There is no standard management for patients with high Antistreptolysin O titre (ASOT). Three therapeutic measures were tried in this study. Long acting penicillin (LAP) and the macrolide azithromycin as medical treatment and tonsillectomy as surgical treatment. A.S.O.T. was measured at intervals following the treatment to show the best response. The study was conducted on 109 patients, 50 patients were treated by L.A.P., 40 patients were treated by azithromycin and 19 patients were treated by tonsillectomy. The results revealed that tonsillectomy is better than medical treatment as 86.3% of patients returned to their normal A.S.O.T. after tonsillectomy and 64.4% of patients retuned to normal after medical treatment. L.A.P. is better than azithromycin as 66% of patients retuned to normal after L.A.P. while 62.5% of patients retuned to normal after azithromycin.The best response to medical treatment was after the 6th week either with L.A.P. or azithromycin while it was after the 10th week regarding tonsillectomy