CLINICAL PRACTICE GUIDELINES – ACUTE AND CHRONIC

TONSILLOPHARYNGITISITIS AND OBSTRUCTIVE ADENOIDAL

HYPERTROPHY AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY
SCOPE OF THE PRACTICE GUIDELINE
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.

Core Group:
Ma. Sheila Jardiolin, MD
Agnes Remulla, MD
Victoria Sarmiento,MD
Michael Sarte, MD
Cesar Villafuerte Jr. MD, MHA
Robie Zantua, MD

Research Assistant :
Corrie Aberin, MD

ACUTE AND CHRONIC TONSILLITIS

OBJECTIVESPURPOSE AND SCOPE OF THE GUIDELINE

The objectives of the guidelines 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.

TARGET POPULATION. Setting and providers of care

This clinical practice guideline is intended to be used by members of the Philippine Society of
Otolaryngology – Head and Neck Surgery and the ENT resident physicians. It covers the
diagnosis and management of tonsillitis in the pediatric and adult population.

LITERATURE SEARCH

This guideline is based on the Clinical Practice Guidelines of the Philippine Society of
Otorhinolaryngology – 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 Otorhinolaryngologygy-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:

]
Meta-analysis 24
Randomized controlled trial 17
Non-randomized controlled study 7
Descriptive study 33
Committee report 12
Guidelines 6

DEFINITIONS

1
Acute Tonsillopharyngiitisllopharyngitis – 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 pharynx and or 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).
1,22
..
IDSA, Cummings (1998)

Bacterial tonsillopharyngitis – inflammatory condition of the pharynx and or tonsils caused by

Group A beta-hemolytic streptococci (GABHS), Hemophilus influenza and Moraxella
catarrhalis.22.

Cummings (1998) and Paparella

Streptococcal tTonsillopharyngitisopharyngitis – 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 isIt is usually
associated with complications such as glomerulonephritis and rheumatic heart diseasefever.)

Fungal – characterized by white plaques on the oral-pharyngeal mucosa which reveals a

raw, bleeding surface when removed. This is caused by Candida albicans.

Chronic Tonsillopharyngiitis – 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
otolaryngologists.

Majority of the Panel voted 4 episodes of tonsillitis in a year is the indication for
Tonsillectomy instead of 5 episodes

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 “mickey mouse”, “99
bananas” , and “baseball”. mama”, “mana”, “nina”, “nganga”, “mga”, “mani” and “mano”.

PREVALENCE AND BURDEN OF ILLNESS

2
 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 2nd 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 (Ttable 1).

Tablable 1- - e 1. Philippine General Hospital – Out Patient Department ORL Clinic

(January to May 2005)

Chronic Total
Acute Acute Acute
Hypertrophic OPD
Tonsillitis Pharyngitis Tonsillopharyngitis
Tonsils consults

Consults 10 4 21 76 13,517
Prevalence 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 tTonsillitis in 2004. They admitted
148 patients from these for pPeritonsillar abscess. For the University of Sto. Tomas (UST)- Out
Patient Department, they had 3,456 consults for tTonsillitis in 2004 for both pediatric and adult
patients. And out of these 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).

RECOMMENDATIONS ON THE DIAGNOSIS OF ACUTE AND CHRONIC

TONSILLOPHARYNGITISITIS AND OBSTRUCTIVE ADENOIDAL HYPERTROPHY

1. The diagnosis of acute tonsillopharyngitisitis may be made clinically for both children
and adults. It is important to differentiate whether the infection is viral or , bacterial or
fungal in etiology.

Grade B RRecommendation

a.

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 1`4.9% among
white non-Hispanics, 6.5% among black non-Hispanics and 10.2% among Hispanics (1988
National Health Survey on Child Health, US)2.

