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ent.tonsillitis-recurrent.core.v1PRODUCTION
ent.tonsillitis-recurrent.core.v1

Recurrent tonsillitis & tonsillectomy candidacy (Paradise criteria, AAO-HNSF 2019 update)

general_internal_medicinechronicsubacutepediatricadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a LONGITUDINAL tonsillectomy-candidacy engine — NOT a per-episode antibiotic engine (ent.pharyngitis.core.v1 owns the acute episode). Two jobs: (A) decide whether the patient meets Paradise criteria with adequate documentation, with watchful-waiting bias per AAO-HNSF 2019 (Mitchell PMID 30798778); (B) identify modifying factors and red-flag mimics (PFAPA, malignancy, OSA) that change the pathway.

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longitudinal scope confirmed; per-episode antibiotic decisions routed to ent.pharyngitis.core.v1

Patient inputs (15)

Annual episode count for the past 2 years — the year-2 Paradise threshold is ≥5/year for 2 years (Paradise NEJM 1984 PMID 6700642)

Annual episode count for the past 3 years — the year-3 Paradise threshold is ≥3/year for 3 years (Paradise NEJM 1984 PMID 6700642)

Age governs anaesthetic risk, perioperative bleeding risk, codeine contraindication (<12 years), and overnight-monitoring requirement (<3 years or severe OSA) (AAO-HNSF 2019 Mitchell PMID 30798778)

Loud habitual snoring, witnessed apnoeas, daytime hypersomnolence — obstructive sleep apnoea / sleep-disordered breathing is a SEPARATE tonsillectomy indication on its own pathway (AAO-HNSF 2019 Mitchell PMID 30798778); polysomnography is required pre-op in defined subgroups

Bleeding diathesis (vWF, haemophilia, antiplatelet/anticoagulant use), syndromic / craniofacial anomalies, cardiac disease, severe asthma, OSA-related comorbidities — all alter perioperative risk and inform shared-decision-making (AAO-HNSF 2019 Mitchell PMID 30798778)

Number of documented sore-throat episodes in the past 12 months — the year-1 Paradise threshold is ≥7. Documentation is required: AAO-HNSF 2019 demands sore throat + ≥1 of (T>38.3°C, cervical adenopathy, tonsillar exudate, positive GAS test) per episode (Mitchell PMID 30798778)

Each counted episode MUST be documented as sore throat + ≥1 objective criterion (T>38.3°C / cervical adenopathy / tonsillar exudate / positive GAS test / prior antibiotic for GAS). Undocumented episodes do NOT count toward Paradise threshold (AAO-HNSF 2019 Mitchell PMID 30798778)

Unilateral tonsillar enlargement, mass, ipsilateral persistent adenopathy, B symptoms (weight loss, night sweats, fevers without infection) — malignancy work-up (lymphoma, head/neck SCC) takes priority; route OUT (clinical)

Per-episode antibiotic regimen gating (penicillin V / amoxicillin first-line, cephalexin if non-anaphylactic, clindamycin / azithromycin if severe) — per-episode dosing OWNED by ent.pharyngitis.core.v1; documented here as a tonsillectomy-modifying factor (multiple antibiotic allergies)

Regular monthly fever spikes + aphthous stomatitis + pharyngitis + cervical adenitis = PFAPA / Marshall syndrome; tonsillectomy is curative in many cases — distinct pathway from classical recurrent GAS (AAO-HNSF 2019 Mitchell PMID 30798778)

Per-episode RADT confirms GAS — required at each episode to count it toward Paradise documentation; per-episode treatment is OWNED by ent.pharyngitis.core.v1 (IDSA 2012 Shulman PMID 22965026)

Back-up throat culture after negative RADT in children/adolescents per IDSA 2012 (higher ARF risk in this population); supports documentation per episode (AAO-HNSF 2019 Mitchell PMID 30798778)

≥1 peritonsillar abscess is an AAO-HNSF 2019 modifying factor that can shift the threshold even without meeting strict Paradise (Mitchell PMID 30798778)

