What is the recommended diagnosis and management approach for a patient with chronic tonsillitis, considering their medical history and potential underlying conditions such as obstructive sleep apnea or tonsillar abscess?

Chronic Tonsillitis: Diagnosis and Management

Diagnostic Criteria

Chronic tonsillitis is diagnosed based on documented recurrent episodes meeting specific frequency thresholds: ≥7 episodes in the past year, ≥5 episodes per year over 2 years, or ≥3 episodes per year over 3 years. 1, 2

Required Documentation for Each Episode

Each episode must be contemporaneously documented in the medical record and include sore throat PLUS at least one of the following: 1

• Temperature ≥38.3°C (101°F)
• Cervical lymphadenopathy (tender nodes or >2 cm)
• Tonsillar exudate
• Positive test for group A beta-hemolytic streptococcus (GABHS)

Critical Diagnostic Pitfall: The Carrier State

A major diagnostic error is confusing chronic GABHS carriers experiencing viral infections with true recurrent bacterial tonsillitis. 3, 4 Carriers harbor GABHS in their pharynx without active infection and test positive during intercurrent viral illnesses. Treating these patients repeatedly with antibiotics provides no benefit and may cause harm. 3

Confirming Bacterial vs. Viral Etiology

• Rapid antigen detection testing (RADT) and/or throat culture should be performed before initiating antibiotics 2, 4
• Viral features that argue against bacterial infection include: cough, rhinorrhea, hoarseness, conjunctivitis, oral ulcers, viral exanthem, or gradual onset 4
• When viral features are present, testing for GABHS is not recommended 4

Management Algorithm

Step 1: Determine Episode Frequency

If episodes are <7 in the past year, <5 per year over 2 years, OR <3 per year over 3 years → STRONG RECOMMENDATION for watchful waiting. 1

The natural history favors spontaneous improvement. Control groups in randomized trials showed dramatic reductions in throat infections over time (averaging only 0.45-1.17 episodes annually without surgery). 1 Watchful waiting avoids unnecessary surgery with potential complications including hemorrhage, pain, infection, and anesthesia risks. 1

Step 2: If Frequency Criteria ARE Met

Tonsillectomy may be recommended (Option) when frequency criteria are met WITH proper documentation. 1 However, this remains an option rather than a mandate because:

• Many cases resolve spontaneously even when meeting Paradise criteria 1
• Tonsillectomy provides only modest benefit (approximately 1 year of reduced infections) 3
• Shared decision-making is essential given the favorable natural history 3

Step 3: Assess for Modifying Factors

Even if frequency criteria are NOT met, evaluate for modifying factors that may favor tonsillectomy: 1

• Multiple antibiotic allergies/intolerance
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis)
• History of >1 peritonsillar abscess (note: changed from "≥1" to ">1" in 2019 update) 1
• Severe infections requiring hospitalization 1
• Lemierre syndrome 1
• Family history of rheumatic heart disease 1

Step 4: Screen for Obstructive Sleep-Disordered Breathing

Ask caregivers about comorbid conditions that may improve after tonsillectomy in children with tonsillar hypertrophy and obstructive sleep-disordered breathing: 1

• Growth retardation
• Poor school performance
• Enuresis
• Asthma (added in 2019 update) 1
• Behavioral problems

Polysomnography should be obtained before tonsillectomy if the child is <2 years old or has obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1

Active Infection Management

For Confirmed GABHS Tonsillitis

• First-line: Penicillin V oral for 10 days or amoxicillin 3
• Non-anaphylactic penicillin allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 3
• Anaphylactic penicillin allergy: Clindamycin, azithromycin, or clarithromycin 3

For Viral Tonsillitis (70-95% of cases)

Antibiotics are NOT indicated and provide no benefit. 4, 5 Treatment is supportive: 4

• NSAIDs (ibuprofen) or acetaminophen for pain/fever
• Warm salt water gargles
• Adequate hydration and rest
• Expected improvement in 3-7 days

Carrier Eradication (Only When Specifically Indicated)

Antibiotics for carriers are considered ONLY during: 3

• Community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive GABHS infection
• Outbreak of GABHS pharyngitis in closed/partially closed community
• Personal/family history of acute rheumatic fever

Preferred regimen: Clindamycin 20-30 mg/kg/day in three divided doses (maximum 300 mg per dose) for 10 days 3

Key Clinical Pitfalls to Avoid

• Never initiate antibiotics without confirming GABHS infection through diagnostic testing 2
• Never recommend tonsillectomy without proper documentation meeting Paradise criteria 3
• Never treat positive GABHS tests in asymptomatic carriers or those with viral symptoms 3
• Never use short courses of antibiotics; always complete 10-day regimens 3
• Never perform follow-up throat cultures in asymptomatic patients who completed appropriate therapy 3
• Never administer perioperative antibiotics for tonsillectomy (strong recommendation against) 1
• Never use codeine for post-tonsillectomy pain (FDA black box warning) 1
• Never use aspirin in children with viral tonsillitis (risk of Reye's syndrome) 4

Perioperative Counseling

Counsel patients and caregivers that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. 1 Additionally, emphasize the importance of managing posttonsillectomy pain with reminders to anticipate, reassess, and adequately treat pain after surgery. 1