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This clinical practice guideline is for use by the Philippine Society of Otolaryngology-Head and
Neck Surgery. It covers the diagnosis and management of acute and chronic tonsillopharyngitis
and obstructive adenoidal hypertrophy in adults and children.
The objectives of the guideline are (1) to describe clinical and epidemiologic features of tonsillitis
in children and adults including socioeconomic burden of disease; (2) to enumerate current
diagnostic techniques, and (3) to describe treatment options.
This guideline is based on the Clinical Practice Guidelines of the Philippine Society of
Otolaryngology – Head and Neck Surgery (1996) on Acute and Chronic Tonsillitis. This was
updated using available articles published in the past 10 years as found in The National Library of
Medicine’s PubMed database using the keyword tonsillitis. The search was limited to English
language articles involving humans. The search yielded 161 articles which were carefully
screened for relevance to the guideline. Of these, ninety-two (92) abstracts were selected and full
text journals were obtained whenever possible. In addition, several guidelines on sore
throat/pharyngitis and indications for tonsillectomy were included. These are the: Clinical Practice
Guideline on Tonsillitis by the American Academy of Otolaryngology-Head and Neck Surgery;
Clinical Practice Guidelines on the Management of Sore Throat of the Academy of Medicine
Malaysia (2003); National Clinical Guideline on the Management of Sore Throat and Indications
for Tonsillectomy of the Scottish Intercollegiate Guidelines Network (1999); Practice Guidelines
for the Diagnosis and Management of Group A Streptococcal Pharyngitis of the Infectious
Disease Society of America (2002); Practice Guidelines on the Diagnosis and Management of
Group A Streptococcal Pharyngitis of the American Family Physician (2003); Guideline on Sore
Throat and Tonsillitis of the Finnish Medical Society Duodecim (2004). The chosen articles were
divided as follows:
Randomized controlled trial
Non-randomized controlled study
Descriptive study
Committee report
Acute Tonsillopharyngitis – 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.
The panel further deliberated on whether tonsillitis with signs but without symptoms or
conversely with symptoms but without signs should be admitted in the definition.
However, neither the situation can be reliably taken to mean proof of tonsillar
inflammation and the criteria was considered broad enough to include much of the clinical
spectrum of acute tonsillar infection. Imposing a time frame for the development of
symptoms as an additional diagnostic criterion was also considered but disregarded
since available evidence does not support a definite clinically recognizable period beyond
which acute tonsillitis can be justifiably labeled chronic or persistent in the oropharynx,
oral cavity or systemically.
Viral tonsillopharyngitis – inflammatory condition of the tonsils caused by respiratory viruses
such as adenovirus, influenza, parainfluenza, and respiratory syncitial virus. Other viral agents
include coxsackie, echoviruses, herpes simplex and Epstein Barr Virus (EBV).
Bacterial tonsillopharyngitis – inflammatory condition of the pharynx and or tonsils caused by
Group A beta-hemolytic streptococci (GABHS), Hemophilus influenza and Moraxella catarrhalis.
Streptococcal tonsillopharyngitis – inflammatory condition of the pharynx caused by caused
by Group A beta-hemolytic streptococci (strep throat). It has an incubation period of two to five
days and is most common in children 5 - 12 years of age. The risk of acute rheumatic fever
complicating untreated streptococcal pharyngitis is 1%. This is associated with complications
such as glomerulonephritis and rheumatic heart disease.
Chronic Tonsillopharyngitis – tonsillar inflammation resulting from recurrent clinically
documented attacks of acute tonsillitis occurring 4 times per year. This definition was adapted
from the textbooks of otolaryngology by Cummings and Paparella as well as Brodsky’s review.