Multiple antibiotic allergies / intolerance is an AAO-HNSF 2019 modifying factor (Mitchell PMID 30798778)

Pregnancy gates per-episode antibiotic safety (penicillin/amoxicillin safe, tetracyclines avoided) and defers elective tonsillectomy when possible

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationalseveretonsillar_asymmetry_or_b_symptoms_malignancy_screen
    Unilateral tonsillar enlargement, mass, persistent ipsilateral cervical adenopathy, or B symptoms (weight loss, night sweats, persistent fevers without infection) — recognise malignancy (lymphoma, head/neck SCC)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_tonsillectomy_secondary_haemorrhage
    Post-tonsillectomy bleeding after day 5-10 (the classical secondary-haemorrhage window) — return precaution for every tonsillectomy patient (AAO-HNSF 2019 Mitchell PMID 30798778)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateparadise_criteria_met_with_documentation
    Documented sore-throat episodes meeting one of: ≥7 in past year; ≥5/year × 2 years; ≥3/year × 3 years — each documented with sore throat + ≥1 of T>38.3°C / cervical adenopathy / tonsillar exudate / positive GAS test (Paradise NEJM 1984 PMID 6700642; AAO-HNSF 2019 Mitchell PMID 30798778)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepfapa_marshall_syndrome_pattern
    Regular monthly episodes of fever + aphthous stomatitis + pharyngitis + cervical adenitis in a child — Periodic Fever / Aphthous / Pharyngitis / Adenitis (Marshall) syndrome (AAO-HNSF 2019 Mitchell PMID 30798778)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_peritonsillar_abscess
    History of ≥1 peritonsillar abscess (especially recurrent) — AAO-HNSF 2019 modifying factor favouring tonsillectomy (Mitchell PMID 30798778)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateosa_sleep_disordered_breathing_separate_pathway
    Loud habitual snoring, witnessed apnoeas, daytime hypersomnolence — OSA / sleep-disordered breathing is a SEPARATE indication for tonsillectomy on its own AAO-HNSF 2019 pathway (Mitchell PMID 30798778)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Recurrent tonsillitis — per-episode confirmed-GAS regimen (routed to acute pharyngitis engine for primary dosing) + AAO-HNSF 2019 perioperative bundle when tonsillectomy proceeds
axis: recurrent_tonsillitis_per_episode_and_perioperativestep 1 - Step 1 — Per-episode confirmed GAS treatment (primary engine ent.pharyngitis.core.v1, recapped here for longitudinal documentation)
Selected step "Step 1 — Per-episode confirmed GAS treatment (primary engine ent.pharyngitis.core.v1, recapped here for longitudinal documentation)" — Each documented sore-throat episode with RADT/culture-positive GAS; the per-episode regimen is OWNED by ent.pharyngitis.core.v1; included here so episodes are dose-mapped and documentation-counted toward Paradise (IDSA 2012 Shulman PMID 22965026; AAO-HNSF 2019 Mitchell PMID 30798778)
  • penicillin V
    first line
    natural_penicillin
    adult 500 mg (child 250 mg) • PO • BID-TID × 10 days (max: adult 1 g/day)
    triggers: gas_confirmed_per_episode, no_penicillin_allergy
    IDSA 2012 Shulman (PMID 22965026); per-episode dosing OWNED by ent.pharyngitis.core.v1 — recapped here for documentation completeness
    rxcui 7984
  • amoxicillin
    first line
    aminopenicillin
    50 mg/kg (max 1 g) once daily OR 25 mg/kg BID • PO • once daily–BID × 10 days (max: 1 g/day)
    triggers: gas_confirmed_per_episode, pediatric_adherence, no_penicillin_allergy, mononucleosis_excluded
    IDSA 2012 Shulman (PMID 22965026) — once-daily palatable suspension improves pediatric adherence; AVOID if mononucleosis plausible (amoxicillin rash). Per-episode dosing OWNED by ent.pharyngitis.core.v1
    rxcui 723
  • cephalexin
    contraindication substitute
    1st_gen_cephalosporin
    adult 500 mg BID • PO • BID × 10 days (max: adult 1 g/day)
    triggers: gas_confirmed, non_anaphylactic_non_severe_penicillin_allergy
    IDSA 2012 Shulman (PMID 22965026) — first-gen cephalosporin acceptable for non-anaphylactic / non-severe penicillin allergy. Per-episode dosing OWNED by ent.pharyngitis.core.v1
    rxcui 2231
  • clindamycin
    contraindication substitute
    lincosamide
    7 mg/kg TID (adult 300 mg TID) • PO • TID × 10 days (max: adult 900 mg/day)
    triggers: gas_confirmed, severe_anaphylactic_penicillin_allergy, macrolide_resistance_concern
    IDSA 2012 Shulman (PMID 22965026) — preferred over macrolide where macrolide resistance concerns; counsel C. difficile risk. Per-episode dosing OWNED by ent.pharyngitis.core.v1
    rxcui 2582
  • azithromycin
    contraindication substitute
    macrolide
    adult 500 mg day 1 then 250 mg × 4 d (peds 12 mg/kg day 1 then 6 mg/kg × 4 d) • PO • once daily × 5 days (max: adult 500 mg/day)
    triggers: gas_confirmed, severe_penicillin_allergy, check_local_GAS_macrolide_resistance
    IDSA 2012 Shulman (PMID 22965026) — macrolide option for severe penicillin allergy; resistance variable (can exceed 10%). Per-episode dosing OWNED by ent.pharyngitis.core.v1
    rxcui 18631

