What is the treatment for membranous tonsillitis?

Treatment of Membranous Tonsillitis

The treatment of membranous tonsillitis requires first determining whether the infection is bacterial or viral through rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus, with penicillin V for 10 days as first-line therapy only for confirmed bacterial cases. 1, 2, 3

Diagnostic Approach

The critical first step is distinguishing bacterial from viral etiology, as this fundamentally changes management:

• Perform RADT and/or throat culture for Group A Streptococcus (GAS) before initiating antibiotics 1, 2, 3
• Order a peripheral blood smear to evaluate for Epstein-Barr virus (EBV), which causes 24% of membranous tonsillitis cases and shows Downey cells in 98% of EBV-positive patients 4
• Bacterial tonsillitis presents with sudden onset sore throat, fever >38.3°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2, 3
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 1

Important caveat: Recent data shows GAS accounts for only 31.2% of membranous tonsillitis cases, while EBV causes 24.3% and other viral etiologies cause 44.4%, making diagnostic testing essential to avoid inappropriate antibiotic use 4

Treatment for Confirmed Bacterial (GAS) Tonsillitis

When GAS is confirmed by testing:

• Prescribe penicillin V for 10 days as first-line therapy 1, 2, 3
• Amoxicillin for 10 days is an acceptable alternative first-line treatment 1, 2, 3
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever 1, 2

For penicillin-allergic patients:

• Use cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin 3

Treatment for Viral Tonsillitis (Including EBV)

• Provide supportive care only—no antibiotics 5
• Use ibuprofen, acetaminophen, or both for pain control 3
• Ensure adequate hydration and rest

Critical Pitfalls to Avoid

The most common error is prescribing antibiotics without confirming bacterial infection: Studies show 27% of EBV-positive patients inappropriately received antibiotics, and only 7% of patients with positive throat cultures received appropriate antibiotics 4

Additional pitfalls:

• Never use antibiotic courses shorter than 10 days for confirmed GAS, as this increases treatment failure risk 1, 2
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2
• Do not perform follow-up throat cultures for asymptomatic patients who completed appropriate therapy 1
• Do not initiate treatment based solely on clinical appearance of membranes without microbiologic confirmation 4

When to Consider Tonsillectomy

Tonsillectomy should be considered for recurrent membranous tonsillitis meeting Paradise criteria:

• 7 or more well-documented episodes in the preceding year, OR 1, 3
• 5 or more episodes per year for 2 consecutive years, OR 1, 3
• 3 or more episodes per year for 3 consecutive years 1, 3

Each episode must be documented with temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 3

If criteria are not met, watchful waiting is recommended 1, 2

Perioperative Management (If Surgery Indicated)

• Administer a single intraoperative dose of intravenous dexamethasone (0.5 mg/kg) to decrease postoperative nausea, vomiting, and pain 6, 1
• Do not routinely administer perioperative antibiotics, as evidence shows no benefit 6