HNY Policy and Pathway Repository - York

Systemic illness with marked dysphagia, pyrexia & lethargy - duration 5 –7 days. With swollen tonsils and often tonsillar exudate.

A similar, common and often parallel condition is acute pharyngitis in which lymphoid tissue of the posterior oropharyngeal wall may become inflamed

• Unilateral enlargement with no signs of infection.
• Tonsillar cancer (mostly related to tobacco use but large growth seen in HPV related cancers)
• Unilateral signs
• Signs of obstruction

Management

• Encourage smoking cessation
• Encourage weight loss (if appropriate)
• This is usually a self-limiting disease. 50% are thought to be viral and of course glandular fever is viral. Usually simple OTC the counter remedies are all that is required for pain relief.
• In the UK throat swabs are not usual practice.
• You can use the CENTOR criteria to make a judgement on whether to use antibiotics. You can also consider a delayed prescription. CENTOR was developed for pharyngitis.

The CENTOR criteria are:

One point added for each positive criterion: [1]

• History of fever
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough

The Modified CENTOR Criteria add the patient's age to the criteria: [2]

• Age <15 add 1 point
• Age >44 subtract 1 point

Guidelines for management state: [1]

• 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%)
• 2 or 3 points – consider treating with an antibiotic (see below) - perhaps delayed. (Risk of strep. infection 32% if 3 criteria, 15% if 2)
• 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%)
• Consider a prolonged antibiotic treatment for 10 days. Please refer to North Yorkshire Antibiotic Guidance – acute sore throat.
• First line: Phenoxymethylpenicillin 500mg QDS for 10 days
• Alternative (penicillin allergy): Clarithromycin 250 – 500mg BD for 5 days

If considering referral for a tonsillectomy please note this procedure is not routinely commissioned. Please see the Tonsillectomy Commissioning Statement for full referral criteria.
 

Indications for referral

• 2WR: Sinister red flag features with no signs of infection - to rule out malignancy - 2WR
• Acute: Peri-tonsillar abscess (Quinsy) - Key features are; swelling adjacent to tonsil (usually unilateral), change to voice (hot potato voice), Trismus (limitation to mouth opening).
• Usually needs draining - admit same day.
• Tonsillar enlargement causing acute upper airways obstruction - admit.
   
• Recurrent: Recurrent sore throat where the following documented evidence applies:
  • 7 or more episodes of tonsillitis* in the last year OR
  • 5 episodes per year in the preceding two years OR
  • 3 episodes per year in the preceding three years AND there has been significant severe impact on quality of life indicated by documented evidence of absence from school/work; AND/OR failure to thrive

A frank discussion of the risk and benefits of the operation should be had. It is painful. People can continue with recurrent pharyngitis after a tonsillectomy. There is a 2% risk of post-op bleed that may need to go back to theatre and can be life threatening.
 

Information to include in referral letter

For recurrent tonsillitis

• Timing, number each year in the last few years of proven tonsillitis, effect on quality of life.
• Please comment on the discussion of risks and benefits you have had with the patient.
• Relevant past medical/surgical history.
• Current regular medication.
• BMI/Smoking status/Alcohol status/Employment 
• MUST include a completed tonsillectomy referral form 

Patient information leaflets/ PDAs

• Tonsillitis Patient Information leaflet
   

References

• Acute Sore Throat NICE CKS 2015
• Respiratory Tract Infections (self-limiting): Prescribing Antibiotics (NICE 2008)
• North Yorkshire Antibiotic Guidance (May 2017)
• http://bestpractice.bmj.com/best-practice/monograph/598/diagnosis/criteria.html 
• https://www.oxford.dec.nihr.ac.uk/reports-and-resources/horizon-scanning-reports/pointofcare-tests-for-group-a-streptococcus