3
 American Family Physician, April 2004, Management of GABHS Pharyngitis,
Hayes et. al

b. 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
benefit3. (refer to Table 2)
Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults, Annals of
Internal Medicine, Snow et al, March 2001, Vol. 134, Num.6

Table 21. Clinical and epidemiological features of acute tonsillopharyngitis1,16

Features suggestive of bacterial etiology

Sudden onset
Sore throat /Dysphagia
Dysphagia
Fever
Petechiae
Headache
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

Conjunctivitis
Coryza
Cough

Hoarseness
Diarrhea
Features suggestive of fungal etiology
Immunocompromised host
Patients on prolonged antimicrobial therapy
Highlight 4 Centor criteria from
Whitethe tableonabove
plaques mucosatowhich
emphasize those
bleeds easily with
when bacterial/poss.
removed GABHS
Highlighted features are adapted from the Centor CriteriaBisno et. al. Clinical
2. The diagnosis
InfectiousofDiseases,
obstructive
2002; adenoidal
35: 126-129.hypertrophy should
Diagnosis of Strep bein made
Throat Adults on the basis of enlarged
adenoidslarged tonsils and a persistent difficult in breathing and/or swallowing.
Practice Guidelines for the Diagnosis and Management of Group A Streptococcal
Grade C Recommendation
Pharyngitis. IDSA Guidelines 2002, Bisno et al
Cummings 1998
The following may be used in the diagnosis of obstructive adenoidal hypertrophy:
 Anterior rhinoscopy
 Posterior rhinoscopy
 Intraoral palpation
 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

3. The diagnosis of acute group A streptococcal infection should be suspected on

clinical grounds and may be supported by performance of a laboratory test. 1 .

2. The diagnosis of acute group A streptococcal infection should be suspected on clinical and
epidemiological grounds and may be supported by performance of a laboratory test .

Grade B Rrecommendation

Practice Guidelines for the Diagnosis and Management of Group A Streptococcal

Pharyngitis. IDSA Guidelines, Bisno et al

2.1. a. Throat culture remains to be the gold standard for the diagnosis of
streptococcal pharyngitis with a sensitivity of 90-95%. 9.

Grade B RRecommendation
Rapid Test, throat culture and clinical assessment in the diagnosis of tonsillitis.
Johansson et al, Family Practice; Apr 2003; 20, 2

4
 2.2. b. 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. 1.

Grade C RRecommendation
American Academy of Pediatrics and American Heart Association
Practice Guidelines for the Diagnosis and Management of Group A Streptococcal
Pharyngitis. IDSA Guidelines, Bisno et al

2.3. c. 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. 23.

Grade C RRecommendation
Clinical Practice Guidelines, Management of Sore throat, Academy of Medicine
Malaysia, Tan Kah Kee et al

2.4. d. 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. 8.
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. 19.

Grade C Rrecommendation
Philippine Society of Otolaryngology – Head and Neck Surgery, Clinical Practice
Guidelines Task Force on CPG. 1997

4. 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. The physical
findings may range from normal looking to enlarged tonsils

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.
Grade C Rrecommendation (panel consensus)

5. 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
Grade C Recommendation

The following may be used in the diagnosis of obstructive adenoidal hypertrophy:

 Anterior rhinoscopy
 Posterior rhinoscopy
 Intraoral palpation
 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

Consistent terminology ALL Tonsillitis not pharyngitis

RECOMMENDATIONS ON THE MANAGEMENT OF ACUTE AND CHRONIC TONSILITIS AND

OBSTRUCTIVE ADENOIDAL HYPERTROPHY

5
 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. 23,24,25

1. Management includes a1. symptomatic treatment, b2. antibiotic therapy for GABHS
pharyngitis and, if clinically indicated, 3. surgical treatment.
and, if clinically indicated, c. surgical treatment.

2. 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.
throat. This includes maintaining adequate fluid intake, warm saline gargle, bed rest, use
of analgesics and antipyretics, maintaining good oral hygiene 23,24,25.

Grade B Recommendation
Clinical Practice Guidelines, Management of Sore throat, Academy of Medicine
Malaysia, Tan Kah Kee et al.
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.
Whiteside MW., et al. A controlled study of benzydamine oral rinse ("Difflam") in
general practice,
Curr Med Res Opin. 1982;8(3):188-90.

