Recurrent Tonsillitis and Pharyngitis
In childhood, significant tonsillar disease manifests commonly as either obstructive sleep apnea (not discussed here) or recurrent acute tonsillitis. Children are considered to have an episode of significant tonsillitis if they satisfy at least one of the following criteria: (1) an oral temperature of at least 38.3°C; (2) cervical lymphadenopathy (enlarged by > 2 cm or tender cervical nodes); (3) tonsillar or pharyngeal exudate; and (4) a positive culture for group A β-hemolytic streptococcus. Conventionally, tonsillectomy is indicated if there have been seven or more documented episodes in the preceding year, five or more in each of the 2 preceding years, or three or more in each of the preceding 3 years.16 The other indication for tonsillectomy is obstructive sleep apnea. One study has suggested tonsillectomy is a cost-effective strategy for treating obstructive sleep apnea,17 but in a randomized, controlled trial the risks of surgery were thought to outweigh any benefits.18 Furthermore, about two thirds of operations are performed for less stringent and thus even less evidence-based criteria.19 Usually no other investigations are performed for isolated recurrent tonsillitis in the absence of features listed in Boxes 2 and 3, but there is no good-quality evidence to inform the decision making about the need for further investigation.
Recommendations
Isolated recurrent tonsillitis and pharyngitis do not require further investigation in the absence of any other worrying features (see Boxes 2 and 3). Level of evidence: low.
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