# Recurrent tonsillitis - when to refer for tonsillectomy - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: Tonsillitis - StatPearls (NCBI Bookshelf NBK544342) - https://www.ncbi.nlm.nih.gov/books/NBK544342/ · Tonsillectomy - StatPearls (NCBI Bookshelf NBK536942) - https://www.ncbi.nlm.nih.gov/books/NBK536942/ · Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-full.txt) · Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-clinical.txt) - Verified date: 2026-08 ## Verified against - Tonsillitis - StatPearls (NCBI Bookshelf NBK544342) - https://www.ncbi.nlm.nih.gov/books/NBK544342/ - Tonsillectomy - StatPearls (NCBI Bookshelf NBK536942) - https://www.ncbi.nlm.nih.gov/books/NBK536942/ - Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-full.txt) - Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-clinical.txt) ## Treatment metadata - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text RECURRENT TONSILLITIS - WHEN TO REFER FOR TONSILLECTOMY Sources: Tonsillitis - StatPearls (NCBI Bookshelf NBK544342) - https://www.ncbi.nlm.nih.gov/books/NBK544342/ · Tonsillectomy - StatPearls (NCBI Bookshelf NBK536942) - https://www.ncbi.nlm.nih.gov/books/NBK536942/ · Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-full.txt) · Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral-clinical.txt) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Onset is sudden, with a sore throat, fever, painful swallowing, and redness at the back of the throat. [fever · painful swallowing · redness · sore throat] - Malaise, headache, bad breath, and a muffled, hot-potato-sounding voice may go along with it. [headache · malaise] - History should cover how long and severe symptoms are, viral features such as cough or a runny nose, prior similar episodes, immune status, and recent sexual activity if an STI is a concern. [cough · runny nose] SIGNS - what you find (5) - Exam can show red, swollen tonsils with pus, tender glands at the front of the neck, and small spots on the palate. [pus] - A temperature over 38°C together with no cough both point toward a bacterial rather than viral cause. [fever] - A shifted uvula can signal a forming peritonsillar abscess. [abscess] - Swollen nodes at the back of the neck plus an enlarged spleen point toward EBV, while a fine sandpaper-like rash suggests strep. [rash · splenomegaly] - Jaw stiffness, one-sided tonsil swelling, or swelling of the outer neck should raise concern for a peritonsillar or deep neck abscess. [abscess] TESTS (7) - The Centor score, built from exudate, tender neck nodes, fever, and absent cough, helps estimate the odds of strep infection. - Rapid strep testing is very specific (88-100%) but its sensitivity varies more widely (61-95%) in children, so a negative result in a strongly suspicious case needs follow-up testing. - A throat culture remains the gold standard for confirming strep, especially when the rapid test is negative but suspicion stays high. - Strep testing usually isn't recommended under age 3, since rheumatic fever risk is low at that age. - Monospot or EBV serology is useful when infectious mononucleosis is a possibility. - Routine blood counts aren't needed for straightforward tonsillitis but can help when a patient looks systemically unwell or dehydrated. - Neck CT is the imaging test of choice when a peritonsillar or deep neck infection is suspected. Source Recurrent tonsillitis - disease-level clinical article (recurrent-tonsillitis-referral- full.txt) Status traced to the source above 1. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Tonsillectomy - StatPearls (NCBI Bookshelf NBK536942) - https://www.ncbi.nlm.nih.gov/books/NBK536942/ Why The subject here is the referral decision, not the treatment of an attack - the antibiotic for an acute episode belongs on the acute tonsillitis and streptococcal pharyngitis entries. What it does is put the counting rule in front of you, because the surgery is decided by documented episodes and the documentation has to start before the referral is thought of. Caution COUNT, AND WRITE IT DOWN AT THE TIME - referral runs on the Paradise criteria, and a child qualifies at any one of three counts: 7 throat infections inside 1 year; 5 a year across 2 years running; or 3 a year across 3 years running. An episode nobody wrote down does not count, so the counting starts at the first visit, not at the referral. WHAT COUNTS AS AN EPISODE - every episode has to be documented at the time, and