Management of Tonsillitis

Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends determining whether the infection is viral or bacterial, with antibiotics prescribed only for confirmed bacterial cases, particularly Group A Streptococcus (GAS) 1, 2, 3
Bacterial tonsillitis is characterized by sudden onset of sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 3
Viral tonsillitis typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 3
Rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus should be performed to confirm bacterial infection before initiating antibiotics 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends a single intraoperative dose of dexamethasone for pain relief in surgical cases 1, 2
First-line treatment for confirmed GAS tonsillitis is penicillin V for 10 days, with amoxicillin as an acceptable alternative 4
The standard 10-day course of antibiotics is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 4, 3

The American Academy of Family Physicians recommends watchful waiting if there have been fewer than seven episodes in the past year, fewer than five episodes per year for the past two years, or fewer than three episodes per year for the past three years 2
Tonsillectomy should be considered for recurrent tonsillitis when the episodes meet Paradise criteria, including 7 or more well-documented episodes in the preceding year, or 5 or more episodes per year for 2 consecutive years, or 3 or more episodes per year for 3 consecutive years 1, 2
All episodes should be disabling, adequately treated, and well-documented 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends against follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy 3
If symptoms persist despite appropriate antibiotic therapy, consider medication compliance issues, possibility of chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 3, 5

Initiating antibiotic therapy without confirming GAS infection through testing 3
Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 4
Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 4, 3
Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 3
Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1, 2