Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Orlando Guntinas-Lichius; Katharina Geißler; Antti A Mäkitie; Ohad Ronen; Patrick J Bradley; Alessandra Rinaldo; Robert P Takes; Alfio Ferlito

doi:10.3389/fsurg.2023.1221932

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Front Surg. 2023 Oct 10:10:1221932. doi: 10.3389/fsurg.2023.1221932. eCollection 2023.

Authors

Orlando Guntinas-Lichius¹, Katharina Geißler¹, Antti A Mäkitie², Ohad Ronen³, Patrick J Bradley⁴, Alessandra Rinaldo⁵, Robert P Takes⁶, Alfio Ferlito⁷

Affiliations

¹ Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany.
² Department of Otorhinolaryngology-Head and Neck Surgery, Research Program in Systems Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
³ Department of Otolaryngology, Head and Neck Surgery, Galilee Medical Center, Affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.
⁴ Department Otorhinolaryngology, Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham, United Kingdom.
⁵ ENT Unit, Policlinico Città di Udine, Udine, Italy.
⁶ Department of Otolaryngology, Head and Neck Surgery, Radboud University Medical Center, Nijmegen, Netherlands.
⁷ International Head and Neck Scientific Group, Padua, Italy.

Abstract

Background: There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods: A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results: The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion: It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

Keywords: outcome; pharyngitis; quality of life; sore throat; tonsillectomy; tonsillitis; tonsillotomy; treatment.

Publication types

Review