These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.


To guide PCH ED staff with the assessment and management of tonsillitis in children.


Tonsillitis is inflammation of the tonsils due to infection.


  • The majority of tonsillitis and pharyngitis is viral and only requires symptomatic treatment.
  • Viruses implicated in tonsillitis and pharyngitis include rhinoviruses, coronaviruses, respiratory syncytial virus, adenovirus, parainfluenza, influenza, herpes simplex virus, enteroviruses and cytomegalovirus.
  • Both viruses and bacteria can cause an exudative tonsillitis.
  • Both viruses and bacteria can cause a high temperature.
  • Epstein-Barr virus (EBV) is a common cause of exudative tonsillitis and pharyngitis.
  • In bacterial tonsillitis (15 to 30% of cases of tonsillitis) an important pathogen is Group A β-Haemolytic Streptococcus (GABHS) also known as Streptococcus pyogenes.2
  • Rapid onset of sore throat and high fever associated with an exudative tonsillitis is more suggestive of a streptococcal tonsillitis, especially if typical viral features are absent.
  • Streptococcal tonsillitis is most common in school-age children, and is uncommon in children less than 3 years old.
  • Other bacterial causes of tonsillitis in children are uncommon and include Mycoplasma pneumoniae.
  • Diphtheria, caused by Corynebacterium diphtheriae is rare in the developed world where immunisation against this disease is routine. 

Risk factors

  • Low socio-economic status
  • Aboriginal and Torres Strait Islander
  • Maori and Pacific Islander
  • Existing rheumatic heart disease.


  • It can be difficult to distinguish clinically between viral tonsillitis (majority) and bacterial tonsillitis
  • Viral tonsillitis is more likely where there are other symptoms of a viral upper respiratory tract infection.


  • Sore throat
  • Difficulty swallowing
  • Cervical lymphadenopathy
  • Fever
  • Headaches
  • Abdominal pain
  • Worsening sleep apnoea
  • Ear aches – referred pain
  • Symptoms of a viral upper respiratory tract infection: rhinorrhoea, cough, hoarseness, watery red eyes.


  • Fever
  • Erythematous tonsils and pharynx with or without exudate
  • Enlarged and tender cervical lymph nodes
  • When severe there may be upper airway obstruction – stridor, drooling, and signs of respiratory distress.
Clinical features that are more suggestive of GABHS include:
  • Scarlantiniform rash
  • Soft palate petechiae – 'doughnut lesions'
  • Exudate on pharynx and / or tonsils
  • Vomiting
  • Tender cervical lymphadenopathy
  • High fever
  • Absence of viral upper respiratory tract symptoms.

With Epstein-Barr virus (EBV) there is exudative tonsillitis and there may be significant malaise, hepato-splenomegaly and submandibular (and generalised) lymphadenopathy.


  • Bacterial throat swab for culture is usually not indicated. Results take 24 to 48 hours.
    • Consider throat swab in high risk patients.

Differential diagnoses1

  • Epstein-Barr virus (Glandular Fever)
  • Herpes stomatitis
  • Hand foot and mouth disease
  • Herpangina
  • Croup
  • Epiglottitis
  • Peri-tonsillar abscess (Quinsy)
  • Retro-pharyngeal abscess
  • Oral thrush (Candidiasis) 


  • The vast majority of children only need symptomatic treatment.
  • Supportive care includes adequate hydration and simple analgesia.
  • Antibiotic therapy is only recommended in high risk patient groups (See Antibiotics section below) and those with severe symptoms of pharyngitis (e.g. requiring hospitalisation, severe pain or dysphagia). If antibiotic therapy is indicated, it should be commenced on clinical features rather than swab result.


  • Airway: If there is airway compromise (eg. stridor) 
    • Consider early ENT and/or anaesthetic involvement
    • Dexamethasone can be used in children ≥ 1 month (dose (PO): 0.6mg/kg up to a maximum of 10mg as a single dose)3.
  • Consider Sepsis management as per ChAMP Empiric Guidelines: Sepsis and Bacteraemia if very unwell.