outpatient playbook — drug actions (3)

  1. 1. per-episode amoxicillin / penicillin V (OWNED by ent.pharyngitis.core.v1)
    rxcui 723
    50 mg/kg (max 1 g) once daily • PO • once daily × 10 days
    trigger: GAS-confirmed episode in patient with no penicillin allergy and no mononucleosis suspicion
    IDSA 2012 Shulman PMID 22965026 — per-episode dosing routed to ent.pharyngitis.core.v1
  2. 2. intraoperative IV dexamethasone (if proceeding to tonsillectomy)
    rxcui 3264
    0.5-1 mg/kg (max 10 mg) • IV • single dose at induction
    trigger: Tonsillectomy proceeding
    AAO-HNSF 2019 Mitchell PMID 30798778 — strong recommendation
  3. 3. ibuprofen + acetaminophen post-tonsillectomy
    rxcui 5640
    10 mg/kg q6-8h ibuprofen plus 15 mg/kg q4-6h acetaminophen • PO • scheduled or PRN
    trigger: Post-tonsillectomy pain
    AAO-HNSF 2019 Mitchell PMID 30798778 — strong recommendation; ibuprofen does NOT significantly increase bleeding

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Patient with documented recurrent throat infections — ≥3 episodes/year for ≥2-3 years OR ≥5/year for 2 years OR ≥7 in past year (Paradise criteria, established Paradise NEJM 1984 PMID 6700642; reaffirmed AAO-HNSF 2019 Mitchell PMID 30798778); Regular periodic fevers + aphthous stomatitis + pharyngitis + cervical adenitis pattern in a child — PFAPA / Marshall syndrome entry; tonsillectomy can be curative (AAO-HNSF 2019 PMID 30798778); History of ≥1 peritonsillar abscess (quinsy) — AAO-HNSF 2019 modifying factor that may favour tonsillectomy without strict Paradise.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Recurrent tonsillitis & tonsillectomy candidacy (Paradise criteria, AAO-HNSF 2019 update)** (ent.tonsillitis-recurrent.core.v1).
Phenotype framing: Terminal differential: classical recurrent GAS tonsillitis meeting Paradise (treat or watchful-wait per AAO-HNSF 2019) vs Paradise-not-met / sub-threshold (watchful waiting recommended) vs PFAPA (regularity + aphthous + adenitis pivot — tonsillectomy can be curative) vs OSA / sleep-disordered breathing (snoring + apnoeas + polysomnography pivot — separate tonsillectomy pathway) vs streptococcal carrier (asymptomatic positive culture — do NOT treat or operate) vs malignancy (asymmetry / mass / B symptoms — biopsy pathway) vs infectious mononucleosis (longer fatigue + posterior nodes + splenomegaly — different pathway). The chosen pathway drives the next step.
Scope: Frame as a LONGITUDINAL tonsillectomy-candidacy engine — NOT a per-episode antibiotic engine (ent.pharyngitis.core.v1 owns the acute episode). Two jobs: (A) decide whether the patient meets Paradise criteria with adequate documentation, with watchful-waiting bias per AAO-HNSF 2019 (Mitchell PMID 30798778); (B) identify modifying factors and red-flag mimics (PFAPA, malignancy, OSA) that change the pathway.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Recurrent tonsillitis — per-episode confirmed-GAS regimen (routed to acute pharyngitis engine for primary dosing) + AAO-HNSF 2019 perioperative bundle when tonsillectomy proceeds** — step "Step 1 — Per-episode confirmed GAS treatment (primary engine ent.pharyngitis.core.v1, recapped here for longitudinal documentation)".