The study by Paradise et. al. (1993) demonstrated that patient recall of the number of
sore throat episodes grossly overestimates the frequency of subsequent episodes. While
the study may be prone to maturation bias (i.e., the patients really got better with time) it
does question the validity of patients’ (or parental) recall when unverified by medical
consultation. Even medical validation is no guarantee of true tonsillitis because of the
lack of a widely accepted clinical definition among general practitioners, pediatricians and
Obstructive Tonsillar Hypertrophy – presence of enlarged tonsils enough to cause symptoms
of functional obstruction of the air and food passages such as snoring and dysphagia.
The degree of obstruction may be expressed in terms of Clinically Assessed Size (CAS)
scale in which the distance between the tonsils and the distance between the anterior
tonsillar pillars are measured while the tongue is gently depressed. The ratio between the
two is a measure of tonsillar encroachment on oropharyngeal space. While the scale
lacks clinical validity at present the panel recognized its potential for standardizing
tonsillar examination findings.
Obstructive adenoidal hypertrophy – presence of enlarged adenoids enough to cause
symptoms of chronic mouth breathing, snoring, hyponasal speech and eustachian tube
dysfunction. Hyponasal speech can be detected by a lack of change in voice nasality whether
the nose is pinched shut or not. The test words recommended are “mama”, “mana”, “nina”,
“nganga”, “mga”, “mani” and “mano”.
In an analysis of the health situation in Vietnam for children under 5 years, the World Health
Organization – Regional Office for the Western Pacific (2005) cited the incidence of acute
pharyngitis and acute tonsillitis as 251.39 rate per 100,000 population (0.25%) in 2002 and was
ranked as 2 leading cause of morbidity.
It is estimated that approximately 50% of cases of acute pharyngotonsillitis have a viral etiology.
In 15 – 20% of cases, a primary bacterial pathogen, most commonly a streptococcal organism is
recovered (Discolo 2003). Epidemiological data from western countries, in general, as specifically
GABHS infections, both community and hospital based are more readily available. However,
there is considerable variation in the prevalence of GABHS sore throats from one country to
another. In Dhaka, Bangladesh, 22% of 601 children studied had a positive culture but only 2.2%
was due to GABHS (Faruq 1995). In Israel, the prevalence is 15% among 152 symptomatic
children aged 3 months to 5 years of age (Amir 1994). In the Italian –French study, 26% of 865
children from 5 months to 14 years had GABHS pharyngitis (Cauwenberge 1999). Overall, he
figure is less than 30% in most countries. In the adult population GABHS is responsible for 5-10%
of cases of acute pharyngitis (Bisno 2001).
In our local setting, the Philippine General Hospital – Out Patient Department ORL Clinic had 10
consults for Acute Tonsillitis, 4 consults for Acute Pharyngitis, and 21 consults for Acute
Tonsillopharyngitis and 76 consults for Chronic Hypertrophic Tonsils out of 13,517 patients during
the period of January to May of 2005. The prevalence rate is 7 out of 1000 patients for Acute
Tonsillitis, 3 out of 1000 patients for Acute Pharyngitis, 15 out of 1000 patients for Acute
Tonsillopharyngitis, and 56 out of 1000 patients for Chronic Hypertrophic Tonsils from January to
May of 2005 (Table 1).
Table 1-Philippine General Hospital – Out Patient Department ORL Clinic
(January to May 2005)
7 / 1000
3 / 1000
15 / 1000
56 / 1000
In the University of Perpetual Help Binan and Rizal and Sta. Rosa Polyclinic and Community
Hospital 4,080 patients with ages ranging from 1 to 18 years old, and 680 age >19 years old were
referred to the Out Patient Department of these institutions for tonsillitis in 2004. They admitted
148 patients from these for peritonsillar abscess. For the University of Sto. Tomas (UST)-Out
Patient Department, they had 3,456 consults for tonsillitis in 2004 for both pediatric and adult
patients. 85 of these patients subsequently underwent surgery.
The economic impact of tonsillitis locally is not known due to paucity of studies. Research from
other countries may provide insight into the socioeconomic impact of this condition. In the adult
population, about 6.7 million visits annually were for sore throat (Barlet 1997). In the UK, it is
estimated that visits for consultation for sore throat alone cost the NHS 60 million pounds per
annum (National Ambulatory Medical Care Survey 1989-1999).
