What is the best approach for a systematically well pediatric patient with unilateral tonsillar opacity and no fever?

Unilateral Tonsillar Opacity in a Well-Appearing Child Without Fever

In a systematically well pediatric patient with unilateral tonsillar opacity and no fever, the priority is to rule out a foreign body or peritonsillar abscess, then observe without antibiotics unless Group A Streptococcus is confirmed or the patient develops systemic symptoms. 1, 2

Immediate Assessment

Critical Red Flags to Exclude

• Foreign body: Unilateral tonsillar findings with recurrent episodes should raise suspicion for an embedded foreign body, which can present as recurrent unilateral tonsillitis without systemic symptoms 1
• Peritonsillar abscess: Even without fever, assess for trismus, uvular deviation, "hot potato voice," or asymmetric tonsillar bulging beyond the midline 2
• Malignancy: Persistent unilateral tonsillar asymmetry (especially if firm, non-tender, or progressively enlarging) warrants consideration of lymphoma or other malignancy, though this is rare in children

Physical Examination Specifics

• Document the exact appearance: Is this exudate, a white patch, or actual tonsillar asymmetry? 3
• Palpate the tonsil gently if cooperative—a foreign body may be palpable 1
• Assess for cervical lymphadenopathy (>2 cm or tender nodes suggest bacterial infection) 3
• Check for tonsillar exudate versus membrane versus opacity 3

Diagnostic Approach

Testing Strategy

Perform rapid antigen detection test (RADT) or throat culture for Group A Streptococcus even in the absence of fever, as 15-30% of children aged 5-15 years with tonsillitis have streptococcal infection 4, 5. The absence of fever does NOT exclude bacterial infection 3.

• If RADT positive: Treat with penicillin as first-line antibiotic 4, 6
• If RADT negative and low clinical suspicion: Supportive care only 4, 5
• Do NOT obtain anti-streptococcal antibody titers, as they reflect past rather than current infection 7

When to Consider Imaging or ENT Referral

• Persistent unilateral findings beyond 2 weeks despite appropriate management 1
• Any concern for abscess formation (even without fever, as some children with peritonsillar abscess may not mount significant fever) 2
• Progressive tonsillar asymmetry or firmness 1

Management Algorithm

If Group A Streptococcus Confirmed

• Penicillin remains first-line treatment (penicillin V potassium 250 mg 2-3 times daily for children <27 kg, or 500 mg 2-3 times daily for children ≥27 kg, for 10 days) 4, 6
• For penicillin allergy (non-severe): Consider cephalosporins (cefdinir, cefuroxime, or cefpodoxime), as cross-reactivity is <10% 2
• For severe penicillin hypersensitivity: Clindamycin is the drug of choice 2

If Streptococcal Testing Negative

Provide supportive care only: analgesia (acetaminophen or ibuprofen) and hydration 4, 5. The vast majority (70-95%) of tonsillitis cases are viral and do not benefit from antibiotics 4.

Watchful Waiting is Appropriate

This single episode does NOT meet criteria for tonsillectomy consideration, which requires at least 7 documented episodes in one year, 5 per year for 2 years, or 3 per year for 3 years (Paradise criteria) 3, 8. Even children meeting Paradise criteria show only modest benefit from tonsillectomy, with many improving spontaneously 8.

Critical Pitfalls to Avoid

• Do not prescribe antibiotics empirically without confirming Group A Streptococcus, as this contributes to antibiotic resistance and provides no benefit for viral infections 4, 5
• Do not dismiss unilateral findings: While bilateral involvement is more common, unilateral presentation warrants careful evaluation for foreign body or abscess 1, 2
• Do not assume absence of fever excludes serious pathology: Some children with peritonsillar abscess or foreign body may remain afebrile 2, 1
• Document this episode thoroughly in the medical record with specific clinical features (temperature, presence/absence of exudate, lymphadenopathy, laterality) for future reference if recurrent episodes occur 3

Follow-Up Instructions

• Reassess in 48-72 hours if symptoms persist or worsen 8
• Return immediately for fever >38.3°C, difficulty swallowing, drooling, respiratory distress, or severe pain 2, 3
• If this becomes a recurrent pattern (especially unilateral), refer to ENT for direct visualization and possible foreign body removal 1