ENT

Tonsillitis

Infection of the tonsils with fever, sore throat and painful swallowing. Medical management is similar to pharyngitis; recurrent cases are referred to ENT for tonsillectomy opinion.

ICD-10: —
Source: OPD handbook pp.7–11
Status: Draft

Not yet reviewed by a clinician. Check doses and brands against current national guidelines before use.

Symptoms

Fever
Sore throat
Dysphagia (difficulty swallowing)

Red flags Refer urgently if any are present

Greyish membrane over the tonsils suggests diphtheria: urgent referral to an ENT consultant for diphtheria antitoxin, admission and observation

Diagnosis

Differential diagnosis: pharyngitis
Examine the tonsils: enlarged, inflamed (grade the tonsils; grade III in recurrent cases)

Treatment

Step 1 of 5

1. Antibiotic (choose one)

Same choices as pharyngitis

Prescription

AmoxicillinPenicillin antibiotic

Doseas pharyngitis

Brand Amoxil

Also sold as Amoxil, Dispermox

Caution: Penicillin allergy

Amoxicillin + Clavulanic acidPenicillin antibiotic + β-lactamase inhibitor

Doseas pharyngitis

Brand Augmentin

Also sold as Augmentin, Co-Amoxiclave, Calamox

Caution: Penicillin allergy; Cholestatic jaundice risk with prolonged use

Cefixime3rd-generation cephalosporin

Doseas pharyngitis

Brand Caricef

Also sold as Cefspan, Cefim, Caricef, Tixomer, Cefiget

Rising resistance in Salmonella Typhi; not reliable as a sole agent in XDR typhoid.

ClarithromycinMacrolide antibiotic

Dose250 mg BD (used when Augmentin and Caricef already tried)

Brand Klaricid

Also sold as Klaricid, Rithmo, Pyloclar, Claricid

Step 2 of 5

2. NSAIDs, serrapeptase and antihistamine

Prescription

NimesulideNSAID

Dose100 mg BD (1+1)

Brand Nims

Also sold as Nims, Nimusil

IbuprofenNSAID

Dose400 mg TDS (1+1+1)

Brand Brufen

Caution: Avoid in dengue (bleeding risk); Avoid in kidney disease, peptic ulcer, late pregnancy; Take with food

Paracetamol (Acetaminophen)Analgesic / antipyretic

Dose1 g TDS (2+2+2)

Brand Panadol

Also sold as Panadol, Calpol, Febrol, Pedrol, Calpol 6 Plus (250 mg/5 mL)

Caution: Do not exceed 4 g/day in adults or 60 mg/kg/day in children; Avoid in severe liver disease

CetirizineAntihistamine

Dose10 mg at night (1+0), HS

Brand Rigix

Also sold as Rigix, Sedil, Antial, Neo-Antial, Cetrix, Zyrtec

SerratiopeptidaseProteolytic enzyme (anti-inflammatory)

Dose10 mg BD (1+1)

Brand Danzen DS

FexofenadineAntihistamine

Doseas pharyngitis

Brand Fexet / Peritone / Jardin

Also sold as Fexet, Telfast

Step 3 of 5

3. Gargles

Gargle with normal saline
Gargle with steroid: Tab Betnisol, 2 tablets dissolved in half a glass of water, TDS

Prescription

Betamethasone soluble tablet (gargle)Corticosteroid (gargle)

Dose2 tablets in half a glass of water, gargle TDS

Brand Betnisol

Step 4 of 5

4. Counselling and referral

Avoid spicy foods, cold drinks and cold water
Opinion by an ENT surgeon for tonsillectomy in recurrent tonsillitis (for example 3 episodes in one year)

Step 5 of 5

5. Paediatric doses (syrups)

TSF = 5 mL.

Prescription

Amoxicillin + Clavulanic acidPenicillin antibiotic + β-lactamase inhibitor

Dose30 mg/kg/dose TDS: 1 y, 10 kg → 1 TSF TDS; 2–4 y, 11–15 kg → 1½ TSF TDS; over 5 y, over 15 kg → 2 TSF TDS

Brand Syp Augmentin 312.5 mg/5 mL

Also sold as Augmentin, Co-Amoxiclave, Calamox

Caution: Penicillin allergy; Cholestatic jaundice risk with prolonged use

Cefixime3rd-generation cephalosporin

Dose10 mg/kg OD: 1 y, 10 kg → 1 TSF OD; 2–4 y, 11–15 kg → 1½ TSF OD; 16–20 kg → 2 TSF OD

Brand Syp Caricef 100 mg/5 mL

Also sold as Cefspan, Cefim, Caricef, Tixomer, Cefiget

Rising resistance in Salmonella Typhi; not reliable as a sole agent in XDR typhoid.

AzithromycinMacrolide antibiotic

DoseOD: 1 y, 10 kg → 1 TSF; 2–5 y, 11–15 kg → 1½ TSF; over 5 y, over 15 kg → 2 TSF

Brand Syp Genthro 100 mg/5 mL (as written)

Also sold as Zithromax, Azomax, Azitma, Arzomic, Zyto, Genthro

Caution: QT prolongation; caution with other QT-prolonging drugs

IbuprofenNSAID

Dose10 mg/kg TDS: 1 y, 10 kg → 1 TSF; 2–4 y, 10–14 kg → 1½ TSF; over 5 y, 15–20 kg → 2 TSF

Brand Syp Brufen 100 mg/5 mL

Caution: Avoid in dengue (bleeding risk); Avoid in kidney disease, peptic ulcer, late pregnancy; Take with food

DexibuprofenNSAID

Dose5–10 mg/kg TDS: 1 y, 10 kg → 1 TSF; 2–4 y, 10–14 kg → 1½ TSF; over 5 y, over 15 kg → 2 TSF

Brand Syp Tercica

CetirizineAntihistamine

DoseUp to 1.5 y → 1 TSF; over 1.5 y → 2 TSF; under 6 months: no cetirizine

Brand Syp Rigix / Sedil / Antial 2.5 mg/5 mL

Also sold as Rigix, Sedil, Antial, Neo-Antial, Cetrix, Zyrtec

Sample prescriptions from the book (patient details removed)

Child 5 y, 12 kg, fever and recurrent sore throat, enlarged inflamed tonsils: Syp Caricef 100 mg/5 mL 6 mL once daily; Syp Tercica 100 mg/5 mL 1+1+1; Syp Neo-Antial at night; avoid cold, sour and oily things.
Young adult, 3 episodes in the last year, grade III tonsils, already used Augmentin and Caricef: Tab Klaricid 250 mg 1+1; Tab Nims 100 mg 1+1; Tab Fexet 60 mg 1+0; Cap PPI 20 mg 1+0; gargle warm salt water; Betnisol 2 tablets in a cup of water, gargle three times a day.