Tonsillitis Management Sheet

Practical step-up plan

When to continue up to 14 days

Use longer total duration up to 10–14 days when:

• symptoms improve slowly
• infection is more severe
• there is recurrent disease
• step-up to amoxiclav
• after drainage of PTA

Admit the patient if any of these are present

How to tell it has turned into an abscess

Quick note for exams

• Simple bacterial tonsillitis: oral antibiotic is enough
• Not improving: reassess, do not escalate blindly
• PTA: drainage + IV antibiotics
• Ceftriaxone alone is not enough for PTA → add metronidazole

One-line quick orders

• Uncomplicated bacterial tonsillitis: Amoxicillin (500 mg), 1×3 po, for 7 days
• If failed, still uncomplicated: Amoxiclav (875/125 mg), 1×2 po, for 7–14 days
• If PTA suspected: Admit, ENT consult, drainage, Ceftriaxone (2 g), 1×1 IV + Metronidazole (500 mg), 1×3 IV

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1. Definition

Tonsillitis = inflammation of the palatine tonsils

• Most common cause → viral (70–80%)
• Bacterial → mainly Group A Streptococcus (GAS)

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2. Clinical Classification

🔹 Acute Tonsillitis

• Duration < 14 days
• Viral vs bacterial

🔹 Recurrent Tonsillitis

• ≥ 7 episodes/year OR
• ≥ 5/year for 2 years OR
• ≥ 3/year for 3 years

🔹 Complicated Tonsillitis

• Peritonsillar abscess (PTA)
• Deep neck infection

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3. Clinical Assessment

Symptoms

• Sore throat
• Fever
• Odynophagia
• Dysphagia

Signs

• Tonsillar erythema ± exudate
• Tender cervical lymph nodes
• Fever

🎯 Centor Criteria (IMPORTANT EXAM TOOL)

Interpretation:

• 0–1 → Viral → NO antibiotics
• 2–3 → Consider test or delayed Rx
• 4 → Likely GAS → Give antibiotics

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4. Management Approach

🏥 Step 1: Decide OPD vs IPD

Think of this as 3 domains: 👉 Airway 👉 Ability to maintain intake 👉 Severity/systemic risk

✅ OPD (Outpatient Management)

You can safely treat as OPD ONLY if ALL are stable

1. Airway is safe

• No stridor
• No drooling
• No voice change (no “hot potato voice”)
• No significant tonsillar enlargement causing obstruction

👉 Meaning: airway is not threatened

2. Patient can maintain oral intake

• Able to swallow fluids and medications
• Mild–moderate odynophagia only
• No signs of dehydration

👉 Clinically:

• moist mucous membranes
• normal urine output
• not lethargic

3. Mild–moderate disease severity

• Fever but not a toxic appearance
• Stable vital signs:
  • HR < 100–110
  • BP stable
  • RR normal
• Pain controlled with oral meds

4. No complication suspected

• Bilateral tonsillar inflammation (typical)
• No asymmetry
• No uvula deviation
• No trismus

5. No high-risk host

• Immunocompetent
• No uncontrolled diabetes
• No chemotherapy / HIV advanced

6. Good follow-up reliability

• Can return if worse
• Has access to care within 24–48 hrs

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🚨 IPD (Admission Criteria – VERY IMPORTANT)

👉 You only need ONE major criterion to be admitted 🔴 1. AIRWAY COMPROMISE (MOST IMPORTANT)

Signs:

• Drooling → cannot swallow saliva
• Stridor → upper airway obstruction
• Muffled voice (“hot potato voice”)
• Severe tonsillar enlargement (“kissing tonsils”)
• Respiratory distress

👉 PathophysiologySwelling/abscess → narrowing of oropharynx → risk of sudden airway obstruction

👉 Exam pearlIf airway risk → DO NOT delay → admit immediately

🔴 2. DEHYDRATION / CANNOT SWALLOW

Clinical signs:

• Cannot take oral meds/fluids
• Dry mucosa
• Reduced urine output
• Tachycardia

👉 Reason:

• Odynophagia → ↓ intake → dehydration
• Oral antibiotics ineffective → need IV route

🔴 3. SEVERE SYSTEMIC TOXICITY / SEPSIS

Signs:

• High fever (>39°C)
• Tachycardia (>110–120)
• Hypotension
• Confusion / lethargy
• Rigors