1.1. a. Paracetamol or Ibuprofen is effective in treatment ( in the first 48 hours ) of

associated with sore throat. 26.

Grade A Recommendation

2. Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis based on
clinical and epidemiological findings and/or supported by laboratory examinations. 27

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

1. Vaccinations against pneumococcus may be used in children to prevent future

episodes of sore throat.
Grade C recommendation
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.

3. 2. Antimicrobial therapy is indicated for patients with acute bacterial tonsillitis

based on clinical and epidemiological findings and/or supported by laboratory
examinations.
and epidemiological findings and/or supported by laboratory examinations 27.
Grade A Recommendation
Del Mar CB et. al, Antibiotics for sore throat, The Cochrane Database of
Systematic Reviews 2005 Issue 3

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 develops28.

Infectious indications for tonsillectomy, Pediatr Clin N Am (2003), Discolo et

al

 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.
Streptococcal Pharyngitis: a review of pathophysiology, diagnosis, and management, J Emerg
Med Kline and Runge, 1994; 12:665-80.

6
 The majority of the studies and guidelines mostly involved patients with acute
tonsillopharyngitis.

2.1. a. Penicillin ishas been the drug of choice for the treatment of streptococcal
pharyngitis. The antibiotic has proven efficacy and safety, a narrow spectrum of
activity and low cost.

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. 30.
Grade A Recommendation
British Medical Journal, May 17, 2005, Penicillin for acute sore throat in children:
Randomized, double blind trial, Zwart et al
CHANGE TITLE TO TONSILLOPHARYNGITIS – MAINTAIN TERMS

2.2. b. First Generation Cephalosporins (first, second or third-generation) may be

used instead of penicillin but may be more expensive. 2nd Second GGeneration
Cephalosporins are as effective as 1st Geneneration Cephalosporin but may be
more expensive than both Penicillins and 1 st Generation Cephalosporin and are
therefore not recommended. 31.

Grade B Rrecommendation

2.3. 2.3. A
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.

10 day course of First Generation Cephalosporin (Cefadroxil with Pediatric dose: 25-50
mg/kg/day once daily, Adult dose: 500mg-2g once daily and Cefalexin with
Pediatric dose: 25-50 mg/kg/day in 4 divided doses, Adult dose: 4-6g/day in 4
divided doses) has been shown to be superior to penicillin in eradicating
GABHS.2. Use of these agents are often reserved for patients with relapse or
recurrence of streptococcal pharyngitis

Grade A Recommendation
American Family Physician, April 15, 2004, Management of GABHS
Pharyngitis

2.4. c. 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. wWho do not manifest hypersensitivity to bBeta 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 divide doses) is recommended as an alternate antibiotic 1.
Grade C Recommendation
Practice Guidelines for the Diagnosis and Management of Group A Streptococcal
Pharyngitis. IDSA Guidelines, Bisno et al

2.5. d. Failure to resolve the infection within 3-4 days justifies shifting to augmented
penicillins, clindamycin, 32rnd generation cephalosporins or higher generation
macrolides. Higher generation macrolides may be used for 3-5 days.

Grade C Recommendation

34. 38. Fungal Tonsillitis - Oropharyngeal candidiasis is treated routinely with

simple, oral
antifungal agents like Nystatin, more potent agents such as Amphotericin or
Fluconazole are required in the treatment of invasive or systemic disease.
Grade C Recommendation
Invasive candidiasis of the Tonsil, Kuo et al, The Journal of Laryngology and Otology.
London: Dec. 1997/. Vol. 111, Iss. 12 pg 1199, 3 pgs.