1. penicillin V adult 500 mg (child 250 mg) PO BID-TID × 10 days (natural_penicillin, first line) — IDSA 2012 Shulman (PMID 22965026); per-episode dosing OWNED by ent.pharyngitis.core.v1 — recapped here for documentation completeness
2. amoxicillin 50 mg/kg (max 1 g) once daily OR 25 mg/kg BID PO once daily–BID × 10 days (aminopenicillin, first line) — IDSA 2012 Shulman (PMID 22965026) — once-daily palatable suspension improves pediatric adherence; AVOID if mononucleosis plausible (amoxicillin rash). Per-episode dosing OWNED by ent.pharyngitis.core.v1
3. cephalexin adult 500 mg BID PO BID × 10 days (1st_gen_cephalosporin, contraindication substitute) — IDSA 2012 Shulman (PMID 22965026) — first-gen cephalosporin acceptable for non-anaphylactic / non-severe penicillin allergy. Per-episode dosing OWNED by ent.pharyngitis.core.v1
4. clindamycin 7 mg/kg TID (adult 300 mg TID) PO TID × 10 days (lincosamide, contraindication substitute) — IDSA 2012 Shulman (PMID 22965026) — preferred over macrolide where macrolide resistance concerns; counsel C. difficile risk. Per-episode dosing OWNED by ent.pharyngitis.core.v1
5. azithromycin adult 500 mg day 1 then 250 mg × 4 d (peds 12 mg/kg day 1 then 6 mg/kg × 4 d) PO once daily × 5 days (macrolide, contraindication substitute) — IDSA 2012 Shulman (PMID 22965026) — macrolide option for severe penicillin allergy; resistance variable (can exceed 10%). Per-episode dosing OWNED by ent.pharyngitis.core.v1

Setting playbook (outpatient) — Track documented episodes against Paradise criteria + watchful-waiting bias (AAO-HNSF 2019), recognise modifying factors (PFAPA, recurrent PTA, antibiotic allergies, OSA, malignancy), and run shared decision-making for tonsillectomy when criteria are met
6. per-episode amoxicillin / penicillin V (OWNED by ent.pharyngitis.core.v1) 50 mg/kg (max 1 g) once daily PO once daily × 10 days — GAS-confirmed episode in patient with no penicillin allergy and no mononucleosis suspicion (IDSA 2012 Shulman PMID 22965026 — per-episode dosing routed to ent.pharyngitis.core.v1)
7. intraoperative IV dexamethasone (if proceeding to tonsillectomy) 0.5-1 mg/kg (max 10 mg) IV single dose at induction — Tonsillectomy proceeding (AAO-HNSF 2019 Mitchell PMID 30798778 — strong recommendation)
8. ibuprofen + acetaminophen post-tonsillectomy 10 mg/kg q6-8h ibuprofen plus 15 mg/kg q4-6h acetaminophen PO scheduled or PRN — Post-tonsillectomy pain (AAO-HNSF 2019 Mitchell PMID 30798778 — strong recommendation; ibuprofen does NOT significantly increase bleeding)

