Tonsillitis and Peritonsillar Abscess Guidelines

In 2012, the Infectious Diseases Society of America (IDSA) released updated guidelines for the diagnosis and management of group A streptococcal (GAS) pharyngitis. Recommendations for diagnosis and testing are summarized as follows ^[19] :

• Testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed to distinguish between GAS and viral pharyngitis
• In children and adolescents, negative RADT results should be backed up by a throat culture; positive results are highly specific and do not require a backup culture
• In adults, routine use of backup throat cultures for those with a negative RADT is not necessary because the risk of subsequent acute rheumatic fever is low in adults with acute pharyngitis
• Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis
• In general, testing for GAS pharyngitis is not recommended for children or adults with a clinical presentation that strongly suggests a viral etiology (eg, cough, rhinorrhea, hoarseness, oral ulcers)
• Acute rheumatic fever is rare in children under age 3 years, and the incidence and classic presentation of streptococcal pharyngitis are uncommon in this age group; thus, testing for GAS pharyngitis is not indicated for children under age 3 years; however, children under age 3 years who have other risk factors, such as an older sibling with GAS infection, may be considered for testing
• Diagnostic testing or treatment of asymptomatic close contacts of patients with acute streptococcal pharyngitis is not routinely recommended

IDSA guideline recommendations for treatment include the following ^[19] :

• Patients with confirmed GAS pharyngitis should be treated for a duration likely to eradicate GAS from the pharynx (usually 10 days) with an appropriate narrow-spectrum antibiotic
• Penicillin or amoxicillin is the drug of choice for those without a contraindication
• Alternative agents for penicillin-allergic individuals include a first-generation cephalosporin, clindamycin, or clarithromycin for 10 days, or azithromycin for 5 days 
• An analgesic such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) may be considered as an adjunct to an appropriate antibiotic for treatment of moderate to severe symptoms or control of high fever; aspirin should be avoided in children
• Adjunctive therapy with a corticosteroid is not recommended
• In patients with recurrent episodes of pharyngitis, consider the possibility that they are a chronic pharyngeal GAS carrier who is experiencing repeated viral infections
• Efforts to identify GAS carriers are not justified because they have a low risk of transmitting GAS pharyngitis to their close contacts and little or no risk for the development of acute rheumatic fever
• Tonsillectomy is not recommended to reduce the frequency of GAS pharyngitis

In joint guidelines for appropriate antibiotic use for acute respiratory tract infection in adults, published in 2016, the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) note that adult patients may be assured that antibiotics are usually not needed for a sore throat because they do little to alleviate symptoms and may have adverse effects. ^[40]

The following are guidelines from the 2019 update of the American Academy of Otolaryngology–Head and Neck Surgery Foundation’s guidelines on tonsillectomy in children ^[21] :

• If fewer than seven episodes of recurrent throat infection have occurred in the past year, less than five episodes per year in the past 2 years, or fewer than three episodes annually in the past 3 years, watchful waiting should be recommended by the clinician
• Tonsillectomy may be recommended if there have been at least seven episodes of recurrent throat infection in the past year, at least 5 episodes annually in the past 2 years, or at least 3 episodes per year in the past 3 years, with the medical record containing documentation for each episode and for at least one of the following: temperature above 38.3°C (101°F), cervical adenopathy, tonsillar exudate, or a positive group A beta-hemolytic streptococcus test
• If children do not meet the criteria in the second guideline but nonetheless have recurrent throat infection, evaluate the patients for modifying factors that may still point toward a need for tonsillectomy; such factors may include, among others, multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis), and a history of more than one peritonsillar abscess

Coronavirus disease 2019 (COVID-19)

Bann et al compiled a set of recommendations for best pediatric otolaryngology practices with regard to the coronavirus disease 2019 (COVID-19) pandemic. These included the following for procedures involving the oral cavity, oropharynx, nasal cavity, or nasopharynx ^[39] :

• Whenever possible, defer procedures involving the nasal cavity, nasopharynx, oral cavity, or oropharynx, as these pose a high risk for COVID-19 owing to the high viral burden in these locations
• Whenever possible, preoperative COVID-19 testing should be administered to patients and caregivers prior to surgical intervention
• Employment of enhanced personal protective equipment (PPE), with a strong recommendation for the use of a powered air-purifying respirator (PAPR), should be undertaken with any patient with unknown, suspected, or positive COVID-19 status
• Limit the use of powered instrumentation, including microdebriders, to reduce aerosol generation

With regard to audiologic evaluation and otologic surgery, the recommendations include the following ^[39] :

• Perform routine newborn hearing screening and early intervention as indicated in the Joint Committee on Infant Hearing (JCIH) recommendations
• Defer tympanostomy tube placement for unilateral otitis media with effusion
• Although it should be prioritized, intervention for bilateral otitis media with effusion and hearing loss may be deferred based on the availability of COVID-19 testing
• Surgery involving the middle ear and mastoid, owing to their continuity with the upper aerodigestive tract, should be considered high risk for COVID-19 transmission
• Whenever possible, defer mastoidectomy, but if the surgery is required, employ enhanced PPE and avoid the use of high-speed drills
• Employment of a PAPR is strongly recommended when, in patients with unknown, suspected, or positive COVID-19 status, high-speed drills are required for otologic procedures

With regard to head and neck surgery and deep neck space infections, the recommendations include the following ^[39] :

• Defer surgical excision of benign neck masses
• A multidisciplinary tumor board should decide the most appropriate treatment modality for pediatric patients with solid tumors of the head and neck, including thyroid cancer, with the availability of local resources taken into account
• Prior to surgical intervention, medical management of infectious conditions should, whenever possible, be attempted; on admission, patients and caregivers should be tested for COVID-19 and strictly quarantined pending test results

With regard to craniomaxillofacial trauma, the guidelines include the following ^[39] :

• When urgent or emergent bedside procedures, including closure of facial lacerations, are required, patients should be presumed positive for COVID-19, even if they are asymptomatic; carry out procedures in a negative-pressure room using enhanced PPE
• Employ closed-reduction techniques, when possible, until preoperative COVID-19 testing is available
• Avoid the use of high-speed drills, to reduce aerosol formation
• When urgent or emergent surgical intervention is required, patients should be presumed positive for COVID-19, even if they are asymptomatic