What is the appropriate evaluation and management of acute tonsillitis in children?

Evaluation and Management of Acute Tonsillitis in Children

For acute tonsillitis in children, obtain a throat swab for culture or rapid antigen testing before prescribing antibiotics, and treat only confirmed Group A β-hemolytic streptococcal (GABHS) infections with penicillin or amoxicillin for 10 days, while providing supportive care with ibuprofen or acetaminophen for all cases. 1, 2

Diagnostic Evaluation

Clinical Assessment

Document the following key features for every episode:

• Temperature ≥38.3°C (101°F) 1, 2
• Presence or absence of anterior cervical lymphadenopathy 1, 2
• Tonsillar exudate 1, 2
• Days of school absence 1

These four clinical features distinguish bacterial from viral etiology and are essential for future surgical decision-making. 1, 2

Microbiological Testing

Obtain a throat swab that contacts both sides of the posterior pharynx and the uvula before initiating antibiotics. 3, 1

• Culture on sheep's-blood agar and identify GABHS by the bacitracin method or equivalent. 3, 1
• Reincubate cultures negative at 24 hours for an additional 24 hours to improve detection sensitivity. 1
• If using rapid antigen detection testing (RADT), confirm negative results with throat culture in children because RADT has lower sensitivity in pediatric populations. 1, 4

Critical pitfall: Approximately 10% of healthy children carry GABHS asymptomatically without clinical disease; therefore, never perform screening tests in asymptomatic children, as positive results do not justify antibiotic treatment. 4

What NOT to Use for Diagnosis

Do not use white blood cell count, ESR, or C-reactive protein to differentiate bacterial from viral tonsillitis or to justify antibiotic therapy. 5 These tests lack specificity and do not reliably distinguish GABHS from viral infections. 5

Treatment

GABHS-Positive Cases

First-line therapy: Penicillin or amoxicillin for 10 days. 1, 2, 6

• The 10-day course is specifically required to prevent rheumatic fever and glomerulonephritis, even though shorter courses may resolve acute symptoms. 4
• Expected response: Clinical improvement within 24-48 hours and fever resolution within 48 hours. 3
• Alternative antibiotics (clindamycin or amoxicillin-clavulanate) may be considered for patients with multiple antibiotic allergies or treatment failures. 1

All Patients (Regardless of Etiology)

Provide analgesia with ibuprofen, acetaminophen, or both for pain control. 1, 2

Never prescribe codeine or codeine-containing medications to children younger than 12 years. 1, 2 This is an explicit contraindication due to risk of serious adverse effects.

GABHS-Negative Cases

Do not prescribe antibiotics; offer only supportive care. 1 Viral tonsillitis (42% of febrile exudative cases, most commonly adenovirus) does not benefit from antibiotics. 5

Documentation Requirements

Meticulously record each episode with temperature, cervical adenopathy, exudate findings, test results, and school-absence days. 1 This is critical because only 17% of patients with frequent infections have sufficient documentation for surgical evaluation. 1

When to Consider Tonsillectomy

Watchful Waiting (Preferred Initial Approach)

Recommend observation rather than surgery when a child has:

• <7 episodes in the past year, OR
• <5 episodes per year over the past 2 years, OR
• <3 episodes per year over the past 3 years 1, 2

Many children improve spontaneously; those awaiting surgery often no longer meet criteria by the time of the procedure. 3

Paradise Criteria for Tonsillectomy

Consider tonsillectomy only if ALL of the following are met:

• Frequency: ≥7 documented episodes in the past year OR ≥5 episodes per year for 2 years OR ≥3 episodes per year for 3 years 3, 1, 2
• Each episode documented with: fever >38.3°C, cervical adenopathy, tonsillar exudate, OR positive GABHS test 3, 1
• Antibiotics administered for proven or suspected streptococcal episodes 3
• Contemporaneous notation in the medical record 3, 1

Important caveat: Even when Paradise criteria are met, tonsillectomy provides only modest short-term benefit (first year only), with no persistent advantage beyond 12 months. 3, 1 In randomized trials, children meeting criteria who were observed without surgery averaged only 1.17 infection episodes in the following year, demonstrating high rates of spontaneous improvement. 1

Modifying Factors That May Favor Earlier Surgery

Consider tonsillectomy before meeting full Paradise criteria if:

• Multiple antibiotic allergies or intolerance 3, 1, 2
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 3, 1, 2
• History of >1 peritonsillar abscess 3, 1, 2
• Recurrent severe infections requiring hospitalization or complications such as Lemierre syndrome 1

Red Flags Requiring Urgent Evaluation

Immediately refer patients with:

• Difficulty swallowing, drooling, or neck tenderness suggesting peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome 1
• Persistent high fever >38.3°C despite appropriate antibiotic therapy 1

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on exudates without microbiological confirmation 1—viral infections commonly present with exudate, especially adenovirus. 5
• Failing to document infection episodes adequately, which impairs future surgical eligibility assessments 1, 2
• Recommending tonsillectomy without satisfying Paradise criteria or without a 12-month observation period 3, 1
• Using shorter antibiotic courses (<10 days) when rheumatic fever prevention is the goal, even though symptom resolution may occur earlier 4
• Performing microbiological screening in asymptomatic children, which leads to unnecessary treatment of carriers 4