Non-pharmacologic actions:
- Maintain a structured longitudinal episode log with date, symptom, objective criterion, and treatment for each documented event
- Annual review of episode count vs Paradise thresholds and watchful-waiting recommendation
- Polysomnography pre-tonsillectomy in defined subgroups (age <2 y or obese / Down / craniofacial / neuromuscular / sickle / mucopolysaccharidoses; uncertain need-for-tonsillectomy in others)
- Shared decision-making conversation when Paradise met — review benefit decay (Paradise Pediatrics 2002 PMID 12093941) and post-op morbidity
- No routine perioperative antibiotics; no codeine <12 years post-tonsillectomy
- Document primary + secondary post-tonsillectomy bleeding rate per surgeon annually (AAO-HNSF 2019)

AVOID / contraindication checks:
- Do not tonsillectomize without documented paradise criteria or modifying factor (AAO HNSF 2019 Mitchell — watchful waiting is the default; tonsillectomy is OPTION not RECOMMENDATION)
- Do not treat or tonsillectomize asymptomatic streptococcal carriers (IDSA 2012 Shulman PMID 22965026; AAO HNSF 2019)
- No codeine or codeine containing analgesia in children under 12 post tonsillectomy (AAO HNSF 2019 strong recommendation against; FDA black box)
- No routine perioperative antibiotics for tonsillectomy (AAO HNSF 2019 strong recommendation against)
- Overnight inpatient monitoring required post tonsillectomy if age under 3y or severe OSA (AAO HNSF 2019 strong recommendation)
- Single intraoperative IV dexamethasone strong recommendation (AAO HNSF 2019)
- Asymmetric tonsil or unilateral mass or B symptoms trigger malignancy work up not routine tonsillectomy (clinical)
- Per episode antibiotic dosing is owned by ent.pharyngitis.core.v1 (this engine documents and tracks, does not duplicate)
- Avoid amoxicillin if mononucleosis plausible (rash; Dibek Misirlioglu 2018 PMID 29617685)

Monitoring

Regimen monitoring:
- episodes per year with documentation tracked longitudinally (Paradise NEJM 1984 PMID 6700642; AAO-HNSF 2019 Mitchell PMID 30798778)
- patient school or work absence quality of life burden
- post tonsillectomy primary and secondary bleeding rates per AAOHNSF 2019 audit requirement
- OSA re evaluation post tonsillectomy 6 8 weeks (Mitchell PMID 30798778 — sleep-disordered breathing may persist or recur)
- PFAPA episode frequency post tonsillectomy (often curative; track formally if PFAPA was the indication)

Setting (outpatient) monitoring:
- Episodes-per-year trajectory + documentation completeness
- OSA features (especially in children with hypertrophic tonsils)
- Return precautions: post-op secondary bleed (peak day 5-10), dehydration, fever, airway concern

Follow-up plan: Pre-op: 6-12 monthly review with formal episode-and-documentation re-count; shared-decision conversation each visit. Post-op: review at 2-3 weeks for haemorrhage / hydration / pain (peak secondary bleed window day 5-10), at 6-8 weeks for symptom resolution + OSA re-evaluation (recurrence possible). Document primary + secondary bleeding outcome in medical record (AAO-HNSF 2019 requirement). Long-term: counsel that tonsillectomy benefit decays beyond 12 months in the moderately-affected group (Paradise Pediatrics 2002 PMID 12093941).
- Close-out criterion: structured longitudinal review + post-op bleeding-outcome documentation completed

Monitoring phase: Pre-tonsillectomy longitudinal: track episodes, documentation quality, and patient-reported burden (school/work absence, QoL); reassess at 6-12 months — many sub-threshold patients regress to fewer episodes naturally. Post-tonsillectomy: assess primary (<24 h) and secondary (>24 h) bleeding rates per individual surgeon (AAO-HNSF 2019 requires annual measurement). Post-op pain control reassessment 24-72 h. Counsel that obstructive sleep-disordered breathing MAY persist or recur post-tonsillectomy (Mitchell PMID 30798778).

