What is the diagnosis and treatment for a child presenting with cough, cold, and some pus points on the tonsil and uvula, but no significant throat pain or toxic symptoms, and an inclination of the uvula to one side?

Diagnosis and Management of Pediatric Tonsillitis with Uvular Deviation

This child most likely has acute bacterial tonsillitis with possible early peritonsillar involvement (suggested by uvular deviation), and should be treated with antibiotics targeting Group A Streptococcus while monitoring closely for progression to peritonsillar abscess.

Clinical Assessment

The presence of pus points (exudate) on the tonsils with uvular deviation to one side is concerning for:

• Bacterial tonsillitis - The exudate on tonsils strongly suggests bacterial infection, most commonly Group A beta-hemolytic Streptococcus (Streptococcus pyogenes) 1, 2
• Early peritonsillar involvement - Uvular deviation indicates asymmetric inflammation and possible early peritonsillar abscess or cellulitis 3, 4
• The absence of significant throat pain is unusual but does not exclude bacterial infection - Some children, particularly younger ones, may not report severe throat pain despite significant tonsillar pathology 1, 4

Key Diagnostic Features to Confirm

Clinical findings suggestive of bacterial (GAS) tonsillitis include: 1

• Tonsillopharyngeal exudate (present in this case)
• Fever (assess if present)
• Tender, enlarged anterior cervical lymph nodes
• Absence of viral features (coryza, hoarseness, cough, conjunctivitis) 1

The uvular deviation is a red flag - This suggests asymmetric peritonsillar inflammation and warrants close monitoring for progression to peritonsillar abscess, which is an indication for urgent ENT evaluation and possible drainage 3

Immediate Management

Microbiological confirmation is mandatory before antibiotics: 1

• Perform rapid antigen detection test (RADT) or throat culture by vigorously swabbing both tonsils and posterior pharynx 1
• However, rapid antigen testing has very low sensitivity in children, so if clinical suspicion is high and RADT is negative, obtain throat culture 5, 3
• Do not withhold antibiotics if clinical presentation strongly suggests bacterial tonsillitis with complications (uvular deviation suggests possible peritonsillar involvement) 1

Antibiotic therapy for confirmed or highly suspected bacterial tonsillitis: 5, 3

• First-line: Penicillin or amoxicillin for 10 days to prevent rheumatic fever and glomerulonephritis 5, 3, 2
• Alternative: Cefuroxime (beta-lactam antibiotic) if penicillin allergy is not severe 5, 3
• Short-course alternatives (azithromycin 12 mg/kg once daily for 5 days or clarithromycin for 3-5 days) provide comparable symptom reduction but only the 10-day therapy has proven effective in preventing rheumatic fever 5, 3, 6

Symptomatic treatment: 5, 3

• Dexamethasone (corticosteroid) to reduce inflammation and pain 5, 3
• Ibuprofen (NSAID) for pain and fever control 5, 3
• Ensure adequate hydration 4

Critical Monitoring for Peritonsillar Abscess

The uvular deviation requires close observation for progression to peritonsillar abscess, which presents with: 3, 4

• Worsening unilateral throat pain
• Trismus (difficulty opening mouth)
• "Hot potato" voice (muffled speech)
• Drooling or difficulty swallowing
• Bulging of the soft palate or peritonsillar area

If any of these develop, immediate ENT referral is required for possible incision and drainage 3

When to Consider Tonsillectomy

Tonsillectomy is indicated for: 5, 3

• Recurrent bacterial tonsillitis: ≥7 well-documented episodes in 1 year, or ≥5 episodes per year for 2 consecutive years (Paradise criteria) 5, 3
• Peritonsillar abscess (especially if recurrent) 5, 3
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) 5, 3
• Allergy to antibiotics 5, 3

For children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis - In other cases (tonsillar hyperplasia), partial tonsillectomy (tonsillotomy) is preferred due to lower risk of hemorrhage and pain 5, 3

Common Pitfalls to Avoid

• Do not assume viral etiology based on minimal throat pain alone - The presence of tonsillar exudate and uvular deviation suggests bacterial infection with possible complications 1, 2
• Do not ignore uvular deviation - This is a warning sign of asymmetric inflammation that may progress to peritonsillar abscess 3, 4
• Do not use over-the-counter cough and cold medications - These are ineffective and potentially dangerous in children, especially those under 2 years 7, 8
• Do not perform microbiological screening in asymptomatic children - 10% of healthy children carry Streptococcus pyogenes without clinical disease, and screening does not justify antibiotic treatment 5, 3
• Do not use short-course antibiotics (3-5 days) if prevention of rheumatic fever is a concern - Only 10-day therapy has proven efficacy for this indication 5, 3

Follow-Up

• Reassess within 48-72 hours to ensure clinical improvement and monitor for progression to peritonsillar abscess 7, 9
• If symptoms worsen or uvular deviation increases, obtain urgent ENT consultation 3, 4
• If cough persists beyond 4 weeks, evaluate according to chronic cough guidelines with chest radiograph and systematic algorithm 1, 7