What is the appropriate workup and treatment for acute tonsillitis with visible tonsilloliths and pharyngeal erythema?

Workup and Treatment of Acute Tonsillitis with Tonsilloliths and Pharyngeal Erythema

The presence of tonsilloliths (tonsil stones) does not alter the standard diagnostic approach to acute tonsillitis; you must perform rapid antigen detection testing (RADT) or throat culture to confirm Group A Streptococcus before prescribing antibiotics, and treat only if the test is positive. 1

Clinical Assessment

Key Historical Features to Elicit

• Sudden onset of sore throat with high fever (≥38.3°C/101°F) strongly suggests bacterial (GAS) infection 1, 2
• Absence of cough, rhinorrhea, hoarseness, or conjunctivitis favors bacterial over viral etiology 1, 2, 3
• Presence of any viral upper respiratory symptoms (cough, runny nose, hoarseness, red eyes) argues strongly against GAS and testing should be omitted 1, 2, 3

Physical Examination Findings

• Tender, enlarged anterior cervical lymph nodes increase the likelihood of GAS infection 1, 2, 3
• Tonsillar exudates (white or yellow patches) are associated with bacterial infection but also occur with viral causes like EBV 1, 3
• Palatal petechiae ("doughnut lesions") are characteristic of GAS pharyngitis 2
• Tonsilloliths themselves are incidental findings—small stones are common and managed expectantly; they do not indicate bacterial infection 4

Diagnostic Testing Algorithm

When to Test

• Test for GAS when the patient has sore throat plus fever and lacks viral features (no cough, rhinorrhea, hoarseness, conjunctivitis) 1, 2, 3
• Do NOT test if obvious viral symptoms are present—testing in this setting yields false positives due to 10–15% asymptomatic GAS carriage 1, 2

Testing Method

• Perform RADT first—a positive result is diagnostic and warrants immediate antibiotic therapy 1, 2, 3
• If RADT is negative in children/adolescents (age ≤18 years), obtain a backup throat culture because RADT sensitivity is only 79–88% and missing GAS increases rheumatic fever risk 1, 2
• In adults, a negative RADT does not require backup culture because rheumatic fever risk is very low 2, 3
• Proper swab technique requires firm contact with both tonsils and the posterior pharynx while avoiding cheeks, gums, and teeth 3

Treatment Recommendations

Confirmed GAS Infection (Positive RADT or Culture)

First-line therapy:

• Amoxicillin 500 mg PO twice daily for 10 days (adults) or weight-based dosing in children (50 mg/kg once daily or 25 mg/kg twice daily) 1, 2, 3
• Penicillin V 500 mg PO twice daily (or 250 mg four times daily) for 10 days is an acceptable alternative 1, 3
• A full 10-day course is mandatory to achieve bacterial eradication and prevent acute rheumatic fever; shorter courses increase treatment failure 1, 2

Penicillin-allergic patients:

• Non-anaphylactic/delayed reactions: First-generation cephalosporin (cephalexin 500 mg PO twice daily for 10 days)—cross-reactivity is only ≈0.1% 1, 3
• Anaphylactic/immediate reactions: Clindamycin 300 mg PO three times daily for 10 days (preferred; only ~1% U.S. resistance) 1, 3
• Alternative for true allergy: Azithromycin 500 mg PO once daily for 5 days (acceptable but 5–8% resistance) 1, 3

Viral Pharyngitis (Negative Testing or Obvious Viral Features)

• Do NOT prescribe antibiotics 1, 2, 3
• Supportive care only: Acetaminophen or ibuprofen for pain/fever, adequate hydration, warm saline gargles, rest 1, 2, 3
• Reassure that symptoms typically resolve in 3–7 days without antibiotics 2, 3

Management of Tonsilloliths

• Small tonsilloliths require no specific treatment—they are common incidental findings and pass spontaneously 4
• Expectant management is appropriate; surgical intervention is rarely needed 4
• Tonsilloliths do not indicate bacterial infection and should not influence antibiotic decisions 4

Critical Pitfalls to Avoid

• Do NOT treat based on clinical impression alone—even experienced physicians cannot reliably differentiate viral from bacterial pharyngitis; microbiological confirmation is mandatory 1, 2
• Do NOT test patients with obvious viral symptoms (cough, rhinorrhea, conjunctivitis)—this leads to false positives from asymptomatic GAS carriers and unnecessary antibiotics 1, 2
• Do NOT shorten antibiotic duration below 10 days (except azithromycin 5 days)—incomplete courses fail to eradicate GAS and increase rheumatic fever risk 1, 2
• Do NOT use broad-spectrum cephalosporins (cefdinir, cefpodoxime) when narrow-spectrum penicillins are effective—this promotes resistance 1, 3
• Do NOT assume tonsilloliths indicate bacterial infection—they are unrelated to acute infectious tonsillitis 4

Expected Clinical Course

• Confirmed GAS infection: Clinical improvement begins within 24–48 hours of starting antibiotics; fever resolves by 48 hours in uncomplicated cases 1
• Viral pharyngitis: Self-limited, resolving in 3–7 days without antibiotics 2, 3

When to Consider Tonsillectomy

• Watchful waiting is strongly recommended if episodes are <7 in the past year, <5 per year for 2 years, or <3 per year for 3 years 1, 4
• Consider tonsillectomy only when meeting Paradise criteria: ≥7 documented episodes in the past year, ≥5 per year for 2 years, or ≥3 per year for 3 years 1
• Each documented episode must include sore throat plus at least one of: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1