UP-PGH DEPARTMENT OF OTORHINOLARYNGOLOGY CLINICAL PRACTICE GUIDELINES

ACUTE AND CHRONIC TONSILLITIS IN CHILDREN

SCOPE OF THE PRACTICE GUIDELINE
This clinical practice guideline is for use by the Department of Otorhinolaryngology of the
Philippine General Hospital. It covers the diagnosis and management of tonsillitis in otherwise
healthy children, older than 1 year of age.
OBJECTIVES
The objectives of the guideline are: (1) to heighten the recognition of tonsillitis, particularly due to
Group A Beta-hemolytic Streptococcus, to avoid delay and serious sequelae; (2) to evaluate
current diagnostic techniques; and (3) to describe treatment options.
LITERATURE SEARCH
This guideline is based on the 1997 Clinical Practice Guidelines of the Philippine Society of
Otorhinolaryngology Head and Neck Surgery and revised according to new evidence. The
National Library of Medicines PubMed database was searched for literature using the keyword
tonsillitis. The search was limited to articles involving humans and those published in English in
the last ten years. It yielded 919 articles, the titles of which were carefully screened for possible
relevance to the guideline. Thirty-seven (37) abstracts were chosen and results were
synthesized. Full text articles were obtained when possible. In addition, several current guidelines
on sore throat / pharyngitis and indications for tonsillectomy were included after evaluation of the
references on which they were based. The chosen articles were divided as follows:
Meta-analysis
6
Randomized controlled trial
8
Non-randomized controlled study
3
Descriptive study
15
Committee report
5
DEFINITION
Acute tonsillitis is defined as the presence of erythematous and/or exudative tonsils with any
one of the following symptoms: sore throat, dysphagia, odynophagia, fever and accompanying
tender enlarged cervical lymph nodes.8
Chronic tonsillitis is defined as tonsillar inflammation resulting from recurrent clinically
documented acute attacks of tonsillitis occurring at least 5 times per year.8
These definitions were adapted from the 1997 CPG of the PSO-HNS. However, the frequency
was increased from 3-4 times a year to at least 5 times a year based on a study by Paradise 25
which indicated that present guidelines for tonsillectomy are not sufficiently stringent. These
patients are usually candidates for surgery, but the modest benefit offered by tonsillectomy to
these moderately affected patients is outweighed by the risks and cost of the operation.25
PREVALENCE
The major issue in most cases of acute tonsillitis is whether it is associated with Group A Betahemolytic Streptococci (GABHS) or to other self-limited etiologies of sore throat, such as a viral
infection. Only about 20% of cases of pharyngitis and tonsillitis are caused by GABHS, but its
associated risks of subsequent acute rheumatic fever and/or acute glomerulonephritis remain a
cause for concern.24 The incidence of rheumatic fever remains high at 100-200 cases per
100,000 children in developing countries in contrast with the 0.5 cases per 100,000 children in
industrialized countries.
The risk of developing rheumatic fever following untreated
tonsillopharyngitis is 1% in the civilian population. 3
In 2002, there were _______cases of acute tonsillitis and ______ cases of chronic tonsillitis seen
at the ORL outpatient clinic of the Philippine General Hospital. ______tonsillectomies were
performed during the same time period. At the Department of Pediatrics, there were 178 patients
with rheumatic fever and 608 patients with rheumatic heart disease for the year 2002. 1

RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE AND CHRONIC TONSILLITIS

1. The diagnosis of acute tonsillitis may be made clinically.
Grade B Recommendation
The symptoms include sore throat (usually lasting more than three days), dysphagia,
odynophagia, anorexia, lethargy and systemic illness. Abnormal physical signs are
erythematous tonsils or pharynx, purulent exudates on tonsils, fever and tender cervical
lymphadenopathy.14, 15, 20, 21
History must ensure whether the above symptom complex occurs at least five times in a
year to determine whether the patient has acute or chronic tonsillitis.
2. The diagnosis of GABHS tonsillitis should be suspected on clinical and
epidemiological grounds.
Grade B Recommendation
The signs and symptoms of both bacterial and viral infection overlap broadly, but the
diagnosis of GABHS infection should be suspected based on epidemiologic and clinical
characteristics.3, 21 Epidemiological features suggestive of GABHS are (1) age 5-15
years; (2) recent close contact with a documented case; and (3) known high prevalence
of GABHS in the community. Pertinent clinical findings include sudden onset sore throat,
odynophagia, dysphagia, fever, vomiting, pharyngeal exudates, scarlatiniform rash and
tender anterior cervical lymphadenopathy. Watery eyes, rhinitis, cough and hoarseness
are negative predictors.
In the United States, where rheumatic fever and rheumatic heart disease are still
reported, clinical diagnosis is still valuable. The Scottish Intercollegiate Guideline Network
does not find the diagnosis of GABHS based on clinical grounds valid or useful, but this
may be due to the rarity of the complications. 20
3. Laboratory testing is recommended for patients who are suspected to have
GABHS infection based on clinical and epidemiological grounds. Positive throat
cultures and rapid antigen tests will confirm GABHS infection.
Grade C Recommendation
.
There is controversy regarding the use of throat culture and rapid antigen tests in the
diagnosis of GABHS infection. Studies from the United Kingdom20 show that these tests
are neither sensitive nor specific for serologically confirmed infection. They considerably
increase costs and alter few management decisions.20 On the other hand, studies from
the United States21 demonstrate that throat culture is still the gold standard for
confirmation of the diagnosis of GABHS pharyngitis, with a sensitivity of 90% to 95%.
Rapid antigen tests have more then 95% specificity, but only 80% to 90% sensitivity
when compared to culture.21 However, the value of early diagnosis in the minority of
cases when streptococcus is present should be weighed against the higher cost incurred
in testing the majority of cases seen. Selective use of diagnostic studies is suggested.

