Tonsillitis treatment

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Tonsillitis Treatment

1. Establish the Cause First

Tonsillitis is most commonly viral (majority of cases). Bacterial causes are less frequent but clinically important.

Feature	Viral	Group A Strep (GABHS)	Infectious Mono (EBV)
Onset	Slow	Rapid	Variable
Fever	None / low-grade	High	High
Exudate	No exudate	± exudate	± exudate
Other	Rhinorrhea, hoarseness	Headache, otalgia, nausea	Malaise, hepatosplenomegaly, petechiae at hard-soft palate junction
Diagnosis	Clinical	Rapid strep test (RADT); throat culture if negative	Monospot; CBC (>50% lymphocytes, >10% atypical)

Note: Antistreptolysin-O (ASO) titres are NOT recommended for diagnosing acute GABHS — they only reflect prior infection. — K.J. Lee's Essential Otolaryngology

2. Viral Tonsillitis

Treatment is supportive:

Analgesics/antipyretics (e.g., paracetamol, ibuprofen)
Adequate hydration
Rest
No antibiotics — they offer no benefit for viral pharyngitis/tonsillitis

Caution with EBV/Mono: Avoid amoxicillin — it causes a maculopapular rash in ~80% of EBV patients. Avoid contact sports due to splenomegaly risk.

3. Bacterial Tonsillitis (Group A Strep — GABHS)

Goals of antibiotic treatment:

Prevent complications (rheumatic fever, glomerulonephritis)
Shorten symptom duration
Reduce transmission

First-Line Antibiotic

Drug	Dose	Duration
Penicillin V (phenoxymethylpenicillin)	Adults: 500 mg BID–TID PO	10 days
Amoxicillin	Equally effective, better palatability	10 days

Penicillin Allergy

Drug	Notes
Azithromycin	5-day course
Cephalosporins (e.g., cefprozil)	Children 2–12 yr: 15 mg/kg/24 hr PO ÷ Q12 hr; ≥13 yr: 500 mg PO Q24 hr — Harriet Lane Handbook
Clindamycin	For true penicillin allergy or recurrent GABHS

Adjunct therapy:

Corticosteroids (single dose dexamethasone or oral prednisolone) — reduce pain and time to symptom resolution
Analgesics, throat lozenges, adequate hydration

4. Recurrent Tonsillitis — When to Consider Tonsillectomy

Paradise criteria (standard guidelines per Cummings Otolaryngology):

Tonsillectomy is recommended when a child has:

≥7 episodes in 1 year, OR

≥5 episodes/year for 2 consecutive years, OR

≥3 episodes/year for 3 consecutive years

Each episode must be documented with at least one of: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive strep culture. — Cummings Otolaryngology Head and Neck Surgery

Other indications for tonsillectomy:

Obstructive sleep apnoea / airway obstruction
Peritonsillar abscess (recurrent)
Suspicion of malignancy
Diphtheria carrier state
PFAPA syndrome (periodic fever, aphthous ulcers, pharyngitis, cervical adenitis)
Febrile seizures triggered by recurrent tonsillitis

5. Chronic Tonsillitis

Defined as persistent low-grade inflammation. Managed with:

Long-term low-dose antibiotics (if infections persist)
Tonsillectomy is often the definitive treatment for truly chronic/recurrent disease — Goldman-Cecil Medicine

6. Complications to Watch For

Complication	Key Features	Management
Peritonsillar abscess	Trismus (best indicator), uvula deviation, odynophagia	Needle aspiration or I&D; IV antibiotics; consider tonsillectomy
Retropharyngeal abscess	Neck stiffness, drooling, stridor	CT neck; surgical drainage; IV antibiotics
Rheumatic fever	Follows untreated GABHS	Prevented by completing antibiotic course
Post-streptococcal GN	Haematuria after GABHS	Supportive; antibiotics do NOT reliably prevent
PANDAS	Neuropsychiatric symptoms triggered by GABHS	Specialist referral

Key takeaway: Most tonsillitis is viral and requires only supportive care. Confirmed GABHS warrants a full 10-day course of penicillin. Tonsillectomy is reserved for recurrent bacterial tonsillitis meeting Paradise criteria, obstructive disease, or complications.

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