Bacterial Tonsillitis: Medical Treatment Versus Surgical Treatment 2026

The pathological process known as acute tonsillitis is characterized by inflammation of the palatine tonsils. The tonsils are part of Waldeyer's ring, a set of lymphocytic conglomerates at the entrance to the aerodigestive tract that include the adenoids or "vegetations", the lingual tonsil and the lymphoid tissue that surrounds the Eustachian tube.

Waldeyer's ring is in turn part of a higher order structure known as MALT, which can be translated as “mucosal-associated lymphoid tissue.” Other components of MALT include Peyer's patches in the digestive tract, lymphoid tissue associated with the nasal passage and the bronchial respiratory tree, among others.

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All of them are capable of producing 5 grams of defensive molecules known as immunoglobulins, especially immunoglobulin A, which constitute the main defense mechanism of the body's mucous membranes in response to food antigens, microorganisms or other particles inhaled or ingested daily.

Children with acute bacterial tonsillitis are characterized by the sudden onset of fever, sore throat, difficulty swallowing (dysphagia), painful swallowing (odynophagia), and swollen cervical lymph nodes. Complications of acute bacterial tonsillitis include abscesses (periatonsillar, retropharyngeal, or parapharyngeal), scarlet fever, acute glomerulonephritis, fever rheumatic disease and streptococcal toxic shock syndrome, which can sometimes be fatal.

How is it cured?

The diagnosis of GABHS infection is usually clinical, although the sensitivity of being guided only by symptoms is not very high and can sometimes lead us to confuse a viral process with a bacterial infection. The rapid streptococcal antigen test (“streptotest”) and, especially, the culture of a tonsillar smear constitute the gold standard for the diagnosis of GABHS, although its cost and lack of accessibility means that it is not always possible to perform them.

GABHS infection is subsidiary to treatment with antibiotics to prevent the appearance of complications, to improve clinical signs and symptoms, to reduce transmission to close contacts and to minimize the potential adverse effects of inappropriate use of antimicrobial therapies, especially the appearance of resistance to conventional antibiotics. The administration over a period of 10 days of oral penicillin is the antibiotic treatment of choice due to its safety, efficacy, limited antibiotic spectrum and low economic cost.

Other treatments with proven therapeutic success include amoxicillin with or without clavulanic acid, cephalosporins, macrolides, clindamycin, vancomycin and rifampicin. Most cases of acute tonsillitis are self-limited and improve in 3-4 days, therefore, most guidelines advise a "watched waiting" period of 72 hours before deciding to prescribe an antibiotic without reduce the risk of complications.

During this period, pain relievers and anti-inflammatories can be used, as well as natural treatments that include echinacea, arnica montana or belladonna. Gargling with warm water and salt has been shown to be effective, although it is not easily performed by children under 4 years of age.

For years, the indications for tonsillectomy, the surgical procedure to remove the tonsils, included situations as diverse as nighttime enuresis, low weight or mental retardation, and in the United States more than one million interventions were performed annually in the 1950s. This led to considerable rejection in public opinion and in the medical class.

Currently, children with recurrent GABHS infections with more than 7 episodes in 1 year, 5 in two consecutive years or 3 in three consecutive years are candidates for this intervention. The intervention is performed under general anesthesia using various techniques (radiofrequency, CO2 laser, ultrasound, etc.).

The postoperative period shows a high morbidity characterized by the appearance of pain, difficulty in feeding and the appearance of bleeding in a global percentage of 1-4%. The influence of surgery on the child's immune system is residual as the publication of meta-analysis in the last year has shown, however, the surgical option should be reserved for cases where the child's quality of life is compromised.

Dr. F. Javier Hernández Calvín is Associate Professor of Medicine at the European University and Head of the Pediatric ENT Unit. Otorhinolaryngology Service of the Quirón-Madrid University Hospital.