Tonsillitis is a common disease of childhood and adolescence. The diagnosis of tonsillitis generally requires the consideration of Group A beta-hemolytic Streptococcus (GABHS) infection. However, numerous other bacteria alone or in combinations, viruses and other infections and non-infectious causes should be considered. Recognition of the cause and choice of appropriate therapy are of utmost importance in assuring rapid recovery and preventing complications.

Penicillin is currently the first-choice treatment for GABHS pharyngotonsillitis. However, the growing failure of penicillin to eradicate GABHS is of concern. This website discusses the potential causes of penicillin failure ( i.e. the presence of beta-lactamse producing bacteria that can “protect” GABHS from penicillins) and methods to overcome them. It also discusses the role of anaerobic bacteria in tonsillitis and its complications.

Tonsillectomy in Children

Tonsillectomy is commonly performed in children. Its frequency varies in different regions and countries. The number of tonsillectomies in the US has decreased progressively in the past 40 years and the decline mainly involved tonsillectomies undertaken for infectious indications, while those done for obstructive indications increased. (1,2) It is estimated that about half a million tonsillectomies are annually performed in children < 15 years of age. (3)
The indications for tonsillectomy and adenoidectomy are classified as obligatory (absolute) or elective (conditional). This depends on the type and severity of the indication.
 Absolute indications are:
  • Obstruction of the nasopharyngeal or oropharyngeal airways by adenoids, tonsils, or both
  • Malignancy or suspicion of tonsil malignancy
  • Uncontrollable bleeding from tonsillar blood vessels

Conditional indications are:
  • Chronic tonsillitis resistant  to antimicrobial therapies
  • Recurrent acute tonsillitis
  • Recurrent peritonsillar or peritonsillar abscess in with a history of recurrent throat infection
  • Tonsillar obstruction that changes the voice quality.
  • Chronic carriage of group A beta-hemolytic Streptococci in those living in a household with frequent GABHS infection resistant to prevention or those in close contact with an individual with rheumatic fever
  • Persons with the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA syndrome) that is not responsive to conservative therapy
  • Refractory Halitosis (bad breathe)


The majority of medical issues related to the tonsils generally decline as children grow. An individual risk benefit assessment regarding the need and utility of performing tonsillectomy as compared to other approaches ( i. e. antimicrobial therapy or watchful waiting) is advisable.

 Assessment of the severity recurrent throat infection is important prior to deciding if tonsillectomy is advisable. The factors that should be considered include the frequency, clinical features, treatment, and documentations of the episodes.(4)

Several studies evaluated the efficacy of tonsillectomy in preventing recurrent tonsillar infection in severely or moderately affected children.(5,6)

The American Academy of Otolaryngology-Head Neck Surgery recently published guideline generated by panel of experts in that stat the indications for tonsillectomy in children. (7) The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature>38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus. These patients qualify as severly affected by the recurrent infection.

The panel also made recommendations for:

 (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years;
(2) assessing the child with recurrent throat infection who does not meet criteria in statement 1  for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess;
 (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems;
(4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing;
(5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management;
 (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and
(7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

Excised tonsils

Some experts suggest tonsillectomy for children with recurrent throat infection who are severely affected ( with at least one of these in each episode: Oral temperature ≥101ºF (38.3ºC), enlarged (>2 cm) or tender anterior cervical lymph nodes, tonsillar exudates, and presence of GABHS)

Studies indicate that children who are mildly or moderately affected (6) have only modest benefits from tonsillectomy and these benefits are outweighed by the potential risks. Evidence suggests that episodes of recurrent infection in children with mild or moderate recurrent throat infection should be treated with symptomatic care and antimicrobial treatment.

Operating room

Complications of tonsillectomy

Tonsillectomy requires general anesthesia and therefore have the risk of variety of complications, some of which are potentially lethal. The incidence of complications depends on the surgical technique used and occurs in 8% and 14%. (6) Complications included bleeding; adverse effects of anesthesia; infection (i.e. pharyngitis, otitis media, bronchitis), severe nausea, and severe or protracted dysphagia. Mortality rate after tonsillectomy was 1 in 12,000, in a recent study and was mostly due to hemorrhage and airway obstruction. (8)