The decision to perform a tonsillectomy in a child with recurrent streptococcal pharyngitis should be based on several factors, including the frequency and severity of episodes, the impact on the child's quality of life, and the response to antibiotic therapy.
Frequency and severity of episodes
- According to the AAFP 2023 guidelines, watchful waiting is recommended over tonsillectomy in patients with recurrent tonsillitis who have had fewer than 7 episodes in the past year, fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years
- The IDSA 2012 guidelines also recommend against performing tonsillectomy solely to reduce the frequency of streptococcal pharyngitis episodes
Impact on quality of life
- The impact on the child's quality of life, such as significant school absences, difficulty swallowing, or sleep disturbances due to tonsillar hypertrophy, should also be considered.
Response to antibiotic therapy
- The IDSA 2012 guidelines recommend initiating appropriate antibiotic therapy, such as penicillin or amoxicillin, at a dose likely to eradicate the organism from the pharynx, usually for 10 days
- For penicillin-allergic patients, alternative regimens include a first-generation cephalosporin (if not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days
Chronic group A streptococcal carriers
- It is important to distinguish between recurrent streptococcal pharyngitis and chronic carriage of group A streptococcus. The IDSA 2012 guidelines recommend not attempting to identify or administer antimicrobial therapy in patients with asymptomatic group A streptococcus carriage, as they are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or non-suppurative complications, such as acute rheumatic fever
In conclusion, tonsillectomy should be considered for a child with recurrent streptococcal pharyngitis when the frequency and severity of episodes are high, the impact on the child's quality of life is significant, and the response to antibiotic therapy is inadequate. However, it is crucial to ensure that the episodes are due to streptococcal infection and not viral pharyngitis or other causes.