7
 4. Surgical treatment (Tonsillectomy with or without Adenoidectomy) – Tonsillectomy may
be Patients with the following conditions
recommended in patients with the following conditions:
may be offered tonsillectomy.
3.1. Grade C
3.2. AdenoTtonsillar hyperplasia with upper airway obstruction, dysphagia, speech
impairment or halitosis
3.2. Recurrent or chronic tonsillitis - (panel concensus at least 4 times a
year)majority of the pPanel 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. 31
Grade C Recommendation
Indications for Tonsillectomy and Adenoidectomy, Laryngoscope, Darrow and
Siemens, Aug. 2002

Grade C Recommendation

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 diminishesTonsillectomy results in significant improvement in quality of life,
decreases health care utilization, and diminish the economic burden of chronic tonsillitis in
the adult population. 32 .
Bhattacharyya et al, Economic benefit of tonsillectomy in adults with chronic
sinusitis, The Annals of Otology, Rhinology and Laryngology, Nov 2002

3.4. Patients with the following conditions may benefit from adenoidectomy
 Recurrent otitis media with effusion. 29.

Grade A Recommendation
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.(cite trial)
3.5. Obstructive adenoidal hypertrophy

Grade C Recommendation

3.56.
NNew 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 scalpel., carbon dioxide laser. 11,13,14,15,16.

Grade C Recommendation
The application of biofilm science to the study and control of chronic
bacterial infections, Journal of Clinical Investigation, Costerton, et al,
112:1466-1477 (2003)
Coblation Tonsillectomy: A double blind randomized controlled study,
Timms et al, The Journal of Laryngology and Otology. London: Jun 2002.
Vol. 116, Iss. 6 pg. 450, 3 pgs
Using the carbon dioxide laser for tonsillotomy in children, Linder et al, Int
J Pediatr Otorhinolaryngol. 1999 Oct 15;50(1):31-6
Effectiveness of the ultrasonic harmonic scalpel for tonsillectomy, Ear,
nose and Throat Journal, Sanjai et al, Aug. 2001
Radiofrequency Tonsil reduction: safety and morbidity and efficacy,
Laryngoscope, Friedman et al., May 2003

4. Vaccinations against pneumococcus may be used in children to prevent future

episodes of sore throat. 18.

Grade C recommendation
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.

Review of vaccination record of children is warranted.d.

8
The validity of this CPG is 2 years only and should not be considered valid beyond
the end of 2008, and new evidence at any time could invalidate these
recommendations.

9
 Child or Adult with
signs and symptoms
of tonsillitis

No No
4 or more Acute
times a Bacterial Supportive management
Tonsillitis ?
year?

Yes
Yes No
Appropriate antibiotics
GABHS? Supportive management
Chronic Tonsillitis
Yes

Appropriate antibiotics
Supportive management

Appropriate antibiotics No
Supportive management Throat Confirms
Consider tonsillectomy Resolution Swab GABHS?
?
Yes Yes

Revise antibiotics
Consider Tonsillectomy
No

Resolution?

Yes

Consider Tonsillectomy

10
 ReferencesBIBLIOGRAPHY

1. 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
Pharyngitis
2. Hayes et. al, American Family Physician, April 2004, Management of GABHS Pharyngitis, April 2004, Hayes et. al
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, Pediatric Infectious Disease Journal. 15 (9) : 806-810, September 1996. Mainous et. al
Streptococcal diagnostic testing and antibiotics prescribed for Pediatric Tonisllopharyngitis, . Pediatric Infectious
Disease Journal. 15 (9) : 806-810, September 1996.
5. Catherine OlivierJournal of Antimicrobial Chemotherapy (2000) 45, 13-21, Rheumatic fever is it still a problem?
Journal of Antimicrobial Chemotherapy (2000) 45, 13-21 Catherine Olivier
6. Adam et. al, Journal of Antimicrobial Chemotherapy (2000) 45, 23-30, 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. Adam et. al
7. Casey, et al., Clinical Infectious Diseases June 15,49(12):1748-55 Epub 2005 May 13, 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.Casey, et al.
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. Johansson et al,
Family Practice; Apr 2003; 20, 2.
10. Chan et al, The Management of Severe Infectious Mononucleosis Tonsillitis and Upper Airway Obstruction, Chan et
al, The Journal of Laryngology and Otology. London: Dec. 2001. Vol.115, Iss. 12; pg. 973, 5 pgs
11. Timms et al, 9. Coblation Tonsillectomy: A double blind randomized controlled study, Timms et al, The Journal
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