A 22-year-old woman presents with a 3-day history of bilateral sore throat, fever (38.5°C), and cervical lymphadenopathy. On examination, both tonsils are enlarged with yellowish-white exudate, and the pharynx is erythematous. There is no uvula deviation or intraoral bulge. She is able to swallow saliva and speak normally. Rapid streptococcal antigen test is positive. What is the most appropriate next step in management?

Explanation

## Diagnosis: Acute Bacterial Tonsillitis (Streptococcal) **Key Point:** The clinical presentation—bilateral sore throat, fever, exudate on both tonsils, cervical lymphadenopathy, and positive rapid streptococcal antigen—confirms acute bacterial tonsillitis (ABT), NOT peritonsillar abscess. The absence of uvula deviation, intraoral bulge, and trismus rules out complications. ### Differential: Acute Tonsillitis vs. Peritonsillar Abscess | Feature | Acute Tonsillitis | Peritonsillar Abscess | |---------|-------------------|----------------------| | **Laterality** | Usually bilateral | Unilateral | | **Uvula deviation** | Absent or midline | Pushed away from affected side | | **Intraoral bulge** | Absent | Present above tonsil | | **Trismus** | Absent or mild | Marked | | **Voice quality** | Normal or slightly hoarse | Muffled ("hot potato voice") | | **Swallowing** | Difficult but possible | Severe; may drool | | **Management** | Antibiotics + supportive care | IV antibiotics + drainage | ### Management of Acute Bacterial Tonsillitis ```mermaid flowchart TD A[Acute Bacterial Tonsillitis Confirmed]:::outcome --> B[Oral Penicillin V 500 mg QID]:::action B --> C[Duration: 10 days]:::action C --> D[Supportive Care]:::action D --> E[Analgesics, Throat Lozenges, Warm Gargles]:::action E --> F[Reassess in 48-72 hrs]:::decision F -->|Improvement| G[Continue Antibiotics to Completion]:::action F -->|No Improvement| H[Consider Penicillin Allergy or Resistance]:::decision H -->|Allergy| I[Switch to Cephalosporin or Macrolide]:::action H -->|Resistance| J[Switch to Amoxicillin-Clavulanate]:::action G --> K[Counsel on Recurrence Risk]:::action ``` **High-Yield:** First-line antibiotic for Group A Streptococcus (GAS) tonsillitis is **oral penicillin V 500 mg four times daily for 10 days**. This prevents suppurative complications (PTA, retropharyngeal abscess) and non-suppurative sequelae (acute rheumatic fever, post-streptococcal glomerulonephritis). **Mnemonic: ABCDE of Acute Tonsillitis Management** - **A**ntibiotics (Penicillin V first-line) - **B**ilateral presentation (usually) - **C**ervical lymphadenopathy - **D**uration: 10 days - **E**xudates (yellowish-white) ### Why Oral Penicillin? 1. **Efficacy:** >95% of GAS are penicillin-sensitive. 2. **Cost-effective:** Oral formulation is inexpensive. 3. **Compliance:** Easier than IV therapy for uncomplicated ABT. 4. **Prevention:** Adequate antibiotic course prevents rheumatic fever and glomerulonephritis. **Clinical Pearl:** The Centor criteria (fever >38°C, exudate, cervical lymphadenopathy, absence of cough) help identify patients likely to have GAS tonsillitis and warrant empiric antibiotics without waiting for culture. **Warning:** Do NOT confuse acute tonsillitis with peritonsillar abscess. The absence of unilateral findings, uvula deviation, and trismus indicates uncomplicated tonsillitis, which does NOT require drainage or IV antibiotics. **Tip:** Tonsillectomy is NOT indicated for a single episode of acute tonsillitis (option D). Indications for tonsillectomy include recurrent tonsillitis (≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years) and obstructive sleep apnea. [cite:Park 26e Ch 16]