👉 Think:

• Bacteremia
• Deep infection

🔴 4. SUSPECTED COMPLICATION (VERY HIGH-YIELD)

Peritonsillar Abscess (PTA)

• Unilateral swelling
• Trismus
• Uvula deviation
• Severe pain

Deep Neck Infection

• Neck swelling
• Neck stiffness
• Toxic appearance

👉 These require:

• Imaging
• Drainage
• IV antibiotics

🔴 5. FAILURE OF OUTPATIENT TREATMENT

• No improvement after 48–72 hours of appropriate antibiotics
• Worsening symptoms

👉 Reason:

• Wrong diagnosis
• Resistant bacteria
• Abscess formation

🔴 6. IMMUNOCOMPROMISED PATIENT

Examples:

• Diabetes mellitus (poor control)
• HIV/AIDS
• Chemotherapy
• Long-term steroids

👉 Why admit?

• Higher risk of:
  • Rapid progression
  • Atypical infection
  • Sepsis

🔴 7. DIAGNOSTIC UNCERTAINTY / NEED PROCEDURE

• Cannot differentiate cellulitis vs abscess
• Need:
  • Needle aspiration
  • CT neck

💊 Step 2: Treatment

A. Viral Tonsillitis (MOST COMMON)

❌ NO antibiotics

✅ Supportive Treatment

• Paracetamol (500 mg), 1–2 tab q6h prn po
• Ibuprofen (400 mg), tid po
• Warm saline gargle
• Hydration, rest

👉 Guideline: NICE / CDC → avoid unnecessary antibiotics

B. Bacterial Tonsillitis (GAS)

✅ First-line (Definitive Treatment)

• Penicillin V (500 mg), 1×2 po, for 10 days

OR

• Amoxicillin (500 mg), 1×3 po, for 10 days

💡 Why?

• Narrow spectrum
• Effective vs GAS
• Prevent rheumatic fever

👉 Guideline: CDC, IDSA

❌ What NOT to use

• Broad-spectrum (amoxiclav, ceftriaxone) ❌ unnecessary
• Short duration ❌ increases recurrence

But in practice, we use Amoxiclav (875/125 mg), 1×2 po, 7–14 days, if Amoxicillin (500 mg), 1×3 po, for 7 days, the result is Fail.

If Penicillin Allergy

• Clindamycin (300 mg), 1×4 po, for 10 days

OR

• Azithromycin (500 mg), 1×1 po, for 5 days

C. Not Improving After 48–72 hrs

👉 Reassess:

• Compliance?
• Viral infection?
• Infectious mononucleosis?
• Complication (PTA)?

Management:

• ❌ Do NOT escalate blindly
• ✅ Re-evaluate diagnosis

🚨 D. Complicated: Peritonsillar Abscess (PTA) Key Signs

• Trismus
• Hot potato voice
• Uvula deviation
• Unilateral swelling
• Drooling

Management

Setting: IPD + ENT consult

✅ Definitive Treatment

• Needle aspiration / incision & drainage

✅ Antibiotics

• Ceftriaxone (2 g), 1×1 IVPLUS
• Metronidazole (500 mg), 3×1 IV

Step-down:

• Amoxiclav (875/125 mg), 1×2 po, 10–14 days

❌ Exam mistake

• Antibiotics alone ❌
• No drainage ❌

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5. Investigations

Routine (NOT always needed)

• Clinical diagnosis

If needed:

• Throat swab (GAS)
• CBC (infection)
• Monospot (EBV)

If an abscess is suspected:

• Needle aspiration
• CT neck with contrast

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6. Complications

• Peritonsillar abscess
• Rheumatic fever
• Post-streptococcal glomerulonephritis
• Deep neck infection

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7. Indication for Tonsillectomy

Paradise Criteria

• ≥7 episodes/year
• ≥5/year for 2 years
• ≥3/year for 3 years

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8. Follow-up

• Review in 2–3 days if worsening
• Return immediately if:
  • breathing difficulty
  • cannot swallow
  • severe pain

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HIGH-YIELD SUMMARY

👉 Most tonsillitis = viral → supportive only 👉 GAS = Penicillin V 10 days 👉 Not improving = reassess, not escalate blindly 👉 PTA = Drain + IV antibiotics (ceftriaxone + metronidazole) 👉 Admit if airway / dehydration / complication