Disposition

Current setting: outpatient — Track documented episodes against Paradise criteria + watchful-waiting bias (AAO-HNSF 2019), recognise modifying factors (PFAPA, recurrent PTA, antibiotic allergies, OSA, malignancy), and run shared decision-making for tonsillectomy when criteria are met

Disposition criteria:
- Stable longitudinal management → continued outpatient with shared-decision review
- Proceeding to tonsillectomy → schedule, OSA polysomnography if required, perioperative bundle
- Same-day discharge appropriate for older healthy patients; overnight admission required for <3 y or severe OSA

Escalation triggers (move to higher acuity):
- Acute peritonsillar abscess during a current episode → ent.peritonsillar-abscess.core.v1
- Acute airway compromise (epiglottitis, deep neck infection) → ent.epiglottitis.core.v1 / ent.deep-neck-space-infection.core.v1
- Sepsis / Lemierre with throat source → id.sepsis.core.v1
- Asymmetric tonsillar mass or B symptoms → ENT urgent biopsy referral (malignancy)
- Post-tonsillectomy haemorrhage requiring intervention → ENT urgent referral / OR

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Unilateral tonsillar enlargement, mass, persistent ipsilateral cervical adenopathy, or B symptoms (weight loss, night sweats, persistent fevers without infection) — recognise malignancy (lymphoma, head/neck SCC)
- [SEVERE] Post-tonsillectomy bleeding after day 5-10 (the classical secondary-haemorrhage window) — return precaution for every tonsillectomy patient (AAO-HNSF 2019 Mitchell PMID 30798778)
- [MODERATE] Documented sore-throat episodes meeting one of: ≥7 in past year; ≥5/year × 2 years; ≥3/year × 3 years — each documented with sore throat + ≥1 of T>38.3°C / cervical adenopathy / tonsillar exudate / positive GAS test (Paradise NEJM 1984 PMID 6700642; AAO-HNSF 2019 Mitchell PMID 30798778)

Citations

- AAO-HNSF Clinical Practice Guideline: Tonsillectomy in Children (Update) — Mitchell et al, Otolaryngol Head Neck Surg 2019 (PMID 30798778 full + PMID 30921525 Executive Summary). Paradise criteria established by Paradise et al, NEJM 1984 (PMID 6700642); moderately-affected children showed only modest benefit in Paradise et al, Pediatrics 2002 (PMID 12093941). All four PMIDs live-PubMed-verified 2026-05-26. [PMID:30798778](https://pubmed.ncbi.nlm.nih.gov/30798778/)
- Cited evidence (PMID 30921525) [PMID:30921525](https://pubmed.ncbi.nlm.nih.gov/30921525/)
- Cited evidence (PMID 6700642) [PMID:6700642](https://pubmed.ncbi.nlm.nih.gov/6700642/)
- Cited evidence (PMID 12093941) [PMID:12093941](https://pubmed.ncbi.nlm.nih.gov/12093941/)
- Cited evidence (PMID 22965026) [PMID:22965026](https://pubmed.ncbi.nlm.nih.gov/22965026/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AAO-HNSF Clinical Practice Guideline: Tonsillectomy in Children (Update) — Mitchell et al, Otolaryngol Head Neck Surg 2019 (PMID 30798778 full + PMID 30921525 Executive Summary). Paradise criteria established by Paradise et al, NEJM 1984 (PMID 6700642); moderately-affected children showed only modest benefit in Paradise et al, Pediatrics 2002 (PMID 12093941). All four PMIDs live-PubMed-verified 2026-05-26. — PMID:30798778
  • Cited evidence (PMID 30921525) — PMID:30921525
  • Cited evidence (PMID 6700642) — PMID:6700642
  • Cited evidence (PMID 12093941) — PMID:12093941
  • Cited evidence (PMID 22965026) — PMID:22965026