each one needs 1 or more of these four alongside a sore throat: a temperature of 38.3 C (101 F) or higher; tender cervical nodes, or nodes bigger than 2 cm; exudate on the tonsils; or a positive test for group A streptococcus. A remembered sore throat with no recorded findings is not an episode. BELOW THE THRESHOLD, THE ANSWER IS TO WAIT - a child who does not meet the Paradise criteria is watched, not referred. The article states the negative outright: a child falling short on all three counts - under 7 episodes in the year before, under 5 a year across the past 2 years, under 3 a year across the past 3 - does not reach the bar for tonsillectomy. THINGS THAT JUSTIFY REFERRING SOONER - surgery can be warranted earlier where there are modifying factors: allergy or intolerance to antibiotics; PFAPA, meaning periodic fever with aphthous stomatitis, pharyngitis and adenitis; or a peritonsillar abscess. Quality of life counts too - where the episodes are frequent enough or severe enough to bite into a child's life, that is itself an indication. THE OTHER, COMMONER REASON TO REFER - obstruction, not infection. Sleep-disordered breathing (SDB) and recurrent tonsillitis are the 2 commonest reasons tonsils come out. Ask about it directly: snoring most nights, apnoea someone has witnessed, restless sleep, poor growth, doing badly at school, and bedwetting at night. The daytime picture is hyperactivity, tiredness and aggression. And a small tonsil does NOT rule it out - tonsil size does not always track the severity of SDB. AN ASYMMETRICAL TONSIL IS A DIFFERENT REFERRAL ENTIRELY - asymmetry of the tonsils is itself an indication for surgery, to exclude cancer. In the palatine tonsils the cancers seen most are squamous cell carcinoma and lymphoma, and in a child almost all of them are lymphoma. One tonsil much bigger than the other, especially with neck nodes or weight loss, is urgent and does not wait for any episode count. LOOK FOR A REASON BEHIND THE RECURRENCE - a common working definition of recurrent tonsillitis is 5 or more episodes in a year. Look underneath it: immunodeficiency is the one the article names. And in an adolescent or young adult with marked fatigue, nodes at the back of the neck, or an enlarged liver or spleen, think of EBV - infectious mononucleosis. THE COMPLICATIONS THAT MEAN SEND TODAY - a peritonsillar abscess, a retropharyngeal abscess, Lemierre syndrome, or a threatened airway all need escalating urgently. A quinsy has a recognisable face: sore throat on one side, trismus, the uvula pushed across, and a thick muffled voice, as though the child were speaking round a hot potato. BE HONEST ABOUT WHAT THE OPERATION BUYS - in the short term it does deliver: fewer sore throats, and fewer days missed from school or work. Over the long term the evidence for benefit is thin. Set that expectation before referring, not after the operation. AND ABOUT WHAT IT COSTS - bleeding is among the commonest complications afterwards, and the most feared; one study put unplanned return visits for bleeding at 2.8% of children, and it happens more often at night. Post-tonsillectomy bleeding is a hospital emergency, not a clinic problem. Pain is the other one, and it is the leading cause of trouble after the operation: it cuts down what the child will drink, which brings dehydration, difficulty swallowing and weight loss. Send the family home able to spot dehydration, and pressing the child to keep drinking. PROLONGED PROPHYLACTIC ANTIBIOTICS ARE NOT THE ALTERNATIVE TO REFERRAL - the article does record that antibiotic prophylaxis can cut how often episodes come back, naming long-acting benzathine penicillin and low-dose azithromycin. But it gives no dose, no duration and no age band, so nothing is printed as a prescribing row and the decision sits with the ENT or paediatric team. Note too that a chronic carrier of group A streptococcus usually needs NO treatment at all, because the risk of passing it on or of complications is low - a positive swab between episodes may be carriage, not infection. WHAT NOT TO DO WHILE WAITING - current CDC and American College of Physicians guidance is to give an antibiotic only where group A streptococcus has been confirmed, by rapid antigen test or by throat culture. Treating every sore throat with an antibiotic inflates the episode count with episodes that were never bacterial, and delays the real decision. 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