What is the management plan for a patient with recurrent tonsillitis?

Management of Recurrent Tonsillitis

For recurrent tonsillitis, recommend watchful waiting if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years; tonsillectomy should be considered only when these Paradise criteria are met with proper documentation of each episode. 1, 2, 3

Diagnostic Documentation Requirements

Before any treatment decision, each episode must be documented with specific clinical features 1, 2, 3:

• Temperature ≥38.3°C (101°F) 1, 3
• Cervical lymphadenopathy 1, 3
• Tonsillar exudate 1, 3
• Positive test for group A beta-hemolytic streptococcus (rapid antigen detection test or throat culture) 1, 2, 3

The primary care provider must collate documentation from all visits including symptoms, physical findings, test results, days of school/work absence, and quality of life impacts 1, 3. This comprehensive documentation is essential because many patients awaiting tonsillectomy no longer meet criteria by the time of surgery, highlighting the self-limited nature of this condition 3.

Medical Management Algorithm

Acute Episode Treatment

For confirmed bacterial (GAS) tonsillitis, prescribe penicillin V for 10 days as first-line therapy. 2 Amoxicillin is an acceptable alternative 2. The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis 2.

For penicillin-allergic patients 2:

• Non-anaphylactic allergy: Use first-generation cephalosporins 2
• Anaphylactic allergy: Use clindamycin, azithromycin, or clarithromycin 2

Recurrent Episodes with Multiple Treatment Failures

For patients with multiple documented episodes despite appropriate treatment, consider alternative antibiotic regimens that achieve higher pharyngeal eradication rates 1, 4:

Oral clindamycin 1:

• Children: 20-30 mg/kg/day divided into 3 doses for 10 days 1
• Adults: 600 mg/day divided into 2-4 doses for 10 days 1

Oral amoxicillin-clavulanic acid 1, 4:

• Children: 40 mg/kg/day (amoxicillin component) divided into 3 doses for 10 days 1
• Adults: 500 mg twice daily for 10 days 1

These regimens show superior clinical and microbiological effects compared to penicillin in patients with recurrent episodes 4. However, they should be reserved for true treatment failures, not used as first-line therapy 1.

Surgical Management: Tonsillectomy Criteria

Paradise Criteria for Surgery

Tonsillectomy may be considered when the patient meets ALL of the following 1, 3, 5:

• ≥7 documented episodes in the preceding year, OR 1, 3, 5
• ≥5 episodes per year for each of the preceding 2 years, OR 1, 3, 5
• ≥3 episodes per year for each of the preceding 3 years 1, 3, 5

Each episode must include documentation of sore throat PLUS at least one qualifying clinical feature (temperature, adenopathy, exudate, or positive GAS test) 1, 3. Antibiotics must have been administered in conventional dosage for proven or suspected streptococcal episodes 3.

Modifying Factors That May Favor Earlier Surgery

Even when Paradise criteria are not fully met, assess for modifying factors that may nonetheless favor tonsillectomy 1, 2, 3:

• Multiple antibiotic allergies or intolerance 1, 3
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1, 3
• History of >1 peritonsillar abscess 1, 3
• Obstructive sleep-disordered breathing with tonsillar hypertrophy 6
• Significant impact on growth and development 3

Expected Surgical Outcomes

Tonsillectomy may decrease the number of recurrences of symptomatic pharyngitis in some patients, but only for a limited time 1. The natural history data shows that untreated children experienced only an average of 1.17 episodes in the first year after observation, 1.03 in the second year, and 0.45 in the third year 3. This emphasizes that many cases improve spontaneously without surgery 3, 7, 8.

Watchful Waiting Protocol

For patients NOT meeting Paradise criteria, strongly recommend watchful waiting with close monitoring. 1, 3, 7 This does not imply inaction 1.

Implement a 12-month observation period with 1, 3:

• Regular clinic visits to document episodes accurately 1
• Recording of clinical characteristics, test results, and quality of life impacts 1, 3
• Education on infection prevention including hand hygiene and respiratory etiquette 3
• Reassessment after 12 months before reconsidering surgery 3

The rationale is that 55-60% of patients eligible for tonsillectomy will not develop further episodes during observation 8, and Cochrane reviews demonstrate that benefits of tonsillectomy do not persist beyond the first year 3.

Critical Pitfalls to Avoid

Never initiate antibiotics without confirming GAS infection through testing 2. Most cases (70-95%) are viral and do not require antibiotics 7.

Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis 2. Shorter courses may resolve symptoms but fail to eradicate bacteria and prevent complications 2.

Never perform tonsillectomy without meeting appropriate frequency and documentation criteria 2. Surgery should be avoided in conditions with favorable natural history 1.

Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2. Reserve clindamycin and amoxicillin-clavulanic acid for true treatment failures 1, 4.

Never prescribe continuous long-term antibiotic prophylaxis to prevent recurrent episodes 1. Prophylaxis is not recommended except to prevent recurrence of rheumatic fever in patients with previous rheumatic fever 1. Long-term azithromycin has been shown ineffective 8.

Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2. This practice is unnecessary and not recommended 1.