1. The diagnosis of acute tonsillopharyngitis may be made clinically for both children
and adults. It is important to differentiate whether the infection is viral or bacterial in
Grade B Recommendation
Approximately 30 to 60% have a viral etiology (rhinovirus, adenovirus, and others) only 5 to
10% are caused by bacteria, with Group A beta-hemolytic streptococci being the most
common bacterial etiology. In Hongkong, 2.65% of those more than 14 years of age have
GABHS pharyngitis. In the US, the 1988 prevalence rates of recurrent tonsillitis was 14.9%
among white non-Hispanics, 6.5% among black non-Hispanics and 10.2% among Hispanics
(1988 National Health Survey on Child Health, US) .
There are several reasonable approaches to the diagnosis of GABHS in an otherwise healthy
adult, such as use of clinical criteria alone or use of rapid antigen testing as an adjunct to
clinical screening. Either of these strategies is associated with reasonable diagnostic
accuracy (approximate sensitivity > 70%, specificity > 70% and allows treatment decisions to
be made early in the course of illness, when patients can receive symptomatic benefit . (refer
to Table 2)
Table 2. Clinical features of acute tonsillopharyngitis
Features suggestive of bacterial etiology
Sudden onset
Sore throat /Dysphagia
Nausea, vomiting, and abdominal pain
Inflammation of pharynx and tonsils
Patchy discrete exudates
Tender, enlarged anterior cervical nodes
Patients aged 5-15 years
History of exposure
Features suggestive of viral etiology
Highlighted features are adapted from the Centor Criteria
2. The diagnosis of acute group A streptococcal infection should be suspected on
clinical grounds and may be supported by performance of a laboratory test.
Grade B Recommendation
2.1. Throat culture remains to be the gold standard for the diagnosis of streptococcal
pharyngitis with a sensitivity of 90-95%.
Grade B Recommendation
2.2. A positive rapid antigen detection test (RADT) may be considered definitive
evidence for treatment of streptococcal pharyngitis, with specificity of 95% and
sensitivity of 89.1%. These values are similar to those of throat culture which has
a 99% specificity and 83.4% sensitivity. RADT, however, is not widely available
locally and cannot be considered part of routine diagnostic assessment.
Grade C Recommendation
2.3. Either a positive throat culture or RADT provides adequate confirmation of
GABHS in the pharynx, but a negative RADT result should be confirmed with a
throat culture whenever possible.
Grade C Recommendation
2.4. 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
Consequent to the risk of complications developing from untreated GABHS
infection, early diagnosis and appropriate antimicrobial treatment is warranted.
Attempts to study the predictive value of the various signs and symptoms have
not been particularly reliable.
Grade C Recommendation
3. The diagnosis of chronic tonsillitis can be made by a history of medically documented
episodes of acute tonsillitis for at least 4 times a year.
Grade C Recommendation
There are four randomized controlled trials (RCT) on tonsillectomy versus non-surgical
intervention studies in children but no RCT in adults. Scottish Intercollegiate Guidelines
Network advised more than 5 episodes and American Academy of Otolaryngology-Head and
Neck Surgery more than 3 episodes as indication for tonsillectomy. Non-controlled studies
demonstrated reduction in number of sore throats and improved general health with
tonsillectomy. The panel concensus for this CPG is at least 4 episodes a year.
4. The diagnosis of obstructive adenoidal hypertrophy should be made on the basis of
enlarged adenoids and a persistent difficult in breathing and/or swallowing.
Grade C Recommendation
The following may be used in the diagnosis of obstructive adenoidal hypertrophy:
• Anterior rhinoscopy
• Posterior rhinoscopy
• Intraoral palpation (palpation can be done in children with and without
• Soft tissue lateral films of the nasopharynx may be used to determine the
adenoid enlargement but its low sensitivity and the need for proper radiologic
techniques is emphasized
Management includes symptomatic treatment, antibiotic therapy for GABHS pharyngitis and, if
clinically indicated, surgical treatment.
