A clinical approach to tonsillitis, tonsillar hypertrophy, and peritonsillar and retropharyngeal abscesses

On the basis of strong research evidence (level A), children older than 3 years with sore throat in the absence of viral symptoms should be tested for group A Streptococcus (GAS) pharyngitis. • On the basis of strong research evidence (level A), oral or intramuscular penicillin and amoxicillin are first-line treatments for GAS pharyngitis. • On the basis of research evidence (level B), first-generation cephalosporins, macrolides, or clindamycin are acceptable alternatives for penicillin-allergic patients. • On the basis of research evidence (level B), asymptomatic carriers of GAS should not be treated with antibiotic therapy. • On the basis of limited evidence (level C), diagnosis of peritonsillar abscesses can usually be made based on clinical suspicion and laboratory testing/imaging are often unnecessary. • On the basis of research evidence (level C), imaging for retropharyngeal abscess should be reserved only when the diagnosis is in question, when operative management is required, or when there is lack of improvement after 48 to 72 hours of intravenous antibiotic therapy. On the basis of expert opinion (level D), decision to proceed with tonsillectomy and adenoidectomy (T&A) should be made jointly between the physician and patient family after counseling them about the risks, benefits, and consideration of individual preferences. Cases that do not meet the criteria for T&A (severe recurrent throat infections, moderate throat infection with modifying factors, sleepdisordered breathing with comorbid conditions and/or abnormal polysomnography) should be managed by watchful waiting.