What steroid is recommended for treating swollen tonsils?

Steroid Treatment for Swollen Tonsils

For acute swollen tonsils in adults with severe symptoms (Centor score 3-4), give a single oral dose of dexamethasone 10 mg alongside antibiotic therapy; for children undergoing tonsillectomy, administer intravenous dexamethasone 0.5 mg/kg intraoperatively. 1, 2

Clinical Context and Decision Algorithm

The approach to steroid use depends critically on the clinical scenario:

For Acute Tonsillitis/Pharyngitis (Non-Surgical)

Adults with severe presentations:

• Calculate the Centor score (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1
• If Centor score 3-4: Consider single-dose dexamethasone 10 mg orally in conjunction with appropriate antibiotic therapy 1
• The benefit is modest and most pronounced in severe cases; the effect is considerably smaller in typical primary care populations where most patients do not have severe presentations 1
• Dexamethasone works through anti-inflammatory properties that reduce pharyngeal inflammation and swelling 1

Important contraindications to exclude:

• Diabetes mellitus or glucose dysregulation 1
• Patients already receiving exogenous steroids 1
• Endocrine disorders 1, 2

Children with acute tonsillitis:

• No significant benefit has been demonstrated for corticosteroids in children with sore throat 1
• Steroids should not be used routinely 1

For Perioperative Tonsillectomy

Children undergoing tonsillectomy:

• Administer a single intraoperative dose of intravenous dexamethasone 0.5 mg/kg (this is a strong recommendation) 2, 3
• Lower doses (0.15-1.00 mg/kg) may be equally effective, with maximum dose range of 8-25 mg 2
• Timing: Give following induction of anesthesia and at the time of surgery 4

Benefits of perioperative dexamethasone:

• Decreased postoperative nausea and vomiting up to 24 hours post-tonsillectomy 2, 3
• Decreased throat pain with lower pain scores and longer latency to analgesic administration 2, 3
• Decreased time to first oral intake 2, 3
• Likely results in increased patient satisfaction and decreased overnight hospital admission 2

For Peritonsillar Abscess

Adults with peritonsillar abscess:

• Single high-dose intravenous steroid in addition to antibiotic therapy after needle aspiration is more effective than antibiotics alone 5
• This approach significantly reduces fever, throat pain, dysphagia, trismus, and hours hospitalized (p < 0.01) 5

Why Not Other Steroids or Routes?

• Dexamethasone is preferred because it is 25 times more potent than hydrocortisone, providing adequate anti-inflammatory effect without requiring complex weight-based calculations in adults 1
• The effect of steroids appears smaller when administered orally compared to intravenous routes in some contexts 1
• Prednisolone 25-60 mg daily for 5-7 days may be considered for severe inflammation with airway compromise, but this is reserved for exceptional cases 6

Critical Caveats and Pitfalls

Do not use steroids routinely:

• Acute tonsillitis is typically self-limited, with most patients improving within 7-10 days regardless of treatment 6
• First-line treatment should be supportive care with adequate hydration and analgesia (ibuprofen or paracetamol) 6
• The American Academy of Otolaryngology-Head and Neck Surgery recommends against empirically prescribing corticosteroids for throat conditions before visualization of the larynx 6

Avoid chronic or repeated use:

• Chronic use of oral or parenteral corticosteroids is inappropriate in tonsillitis 2
• Long-term or repeated parenteral corticosteroids are contraindicated due to greater potential for adverse effects including cardiovascular disease, metabolic changes, osteoporosis, and avascular necrosis 3, 6

Recognize when steroids are NOT indicated:

• Do not prescribe antibiotics routinely for tonsillectomy (strong recommendation against) 2
• Empiric steroid use without proper evaluation may delay appropriate diagnosis and treatment 6
• Studies were not sufficiently powered to detect adverse effects of short courses, so the risk-benefit ratio must be carefully considered 1