ENT & Audiology

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Recurrent Tonsillitis/Tonsillectomy

This guidance covers recurrent acute tonsillitis and referral for tonsillectomy.

Assessment

Signs and Symptoms

Typical features of tonsillitis include:

soreness of the throat especially upon swallowing
swollen neck glands
enlarged erythematous tonsils — with or without exudates
fever
can be associated with small red haemorrhagic spots on the hard and soft palate
nausea, vomiting, and abdominal pain are also common (children only)

History and Examination

Caution with examination of the throat of anyone with suspected epiglottitis (dysphonia, drooling, sepsis or stridor)

Differential Diagnoses

Consider differential diagnoses:

Epiglottitis
Infectious mononucleosis (glandular fever)
Malignancy - be suspicious if there is unilateral enlargement and subacute or chronic symptoms, or if swelling is painless
Embedded foreign body:
- suggestive history
- unilateral pain
- abscess formation

Red Flags

Consider immediate admission to hospital if patient presents with:

sore throat associated with stridor or respiratory difficulties, drooling, systemically very unwell, painful swallowing, muffled voice - suspect acute epiglottitis
dehydration or reluctance to take any fluids
severe suppurative complications, e.g.:
- peritonsillar abscess (also known as quinsy) or cellulitis
- parapharyngeal abscess
- retropharyngeal abscess
- Lemierre's syndrome (fusobacterial pharyngitis associated with isolated internal jugular vein (IJV) thrombosis and high risk of complications)
signs of being markedly systematically unwell
immunosuppressed patients
malignancy − be suspicious if there is unilateral enlargement and subacute or chronic symptoms persist for more than 3 weeks, or if swelling is painless

Investigations

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.

Management

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)

Self-care advice:

For pain relief:
- In adults:
- - consider non-steroidals and simple analgesia
- In children:
- - paracetamol
  - ibuprofen should be used with caution in children with or at risk of dehydration
Drink adequate fluids
Adult patients may wish to try medicated lozenges with local anaesthetic/ Non-steroidal anti-inflammatory drugs (NSAID)/ antiseptic, but these may only reduce pain in small amount

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):

Fever - Fever in the preceding 24 hours (measured or subjective)
P - Purulence on the tonsillar bed
A - Attend (self-refer) promptly i.e. within three days of symptom onset
I – Severely inflamed tonsils
N - No cough or coryza (inflammation of mucus membranes in the nose)

Scores

0-1 – Do not offer an antibiotic
2-3 – (Likelihood of streptococcal disease <40%, review at three days or use delayed prescription) Consider no antibiotic or a delayed antibiotic prescription
4-5 – (Likelihood of streptococcal disease >60%) Consider an immediate antibiotic or a delayed antibiotic prescription

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:

Their low sensitivity and specificity, they do not distinguish between carriage and infection with haemolytic streptococci
It takes time to obtain results (48-72 hours)

Immediate prescription of antibiotics is recommended in patients who:

Are systemically very unwell
Show signs and symptoms suggestive of serious illness
Are at risk of developing complications because of pre-existing co-morbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
Are older than 65 years with acute cough and two or more of the following criteria; or older than 80 years with acute cough and one of more of the following criteria:
- Hospitalisation in previous year
- Type 1 or type 2 diabetes
- History of congestive heart failure
- Current use of oral glucocorticoids

Formulary Chapter 5: Infections - respiratory tract infections

Seek specialist advice if no response to appropriate antibiotics or if there is clinical deterioration

Referral

Referral Criteria

Tonsillectomy will only be routinely commissioned in adults and children in Devon in the following circumstances:

Peritonsillar abscess (Quinsy)
Tonsillar enlargement causing or contributing to acute upper airways obstruction
Recurrent acute sore throat due to tonsillitis with the following criteria:

Documented evidence of:

7 or more episodes of tonsillitis in the last year; OR
5 or more such episodes per year in the preceding two years; OR
3 or more such episodes per year in the preceding three years;

AND

There has been significant impact on quality of life indicated by documented evidence of symptoms that act as a barrier to employment or education or carrying out carer activities; OR
Failure to thrive

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:

Acute and chronic renal disease resulting from acute bacterial tonsillitis (assessment to include renal specialist)
As part of treatment of severe guttate psoriasis (assessment to include dermatology specialist)
Metabolic disorders where periods of reduced oral intake could be dangerous to health (assessment to include paediatrician or endocrinologist)
PFAPA (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) (assessment to include paediatrician)
Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous (assessment to include paediatrician, or haematology or immunology specialist)

Tonsillectomy/adenotonsillectomy will be funded in children under 16 where obstruction of the airway results in obstructive sleep apnoea syndrome, and the following apply:

A significant impact on development, behaviour and/or quality of life demonstrated by supporting evidence such as growth charts, letters from GPs; OR

A strong clinical history (± sleep studies) suggestive of sleep apnoea

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