1. Symptomatic treatment is an integral part in the management of children and adults
with sore throat. This includes maintaining adequate fluid intake, warm saline gargle,
bed rest, use of analgesics and antipyretics, maintaining good oral hygiene.
Grade B Recommendation
1.1. Paracetamol or Ibuprofen is effective in treatment (in the first 48 hours) of
associated with sore throat.
Grade A Recommendation
2. Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis based on
clinical and epidemiological findings with/without supported by laboratory
Grade A Recommendation
Early antibiotic therapy will suppress rapidly infection and lower the risk of transmission within
24 hours allowing children to return to school. Untreated patients usually will improve in 3 – 5
days unless a complication develops .
The majority of the studies and guidelines mostly involved patients with acute
2.1. Penicillin is the drug of choice for the treatment of streptococcal pharyngitis. The
antibiotic has proven efficacy and safety, a narrow spectrum of activity and low
Grade A Recommendation
Amoxicillin (Pediatric dose: 50mg/kg/day in 3 divided doses, Adult dose: 250-500 mg
capsule every 8 hours) is often used in place of Penicillin V (Pediatric dose: 50-100
mg/kg/day in 3-4 divided doses, Adult dose: 1-4 g/day in 3-4 divided doses) as oral
therapy for young children, the efficacy seems equal. This choice is primarily related to
acceptance of the taste of suspension. Intramuscular Benzathine Penicillin G therapy
(Pediatric dose: 100,000 – 250,000 units/kg/day in 4-6 divided doses, Adult dose:
600,000-1.2 M units IM) is preferred for those patients unlikely to complete full 10 day
course of oral therapy.
The likelihood of bacteriologic and clinical cure of GABHS tonsillopharyngitis in
children is significantly higher after 10 days of oral cephalosporin therapy with
cephalexin, cefadroxil, cufuroxime, cefpodoxime, cefprozil, cefixime, ceftibuten,
or cefdinir than after 10 days of oral penicillin .
Grade A Recommendation
Penicillin is inexpensive, narrow in spectrum, endorsed by many treatment
guidelines as the sole agent of choice. Cephalosporins are more expensive and have a
broader spectrum of antibacterial activity. On the other hand, the acquisition cost of the
antibiotic represents a very small percentage of the total cost of management of a patient
with GABHS tonsillopharyngitis. Additional medical visits and loss of school and work
productivity represent the largest cost of treatment failure. We would advocate the
addition of cephalosporins as a treatment of choice for GABHS tonsillopharyngitis based
on our findings that these agents more often produce bacteriologic eradication and
clinical cure compared with penicillin .
2.3 Erythromycin (Pediatric dose: 30-50 mg/kg/day in 4 divided doses, Adult dose: 1-2
g/day in 4 divided doses) is a suitable alternative for patients allergic to penicillin
who manifest hypersensitivity to beta lactam antibiotics.
Grade C Recommendation
For patients allergic to Penicillin and Erythromycin-intolerant Clindamycin (Pediatric
dose: 20-30mg/kg/day in 3 or 4 divided doses, Adult dose: 150-300 mg in 3 or 4 divided
doses) is recommended as an alternate antibiotic .
2.4. Failure to resolve the infection within 3-4 days justifies shifting to augmented
penicillins, clindamycin, 3 generation cephalosporins or higher generation
macrolides. Higher generation macrolides may be used for 3-5 days.
Grade C Recommendation
3. Surgical treatment (Tonsillectomy with or without Adenoidectomy) – Tonsillectomy
may be recommended in patients with the following conditions:
3.1 Tonsillar hyperplasia accompanied by any of the following: upper airway
obstruction, dysphagia, speech impairment or halitosis
3.2 Recurrent or chronic tonsillitis - majority of the panel voted 4 episodes of
tonsillitis in a year is the indication for Tonsillectomy instead of 5 episodes (SIGN
Recommendation is 5 episodes and AAO-HNS is more than 3 episodes).