  • Supportive care also includes encouraging oral fluids and encouraging oral hygiene (brushing teeth and rinsing with an antiseptic mouthwash).
  • Intravenous fluids may be considered if dehydrated.


Suppurative Complications

  • Peri-tonsillar abscess (Quinsy)
  • Retro-pharyngeal abscess
  • Cervical lymphadenitis
  • Sinusitis
  • Mastoiditis
  • Otitis media 

Non-Suppurative complications of GABHS

  • Acute rheumatic fever
  • Post-Streptococcal glomerulonephritis


  • Simple analgesia is sufficient in most cases (paracetamol and ibuprofen).
  • Steroids can have a role in acute pain management.4 Studies have shown that a single dose of dexamethasone3 (dose (PO): children ≥ 1 month 0.6mg/kg up to a maximum of 10mg) will improve pain and allow return to normal activities faster.
  • Avoid aspirin in children because of the risk of Reye’s syndrome.
  • Children older than 12 years may use salt water gargles.
  • Other symptomatic treatments such as salt water gargles, throat lozenges and sprays have varying anecdotal results and have not been proven to be of benefit in clinical trials.


  • Definitive prescription should be made empirically.
  • The main benefits of antibiotics are the prevention of suppurative complications and the prevention of post-infectious immune-mediated acute rheumatic fever and may prevent post-streptococcal glomerulonephritis.
  • Antibiotics administered within 7 to 9 days of the illness are almost 100% successful in preventing acute rheumatic fever. 
  • Antibiotics should only be considered if streptococcal tonsillitis is the likely cause. 
  • In most cases, tonsillitis is self-limiting. Antibiotics shorten the duration of symptoms by 12 to 24 hours4. A shared decision making process should be used in cases when there is a low risk of non-suppurative complications.
  • Antibiotic therapy is recommended for: 
    • patients with severe symptoms (requiring hospitalisation, severe pain or dysphagia)

    and in the following high risk patient groups:

    • patients aged 2 to 25 years with sore throat in communities with a high incidence of acute rheumatic fever (e.g. Aboriginal or Torres Strait Islander children, Maori and Pacific Islander people, children from countries with a high burden of rheumatic fever e.g. refugees) 
    • patients of any age with existing rheumatic heart disease 
    • patients with scarlet fever.
  • Refer to ChAMP Empiric guidelines: Ear, Nose, Throat and Dental Infections

Admission criteria

  • Upper airway obstruction
  • Fever with significant signs of sepsis
  • Suppurative complications
  • Severe dysphagia and inadequate oral hydration (require intravenous fluids)
  • Pain not controlled with oral analgesia.

Referrals and follow-up

GP follow up regarding clinical status (and swab result if taken) within 48 hours.

Referral to a Paediatric Ear, Nose and Throat surgeon if:

  • Recurrent tonsillitis
  • Episodes of severe tonsillitis requiring hospital admission
  • Peritonsillar abscess
  • Obstructive sleep apnoea
Referral to a paediatric respiratory physician for further investigations should be considered where there is a history or obstructive sleep apnoea.


  1. Fleisher, GR (2020) Evaluation of sore throat in children. UpToDate. Accessed at on 01/04/2021
  2. Pichichero ME (2020) Treatment and prevention of streptococcal pharyngitis in adults and children. UpToDate. Accessed at on 01/04/2021
  3. Sore Throat. eTG complete by Therapeutic Guidelines. Amended June 2019. Accessed at on 01/04/2021 
    Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013; CD000023.
  4. Hayward, M. Thompson, R. Perera, P. Glasziou, C. Del Mar and C. Heneghan, “Corticosteroids as standalone or add-on treatment for sore throat.,” Cochrane Database Systematic Review, vol. 17, no. 10, 2012.

Endorsed by:  Drugs and Therapeutics Committee  Date: May 2021

 Review date:  May 2024

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