RECOMMENDATIONS ON THE MANAGEMENT OF ACUTE AND CHRONIC TONSILLITIS

1. Antimicrobial therapy is reserved for symptomatic patients with positive throat
cultures or positive rapid antigen testing.
Grade B Recommendation
The benefits from antibiotic therapy include early resolution of symptoms (if due to
bacterial pathogens) and prevention of cross-infection, rheumatic fever and
glomerulonephritis. However, not all cases of tonsillitis will require the use of antibiotics,
as in self-limiting viral infections. Antibiotics must be used rationally to preserve the
normal flora in the aerodigestive tract, prevent development of resistance in pathogenic
organisms and decrease treatment costs. 2, 21
Several strategies may be employed which strike a balance between overuse and
unreasonable withholding of antibiotics. One may opt not to treat patients unlikely to have
GABHS pharyngitis and treat only those strongly suspected of having GABHS wherein
the diagnosis must be confirmed with laboratory tests. Antibiotics may be started while
awaiting results, but discontinued if results are negative.
2. Penicillin is the drug of choice for compliant patients with GABHS infection.
Grade A Recommendation
Patients with acute GABHS tonsillitis should receive therapy with an antimicrobial agent
in a dosage and for a duration that is likely to eradicate the organism from the pharynx.
Penicillin has a narrow spectrum of activity which includes GABHS, has infrequent
adverse reactions and is not costly. 21 Its bacteriological eradication rate ranges from
84% to 92%, with a clinical cure rate of 96%. 23, 36 However, it is given two to four times a
day for ten days. 19 Alternative antibiotics with less side effects, infrequent dosing,
palatable and efficacious with short-course therapy lead to better outcomes due to good
compliance. Amoxicillin has been shown to be as effective as penicillin, with the
advantage of better palatability. 21 Its bacteriological eradication rate is 86%, with aclinical
cure of 97%.16 Cefuroxime, azithromycin and clarithromycin has been shown to have
bacterial (86%, 98%, 88%) and clinical (95%, unknown, 98%) cure rates comparable with
penicillin.16, 23, 31, 36 Erythromycin, which has been the drug of choice for patients with
penicillin allergy, has a lower bacterial eradication rate of 74% . 5, 21
3. Supportive therapy is recommended for all patients with tonsillitis.
Grade C Recommendation
Adequate supportive care should be part of the routine management of acute tonsillitis.
For those with viral infection, this may be all that is necessary. These include sufficient
fluid intake, bed rest, warm saline gargle and oral hygiene. The use of antipyretics for
fever as well as analgesics, oral anesthetics and antiseptics for patients with marked
throat pain may be recommended.
These are recommendations from the 1997 PSO-HNS CPG, based on strong panel
consensus and expert opinion. They are further supported by similar recommendations
from other guidelines.

4. The absolute indications for tonsillectomy are the following:

4.1 Adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive or
abnormal dentofacial growth
4.2 Suspicion of malignancy
4.3 Hemorrhagic tonsils
Grade C Recommendation
5. The relative indications for tonsillectomy are the following:
5.1 Adenotonsillar hyperplasia with upper airway obstruction, dysphagia, speech
impairment or halitosis
5.2 Recurrent or chronic tonsillitis
5.3 Peritonsillar abscess
5.4 Streptococcal carriage
Grade C Recommendation
6. Patients with recurrent or chronic tonsillitis who meet all of the following criteria
are recommended for surgery:
6.1 Sore throats are due to tonsillitis.
6.2 Five or more episodes of tonsillitis per year
6.3 Symptoms for at least a year
6.4 Episodes of sore throat are disabling and prevent normal functioning.
Grade A Recommendation
The literature on surgery for tonsillitis is scanty; and results of the better-quality studies
contradict each other. Most articles refer to a pediatric population and confuse the issue
with the addition of adenoidectomy. Present guidelines from the American Academy of
Otolaryngology require a minimum of 3 episodes of tonsillitis in a year before surgery is
contemplated. However, Paradise found that this criterion is not stringent enough and
that the modest benefit offered by tonsillectomy to these moderately affected patients are
outweighed by the risks and cost of the operation. 25 The small amount of literature about
tonsillitis in adults suggests that tonsillectomy may be beneficial in terms of decreasing
time off from work and minimizing costs from repeated consults and use of antibiotics.

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