3.3 Peritonsillar abscess occurring in the background of chronic tonsillitis.
3.4 Cases with high ASO, both IgG and IgM subclasses, were considered to have an
indicative factor for tonsillectomy
Grade C Recommendation
The significance of antibody for streptolysin-O concerning tonsillectomy was studied. The
results obtained were as follows. 1. The upper limit of ASO titer in 5,121 school children
was 250 u and a value of more than 333 u was considered abnormal. But the level of the
normal limit was different from year to year. 2. Among 143 cases with a high ASO titer of
more than 833 u, only 12 cases had recurrent tonsillitis. There was no correlation
between the tonsillar hypertrophy and the height of streptococcal antibodies. 3. There
was a correlation between the titers determined by ELISA IgG-ASO and ASO in Todd
units (r = 0.69), but there was no agreement between the titers determined by ELISA
IgM-ASO and ASO in Todd units. 4. IgM-ASO determined by ELISA showed high levels
in cases with early stages of streptococcal infection, focal infection and streptococcal
Tonsillectomy resulted in yearly mean decreases in number of weeks on antibiotics by
5.9 weeks, number of workdays missed by 8.7 days, and physician visits by 5.3 visits.
Tonsillectomy results in significant improvement in quality of life, decreases health care
utilization, and diminish the economic burden of chronic tonsillitis in the adult population.
3.5 Patients with obstructive adenoidal hypertrophy may benefit from adenoidectomy.
Grade C Recommendation
3.6 New surgical modalities for tonsillectomy may be available but are not
recommended as routine procedures because of unproven effectiveness and
higher expense. These include coblation, radiofrequency and ultrasonic harmonic
Grade C Recommendation
Child or Adult with
signs and symptoms
of tonsillitis
4 or more
Supportive management
Appropriate antibiotics
Supportive management
Chronic Tonsillitis
Appropriate antibiotics
Supportive management
Consider tonsillectomy
Appropriate antibiotics
Supportive management
Revise antibiotics
1. Bisno et. al. Clinical Infectious Diseases, 2002; 35: 126-129. Diagnosis of Strep Throat in
Adults Practice Guidelines for the Diagnosis and Management of Group A Streptococcal
2. Hayes et. al, American Family Physician, Management of GABHS Pharyngitis, April 2004,
3. Snow et al, Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults, Annals of
Internal Medicine, March 2001, Vol. 134, Num.6
4. Mainous et. al, Streptococcal diagnostic testing and antibiotics prescribed for Pediatric
Tonisllopharyngitis, Pediatric Infectious Disease Journal. 15 (9) : 806-810, September 1996.
5. Catherine Olivier, Rheumatic fever is it still a problem? Journal of Antimicrobial
Chemotherapy (2000) 45, 13-21
6. Adam et. al, Comparison of short-course (5 day) cefuroxime axetil with a standard 10 day
oral penicillin V regimen in the treatment of tonsillophayngitis Journal of Antimicrobial
Chemotherapy (2000) 45, 23-30.
7. Casey, et al., Higher doses of Azithromycin are more effective in treatment of group A
streptococcal tonsillopharyngitis, Clinical Infectious Diseases June 15,49(12):1748-55 Epub
2005 May 13.
8. Clinical Practice Guidelines on Acute and Chronic Tonsillitis, Philippine Society of
Otolaryngology – Head and Neck Surgery, August 2003
9. Johansson et al, Rapid Test, throat culture and clinical assessment in the diagnosis of
tonsillitis. Family Practice; Apr 2003; 20, 2.
