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 Streptococcus (rapid antigen detection test or throat culture) 1, 2, 3

Primary care providers must collate documentation from all visits including symptoms, physical findings, test results, days of school/work absence, and quality of life impacts 1, 3. Testing before treating is mandatory—use rapid antigen detection testing and/or throat culture before initiating antibiotics to prevent unnecessary antibiotic use in viral cases 2.

Medical Management Algorithm

Acute Episode Treatment

For confirmed Group A Streptococcus tonsillitis:

• First-line: Penicillin V for 10 days (gold standard) 2, 4
• Alternative: Amoxicillin for 10 days 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: First-generation cephalosporins 2
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 2

Recurrent Episodes with Treatment Failure

For patients with multiple recurrent episodes despite standard treatment, consider alternative antibiotics that achieve higher pharyngeal eradication rates 1, 5:

• Clindamycin: Children 20-30 mg/kg/day in 3 divided doses for 10 days; Adults 600 mg/day in 2-4 divided doses for 10 days 1
• Amoxicillin-clavulanate: Children 40 mg/kg/day in 3 divided doses for 10 days; Adults 500 mg twice daily for 10 days 1
• Benzathine penicillin G (IM) with or without rifampin for compliance concerns 1

Evidence shows clindamycin and amoxicillin-clavulanate are superior to penicillin for preventing future attacks in patients with recurrent acute pharyngo-tonsillitis, though these studies have moderate quality due to high risk of bias 5. Long-term azithromycin prophylaxis is not effective and showed no reduction in tonsillitis episodes 6.

What NOT to Do

• Never prescribe continuous long-term antibiotic prophylaxis to prevent recurrent episodes (except for patients with history of rheumatic fever) 1
• Never initiate antibiotics without confirming GAS infection through testing 2
• Never use antibiotic courses shorter than 10 days for GAS tonsillitis 2
• Never perform routine follow-up throat cultures for asymptomatic patients who completed appropriate therapy 1, 2

Surgical Management: Tonsillectomy Criteria

Paradise Criteria for Tonsillectomy

Tonsillectomy may be recommended when ALL of the following are met 1, 3:

• ≥7 documented episodes in the past year, OR
• ≥5 documented episodes per year for 2 years, OR
• ≥3 documented episodes per year for 3 years 1, 3
• Each episode documented with temperature, cervical adenopathy, tonsillar exudate, or positive GAS test 1, 3
• Antibiotics administered in conventional dosage for proven or suspected streptococcal episodes 3

Watchful Waiting (Strong Recommendation)

Watchful waiting is strongly recommended for patients not meeting Paradise criteria 1, 3. The natural history is favorable—untreated children experienced only 1.17 episodes in the first year, 1.03 in the second year, and 0.45 in the third year after observation 3. Many children awaiting tonsillectomy no longer meet criteria by surgery time 3.

Watchful waiting requires active monitoring with regular clinic visits and accurate documentation of each pharyngotonsillitis episode 1.

Modifying Factors That May Favor Earlier Surgery

Assess for modifying factors even when Paradise criteria are not fully met 1, 2, 3:

• Multiple antibiotic allergies or intolerance 1, 3
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 1, 3
• History of >1 peritonsillar abscess 1, 3
• Obstructive sleep-disordered breathing with tonsillar hypertrophy 7
• Significant impact on growth and development 3

Expected Surgical Outcomes

Tonsillectomy may decrease recurrences of symptomatic pharyngitis in some patients, but benefits are limited in duration and only persist for approximately the first year 1, 3. The procedure carries risks including vomiting, bleeding, pain, infection, and anesthesia complications 1.

Special Consideration: Concurrent Obstructive Sleep-Disordered Breathing

If the patient has obstructive sleep-disordered breathing (snoring, mouth breathing, grade 3 tonsillar hypertrophy), this alone justifies tonsillectomy regardless of infection frequency 7. The oSDB symptoms provide sufficient clinical evidence for surgical intervention without mandatory polysomnography in otherwise healthy children 7. Recurrent tonsillitis serves as an additional supporting factor 7.

Polysomnography should be obtained if the patient is <2 years old, obese, has Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 7.

Critical Pitfalls to Avoid

• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria 2
• Never delay documenting episodes—accurate records are essential for surgical decision-making 1, 3
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2
• Do not delay surgery for "watchful waiting" when obstructive symptoms are present—watchful waiting is only appropriate when Paradise criteria are not met AND there are no obstructive symptoms 7

Follow-Up Protocol

If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 2. A 12-month observation period is recommended before reconsidering tonsillectomy, with documentation of all throat infection episodes and their impact on quality of life 3.