Approach

It is important to establish whether the patient has acute tonsillitis and not another, potentially dangerous, cause of sore throat (such as retropharyngeal abscess or acute epiglottitis), or if the patient might have a comorbidity (such as HIV infection or infectious mononucleosis). It is also important to decide if the patient's overall condition or any comorbidity warrants further testing and/or antibiotics. In patients with difficulty breathing, complete dysphagia, or inability to manage their secretions, hospital admission for intravenous hydration, analgesia, and antibiotics as well as further imaging and visualization of the airway may be indicated.

In vulnerable people (e.g., infants, very old, immunosuppressed, or immunocompromised patients), tonsillitis may be more severe. Antibiotics and/or admission to the hospital for a limited period of time may be advisable due to the increased risk of serious infection and complications, especially if the presenting symptoms are severe.

Analgesics

In most cases, acute tonsillitis is a viral, self-limited condition that requires only analgesic treatment.

  • Acetaminophen can be used for symptom relief.

  • Nonsteroidal anti-inflammatory drugs, including aspirin, are another option.[24][25] However, aspirin should not be used in children (under ages 16 years in the UK; age cutoffs may vary in other countries) due to concerns about Reye syndrome.[26]

  • Patients at home can also use local medications for the relief of their sore throat. These include topical lidocaine or other analgesic or mild antiseptic lozenges, oral sprays, gels, and mouthwashes (e.g., warm salt water). Although there is no evidence that these can reduce the duration of their sore throat, there is some limited evidence that they provide symptomatic relief in some patients.[27][28]

Use of antibiotics

There is debate about the use of antibiotics in the treatment of the 5% to 15% of adults and 15% to 30% of children with tonsillitis who have group A beta-hemolytic streptococcal (GABHS) infection. The arguments in favor of the use of antibiotics are that they could potentially:[29]

  • Reduce the duration and severity of symptoms

  • Prevent suppurative and nonsuppurative complications

  • Reduce transmission of infection.

Antibiotics have been found to confer relative benefits in the treatment of sore throat compared with placebo, but the absolute benefits are modest.[29] A Cochrane review found that the use of antibiotics results in reduction of the duration of symptoms by about 16 hours by the first week, with the number of people with sore throat who must be treated by day 3 (number needed to treat [NNT]) being 3.7 for those with positive throat swabs for Streptococcus.[30] Given that there is a potential indication for antibiotics in cases of GABHS tonsillitis but none in viral tonsillitis, antibiotics should be limited to those with confirmed GABHS tonsillitis. In patients with thus confirmed GABHS tonsillitis, the use of antibiotics would be potentially justified, taking into account that if they are not initiated early their efficacy is lessened in terms of symptom reduction, and, beyond 9 days of symptom onset, for rheumatic fever prevention.[29]

The use of antibiotics at the first instance and without the need for any testing is indicated in patients who are critically ill or who are from vulnerable populations in which susceptibility to acute rheumatic fever is high (e.g., in South Africa, Australian indigenous communities, Maori communities of New Zealand, the Philippines, and in many developing countries).[13]

A Centor score ≥3 may be a decision rule for considering antibiotics, but these should be used with caution in low prevalence setting of GABHS pharyngitis, such as primary care as individual signs and symptoms are not powerful enough to discriminate GABHS pharyngitis from other types of sore throat where the addition of rapid streptococcal antigen test and/or throat can be helpful.[12] A Cochrane review examining prescription of antibiotics for people with a sore throat in an ambulatory care setting found that rapid testing to guide antibiotic treatment for sore throat in primary care can potentially reduce antibiotic prescription rates by 25%.[21]

Many patients do not respond to penicillin, this is due to many reasons:

  • Nonadherence

  • Re-infection

  • Presence of beta-lactamase aerobic and anaerobic bacteria that "protect" GABHS from penicillin

  • The absence of interfering (i.e., antagonistic) organisms.

Choice of antibiotic

Considering complication rate, cost, resistance, and insufficient evidence for clinically meaningful differences between antibiotics for GABHS tonsillitis, penicillin is still recommended as first choice, especially in high-income countries.[18][31][32] There is a need for more evidence in low-income and Aboriginal communities, where risk of complications is high.[33] Penicillin V orally for 10 days is a preferred option.[13][33] For patients who are unable to complete a 10-day oral course, a single intramuscular dose of penicillin G benzathine can be given.[31] One study has shown that oral penicillin V for five days can be a valid alternative to the 10-day regimen.[34] One randomized controlled trial (RCT) of 146 children who had suppurative tonsillitis found that amoxicillin/clavulanate led to a quicker improvement of symptoms than ceftezole (a first-generation cephalosporin that is available only in Asia).[35] 

For patients who are allergic to penicillins, a macrolide (e.g., erythromycin, azithromycin, clarithromycin), a cephalosporin (e.g., cephalexin, cefadroxil), or clindamycin are suitable alternatives.[36] Due to potential cross-reactivity between penicillins and cephalosporins, patients with a penicillin allergy may rarely have a reaction to a cephalosporin and caution is advised. However, this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[37]

There is some evidence that a shorter course of antibiotics (3-6 days of an oral antibiotic) may be equally effective in children when compared with the standard duration 10‐day course of oral penicillin.[30] However, short courses are not advocated in populations with a high incidence of rheumatic fever and individuals with recurrent episodes.[30]

One systematic review of antibiotics for recurrent acute pharyngo-tonsillitis (RAPT) found evidence that clindamycin and amoxicillin/clavulanate are superior to penicillin in patients with RAPT, with preferable effects on the microbiologic flora and the number of future attacks of acute pharyngo-tonsillitis.[38]

Corticosteroids

In patients with sore throat, a single dose of corticosteroid has been shown to reduce symptoms earlier than placebo.[39][40][41] [ Cochrane Clinical Answers logo ] [42][Evidence B] In practice this is indicated in adults and children over 12 years of age with severe symptoms who are not immunocompromised or have infectious mononucleosis.[39] The use of corticosteroids at the onset of fever in patients with periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome has proved effective in several series and case reports and in one RCT.[43] 

Tonsillectomy

Tonsillectomy may be considered for patients who have recurrent symptoms of tonsillitis that do not become less common with time and for whom there is no other explanation for the recurrent symptoms.[3] In its guideline for children ages 1-18 years, the American Academy of Otolaryngology-Head and Neck Surgery recommends watchful waiting for recurrent throat infection if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past 2 years, or under three episodes per year in the past 3 years.[44] In children, tonsillectomy can reduce days and number of episodes of sore throat in the first year.[45] More benefit was reported in those children who were more severely affected.[46] Tonsillectomy in children is also associated with significant improvements in quality of life compared with watchful waiting.[47] Tonsillectomy is also indicated in children with additional exacerbating factors such as obstructive sleep apnea; peritonsillar abscess; and PFAPA syndrome.[43][44][48] Partial tonsillectomy seems to have similar efficacy with less postoperative pain and bleeding.[49] However, more data are needed to establish which patients benefit the most from this procedure.[50][51][Figure caption and citation for the preceding image starts]: Right-sided peritonsillar abscessFrom the collection of Dr Eleftherios Margaritis [Citation ends].com.bmj.content.model.Caption@4352c4da

Use of this content is subject to our disclaimer