10. Chan et al, The Management of Severe Infectious Mononucleosis Tonsillitis and Upper
Airway Obstruction, The Journal of Laryngology and Otology. London: Dec. 2001. Vol.115,
Iss. 12; pg. 973, 5 pgs
11. Timms et al, Coblation Tonsillectomy: A double blind randomized controlled study, The
Journal of Laryngology and Otology. London: Jun 2002. Vol. 116, Iss. 6 pg. 450, 3 pgs
12. Kuo et al, Invasive candidiasis of the Tonsil, The Journal of Laryngology and Otology.
London: Dec. 1997/. Vol. 111, Iss. 12 pg 1199, 3 pgs.
13. Stoker et al, Pediatric Total Tonsillectomy using Coblation Compared to Conventional
Electrosurgery: Prospective, Controlled, Single Blind Study, Otolaryngology Head and Neck
Surgery, 2004 June; 130 (6), 666-75
14. Friedman et al., Radiofrequency Tonsil reduction: safety and morbidity and efficacy,
Laryngoscope, May 2003
15. Sanjaet al, Effectiveness of the ultrasonic harmonic scalpel for tonsillectomy, Ear, nose and
Throat Journal, Aug. 2001 Costerton, et al, The application of biofilm science to the study
and control of chronic
bacterial infections, Journal of Clinical Investigation, 112:14661477 (2003) Johansson et al, Rapid Test, throat culture and clinical
assessment in the
diagnosis of tonsillitis, Family Practice; Apr 2003; 20, 2
16. Rosen C, et al., Effect of pneumococcal vaccination on upper respiratory tract infections
in children. Design of a follow-up study, Scand J Infect Dis Suppl. 1983; 39:39-44.
17. Kline and Runge, Streptococcal Pharyngitis: a review of pathophysiology, diagnosis, and
management, J Emerg Med, 1994; 12:665-80.
18. Del Mar CB et. al, Antibiotics for sore throat,The Cochrane Database of Systematic Reviews
2005 Issue 3
19. Casey et al, Meta-analysis of Cephalosporin versus Penicillin Treatment of Group A
Streptococcal Tonsillopharyngitis in Children. Pediatrics, Evanston: Apr 2004. Vol. 113, Iss.
4; pg 866, 17 pgs.
20. Cummings et al, Otolaryngology Head and Neck Surgery, 2005.
21. Tan Kah Kee et al, Clinical Practice Guidelines, Management of Sore throat, Academy of
Medicine Malaysia,
22. Klingbeil W, et al., Therapy of acute diseases of the upper airway. Comparison of 2 antiseptic
pharyngeal sprays in otorhinolaryngologic practice, Curr Med Res Opin. 1982;8(3):188-90,
Fortschr Med. 1982 Jan 28;100(4):146-9.
23. Whiteside MW., et al. A controlled study of benzydamine oral rinse ("Difflam") in general
practice,Curr Med Res Opin. 1982;8(3):188-90.
24. Bertin et al, Randomized, double-blind, multicenter, controlled trail of Ibupropen vs
acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and
pharyngitis in children. Journal of Pediatrics 119, 811-814
25. Del Mar CB et. al, Antibiotics for sore throat, The Cochrane Database of Systematic Reviews
2005 Issue 3
26. Discolo et al, Infectious indications for tonsillectomy, Pediatr Clin N Am (2003)
27. Coyte et al, The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the
insertion of VT tubes, The new England Journal of Medicine, Vol. 344, No. 16, Apr, 2001
28. Zwart et al, British Medical Journal, May 17, 2005, Penicillin for acute sore throat in children:
Randomized, double blind trial,
29. Indications for Tonsillectomy and Adenoidectomy, Laryngoscope, Darrow and Siemens, Aug.
30. Bhattacharyya et al, Economic benefit of tonsillectomy in adults with chronic sinusitis, The
Annals of Otology, Rhinology and Laryngology, Nov 2002
31. Fujikawa et al, Streptococcal Antibody as an Indicator for Tonsillectomy, Acta Otolaryngol
Suppl. 1988; 454:286-91 (ISSN: 0365-5237)