What is the best treatment approach for a patient with viral tonsillitis?

Treatment of Viral Tonsillitis

Viral tonsillitis should be managed with supportive care only—no antibiotics—focusing on adequate analgesia with acetaminophen or ibuprofen for pain and fever control, along with ensuring proper hydration. 1, 2

Confirming Viral Etiology

Before initiating treatment, it is critical to distinguish viral from bacterial tonsillitis to avoid unnecessary antibiotic use:

• Test before treating: Use rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before considering any antibiotic therapy 1, 3
• Viral tonsillitis accounts for 70-95% of all tonsillitis cases, making it the most common etiology 4, 2
• Clinical features suggesting viral origin include presence of cough, rhinorrhea, hoarseness, and absence of high fever (>38.3°C), tonsillar exudate, and tender cervical lymphadenopathy 3, 5
• Bacterial tonsillitis presents differently with sudden onset sore throat, fever >38.3°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and notably the absence of cough 1, 3

Supportive Care Protocol

The cornerstone of viral tonsillitis management is symptomatic relief:

• Provide adequate analgesia with acetaminophen or ibuprofen for pain and fever control 1
• Ensure adequate hydration and educate caregivers about the importance of fluid intake 1
• Educate caregivers about managing and reassessing pain throughout the illness course 1
• Supportive care is the only appropriate treatment for viral tonsillitis, as antibiotics provide no benefit and contribute to antimicrobial resistance 2, 6

Critical Pitfalls to Avoid

Never initiate antibiotics without confirming GAS infection through testing, as this leads to unnecessary antibiotic exposure in the majority of cases that are viral 1, 3

Additional pitfalls include:

• Do not treat positive GAS tests in patients with viral symptoms (cough, rhinorrhea, hoarseness), as these patients are likely chronic carriers experiencing a viral infection rather than true bacterial tonsillitis 5
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins would be effective for confirmed GAS—this is irrelevant for viral cases but important when bacterial infection is confirmed 3
• Avoid prescribing antibiotics for symptom duration alone without microbiological confirmation, as viral tonsillitis is self-limited 4, 2

When Tonsillectomy Is NOT Indicated

For recurrent viral tonsillitis, surgery is rarely beneficial:

• Watchful waiting is strongly recommended if episodes are fewer than 7 in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years 1, 4
• Spontaneous improvement commonly occurs without surgery, with control groups in randomized trials showing reduction to only 0.3-1.17 episodes per year without intervention 1
• Tonsillectomy should not be performed without meeting Paradise criteria with proper documentation including temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for GAS for each episode 1, 3

Natural History and Expectations

Understanding the self-limited nature of viral tonsillitis helps set appropriate expectations:

• Most cases resolve spontaneously with supportive care alone within 3-7 days 2, 6
• The condition is largely self-limited, and the preponderance of benefit lies in avoiding unnecessary interventions rather than aggressive treatment 7
• Shared decision-making is important given the favorable natural history and the fact that surgical intervention provides only modest short-term improvement even for recurrent cases 5

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