Is it okay to treat tonsillitis with congestion and plugged ears with Kenelog (triamcinolone) 40mg intramuscularly (IM) and oral antibiotics such as penicillin or amoxicillin?

Treatment of Tonsillitis with Congestion and Plugged Ears: Kenalog IM and Oral Antibiotics

The use of intramuscular corticosteroids like Kenalog (triamcinolone) 40mg is not recommended or supported by evidence-based guidelines for the treatment of acute tonsillitis, even when accompanied by congestion and plugged ears; oral antibiotics alone are appropriate when bacterial infection is confirmed.

Antibiotic Treatment for Tonsillitis

When Antibiotics Are Indicated

• Antibiotics should only be prescribed for tonsillitis when group A streptococcal (GAS) infection is confirmed or highly probable based on clinical scoring systems (Centor, McIsaac, or FeverPAIN scores) 1
• Penicillin or amoxicillin remains the first-line antibiotic choice for confirmed GAS pharyngitis/tonsillitis 2, 3
• Standard dosing is penicillin V 50 mg/kg/day in 4 doses for 10 days (max 2000 mg/day) or amoxicillin 50 mg/kg/day 2

Alternative Antibiotics for Treatment Failure

• If the patient has received antibiotics in the past 30 days or has failed initial penicillin therapy, consider amoxicillin-clavulanate (40 mg amoxicillin/kg/day) to cover beta-lactamase producing bacteria that may "shield" GAS from penicillin 2, 4
• Beta-lactamase-producing bacteria are recovered from over 75% of tonsils in patients with recurrent infection and can inactivate penicillin 4
• For penicillin-allergic patients, clindamycin (20-30 mg/kg/day in 3 doses for 10 days) is recommended 2

Management of Associated Congestion and Plugged Ears

Eustachian Tube Dysfunction vs. Acute Otitis Media

• Congestion and plugged ears with tonsillitis typically represent eustachian tube dysfunction from upper respiratory inflammation, not necessarily acute otitis media (AOM) 2
• Acute otitis media requires specific diagnostic criteria: moderate to severe bulging of the tympanic membrane OR new onset otorrhea, OR mild bulging with recent ear pain and intense erythema 2
• If true AOM is diagnosed alongside tonsillitis, amoxicillin or high-dose amoxicillin-clavulanate (90 mg/kg/day amoxicillin component) provides coverage for both conditions 2

When Additional Antibiotics May Be Needed

• If bacterial rhinosinusitis is also present (symptoms >10 days or worsening after initial improvement), amoxicillin-clavulanate (1.75-4 g/250 mg per day in adults) covers both tonsillitis and sinus pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2

Why Kenalog IM Is Not Recommended

Lack of Guideline Support

• No major infectious disease or otolaryngology guidelines recommend intramuscular corticosteroids for acute tonsillitis or associated upper respiratory symptoms 2, 1
• The IDSA guideline for streptococcal pharyngitis makes no mention of corticosteroid therapy as part of standard treatment 2
• The AAP guideline for acute otitis media does not recommend systemic corticosteroids for ear congestion or plugged ears 2

Potential Risks Without Proven Benefits

• Systemic corticosteroids can mask symptoms without treating the underlying infection, potentially delaying recognition of treatment failure or complications
• Intramuscular depot corticosteroids provide prolonged immunosuppression (weeks), which could theoretically increase risk of suppurative complications like peritonsillar abscess, though this specific risk is not well-studied in this context
• There is no evidence that corticosteroids improve the resolution of eustachian tube dysfunction or middle ear effusion associated with upper respiratory infections 2

Recommended Treatment Algorithm

Step 1: Confirm Bacterial Tonsillitis

• Use clinical scoring (Centor/McIsaac/FeverPAIN) or rapid antigen detection test for GAS 1
• Only prescribe antibiotics if bacterial infection is confirmed or highly probable 1

Step 2: Select Appropriate Antibiotic

• First-line: Penicillin V or amoxicillin for 10 days 2, 3
• If recent antibiotic use (past 30 days) or treatment failure: Amoxicillin-clavulanate 2
• If penicillin allergy: Clindamycin 2

Step 3: Symptomatic Management

• Analgesics (acetaminophen or ibuprofen) for pain and fever 2, 5
• Supportive care for congestion (saline irrigation, decongestants if appropriate)
• Avoid intramuscular corticosteroids

Step 4: Reassess at 48-72 Hours

• If no improvement or worsening symptoms, reassess diagnosis and consider antibiotic change 2, 1
• Persistent middle ear effusion after resolution of acute symptoms is common (60-70% at 2 weeks) and does not require additional antibiotics 2

Common Pitfalls to Avoid

• Do not use systemic corticosteroids as routine treatment for tonsillitis or associated upper respiratory symptoms - this lacks evidence and may mask complications
• Do not prescribe antibiotics for viral pharyngitis/tonsillitis, which represents the majority of cases 3, 1
• Do not confuse eustachian tube dysfunction (plugged ears from congestion) with acute otitis media requiring specific treatment 2
• Do not continue the same antibiotic beyond 72 hours without clinical improvement - reassess and change therapy 2, 5