Treatment of Painful Tonsil in an Otherwise Healthy Individual
For an otherwise healthy individual with a painful tonsil, first determine if this is acute bacterial tonsillitis requiring antibiotics or a viral/non-infectious cause that needs only supportive care—use clinical scoring (Centor/McIsaac) and rapid strep testing to guide this decision, then treat with NSAIDs plus acetaminophen for pain regardless of etiology, adding penicillin V for 10 days only if Group A Streptococcus is confirmed. 1
Initial Diagnostic Approach
Determine the Etiology
Bacterial versus viral differentiation is the critical first step, as 70-95% of tonsillitis cases are viral, but 15-30% in children aged 5-15 years and 5-15% in adults are caused by Group A beta-hemolytic streptococcus (GAS), which requires antibiotic therapy to prevent complications including rheumatic fever, acute glomerulonephritis, and abscess formation 1, 2.
Apply a validated clinical scoring system such as Centor, McIsaac, or FeverPAIN score to estimate the probability of bacterial (GAS) tonsillitis 1, 3.
Key clinical features suggesting bacterial tonsillitis include sudden onset of sore throat, fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 1.
Confirmatory Testing
Perform rapid antigen detection testing (RADT) and/or throat culture before initiating antibiotics to confirm GAS infection, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
In ambiguous cases with intermediate clinical scores, a point-of-care GAS swab test is particularly helpful to guide antibiotic decision-making 3.
Pain Management (First-Line for All Cases)
Multimodal Analgesia as Foundation
NSAIDs (such as ibuprofen or flurbiprofen) combined with acetaminophen (paracetamol) are the evidence-based first-line analgesics for acute tonsillitis pain, with high-quality evidence from multiple randomized controlled trials demonstrating significant pain and fever reduction 1.
NSAIDs are strongly recommended as adjunctive therapy for moderate to severe symptoms of Group A Streptococcal pharyngitis and tonsillitis by the Infectious Diseases Society of America 1.
This combination provides superior analgesia compared to either medication alone and should be administered on a scheduled basis rather than as-needed 4.
Additional Supportive Measures
A single dose of dexamethasone may provide additional pain relief in severe cases, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1.
Adequate hydration is essential, particularly in patients with fever, to prevent dehydration 4.
There is no benefit to restricting diet to liquids or cold foods only—patients should be encouraged to maintain adequate nutrition as tolerated 4.
Antibiotic Therapy (Only for Confirmed GAS)
When to Treat with Antibiotics
Antibiotics should only be initiated after confirming GAS infection through testing—do not start empiric antibiotics based on clinical features alone 1.
In high-probability cases with positive testing or in patients at risk for complications, standard antibiotic treatment should be initiated directly 3.
First-Line Antibiotic Choice
Penicillin V for 10 days is the first-line treatment for confirmed GAS tonsillitis, with amoxicillin as an acceptable alternative, according to the Infectious Diseases Society of America 1.
For penicillin-allergic patients, appropriate alternatives include cephalexin, clindamycin, or azithromycin 1.
Azithromycin (12 mg/kg once daily for 5 days in children) demonstrated 98% clinical success at Day 14 and 94% at Day 30, with 95% bacteriologic eradication at Day 14, statistically superior to penicillin V in FDA trials 5.
Critical Antibiotic Considerations
Complete the full 10-day course of penicillin therapy—inadequate duration (less than 10 days) increases risk of treatment failure and complications 1.
Avoid broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1.
Follow-up throat cultures for asymptomatic patients who completed appropriate therapy are not recommended 1.
Important Clinical Pitfalls to Avoid
Do not initiate antibiotics without confirming GAS infection through testing, as this contributes to antibiotic overuse and resistance 1, 3.
Do not underestimate pain severity—tonsillitis is identified as one of the most painful conditions and pain often remains poorly managed in clinical practice 6.
Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent studies and meta-analyses, so NSAIDs should not be withheld due to bleeding concerns 4, 1.
Distinguish between true acute tonsillitis and chronic GAS carriage with intercurrent viral infections, as carriers generally do not require antimicrobial therapy 1.
When to Consider Specialist Referral
If symptoms persist despite appropriate antibiotic therapy, consider medication compliance issues, possibility of chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 1.
Monitor for signs of complications including peritonsillar abscess (severe unilateral pain, trismus, uvular deviation), which requires urgent ENT evaluation 7.
For recurrent tonsillitis, watchful waiting is strongly recommended if there have been <7 episodes in the past year, <5 episodes per year for the past 2 years, or <3 episodes per year for the past 3 years 1, 3.