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This guidance covers recurrent acute tonsillitis and referral for tonsillectomy.
Typical features of tonsillitis include:
Caution with examination of the throat of anyone with suspected epiglottitis (dysphonia, drooling, sepsis or stridor)
Consider differential diagnoses:
Consider immediate admission to hospital if patient presents with:
Throat swabs should not be carried out routinely in primary care management of sore throat unless scarlet fever is suspected.
Consider serology for infectious mononucleosis.
The information below is based on NICE NG84 Sore throat (acute): antimicrobial prescribing (January 2018).
Acute sore throat (including pharyngitis and tonsillitis) is self-limiting and often triggered by a viral infection of the upper respiratory tract.
Symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus). On average, antibiotics shorten the duration of symptoms by about 16 hours over 7 days, and the number of people improving with antibiotics is similar to the number experiencing adverse effects, such as diarrhoea.
For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2019)
The following are not recommended due to a lack of evidence: non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray without antiseptic.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is acute sore throat.
Many products for coughs, colds, and sore throats are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
The poor sensitivity and specificity of the previous sore throat grading criteria (CENTOR) have led to these being replaced with the FeverPAIN criteria.
FeverPAIN criteria are used to identify patients most likely to benefit from antibiotics. Higher scores suggest more severe symptoms and likely bacterial strep cause. (1 point for each, maximum score of 5):
Consider a 5-10 day prescription (delayed for 7 days) for patients presenting with symptoms which do not start to improve within the next 3 to 5 days or if they worsen rapidly or significantly at any time.
Reassess at any time if; symptoms worsen rapidly or significantly, or patient becomes very unwell.
In all cases offer self-care advice, no scoring system can ever be completely accurate, consider safety net precautions.
Invasive Group A Streptococcal infections and other bacteria have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, and a flat red rash over large area of the body, conjunctival suffusion.
Consider antibiotic treatment if confirmed Group A streptococcus infection in a household member and patient presents with symptoms suggestive of Group A streptococcal infection, including acute sore throat.
Chronic carriage of Group A streptococcus: These are apparent bacteriological treatment failures without illness or immunological response. They have a low risk of spread and a low risk of suppurative and non-suppurative complications. Antibiotics are not required.
The usefulness of throat swabs is limited by:
Immediate prescription of antibiotics is recommended in patients who:
Tonsillectomy will only be routinely commissioned in adults and children in Devon in the following circumstances:
Documented evidence of:
In line with NHS England guidance (2018), after appropriate specialist assessment tonsillectomy may be considered at a lower threshold than the above for the following indications:
Tonsillectomy/adenotonsillectomy will be funded in children under 16 where obstruction of the airway results in obstructive sleep apnoea syndrome, and the following apply:
Tonsillectomy is not routinely commissioned solely for the management of snoring.
Tonsillectomy is not routinely commissioned for the treatment of tonsilloliths (tonsil stones).
Head and Neck cancer services are commissioned by NHS England as part of specialist cancer services; treatment of malignancy is therefore out of scope of this guideline and the policy below.
Click on the link for the complete Tonsillectomy Commissioning Policy
This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.
Publication date: March 2020
Updated in accordance with the Devon Tonsillectomy Commissioning Policy October 2019