regimens for treatment failures include: 1, 5
- Amoxicillin-clavulanate
- Penicillin with rifampin
Management Algorithm Based on Episode Frequency
If <7 episodes in past year, <5 per year for 2 years, or <3 per year for 3 years:
Recommend watchful waiting with close monitoring. 1
- Watchful waiting does not mean inaction—closely monitor by regular clinic visits and accurately document each episode. 1
- Record symptoms, physical findings, RADT/culture results, days of school/work absence, and quality of life issues for each episode. 1
If ≥7 episodes in past year, ≥5 per year for 2 years, or ≥3 per year for 3 years:
Tonsillectomy may be considered as an option when Paradise criteria are met with proper documentation. 1
- Each episode must be documented with temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test. 1
- Tonsillectomy provides modest reduction in frequency and severity for approximately 1 year post-surgery. 5
- Balance modest benefits against potential complications: pain, bleeding, dehydration, and rare severe adverse events. 5
Modifying Factors That May Favor Tonsillectomy Despite Not Meeting Paradise Criteria:
Assess for modifying factors including multiple antibiotic allergies/intolerance, PFAPA syndrome, or history of >1 peritonsillar abscess. 1
Management of Carrier State
If the patient is a carrier, antimicrobial therapy is NOT indicated. 4
Consider carrier eradication treatment ONLY in these specific circumstances: 5
- Community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive GAS infection
- Outbreak of GAS pharyngitis in a closed/partially closed community
- Family or personal history of acute rheumatic fever
If carrier eradication is indicated, use clindamycin 20-30 mg/kg/day in three divided doses (maximum 300 mg per dose) for 10 days. 5
What NOT to Do
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 for asymptomatic patients who completed appropriate therapy. 4, 2
Do not assume all positive tests mean active infection—consider carrier state especially if episodes are frequent and close together. 4
Do not initiate antibiotics without confirming GAS infection through testing. 2
Do not use antibiotic courses shorter than 10 days for GAS tonsillitis. 2, 5
Documentation Requirements
For optimal management, collate documentation from all providers (primary care, emergency departments, urgent care centers) including: 1
- Clinical characteristics of each episode
- Symptoms and physical findings
- RADT and/or culture results
- Days of school/work absence
- Quality of life impact using specific scores (Tonsillectomy Outcome Inventory-14 or Tonsil and Adenoid Health Status Instrument) 3