HNY Policy and Pathway Repository - York

• Inflammation of the oropharynx. This can be chronic, lasting for more than a month. It can be relapsing recurrent acute pharyngitis or tonsillitis.
• Maybe due to a recurrent pharyngitis or tonsillitis, for details of tonsillitis see the tonsillitis guideline.
• It can be due to persistent infections such as candida, rhinosinusitis, or recurrent tonsillitis or dental infections.
• It can be associated with chronic irritants such as smoking, alcohol, environmental irritants and reflux associated with obesity
• It can be associated with mouth breathing from polyps or deviated nasal septum or allergic rhinitis
• It can be confused with globus and caused by laryngopharyngeal reflux- see Globus document.
• It can be associated with a tumour.

• Unilateral swelling at the back of the throat.
• Dysphagia - Persistent sore throat particularly with unilateral features and other risk factors such as age, smoking, alcohol.
• Sore throat lasting more than 6 weeks with no cause found should be referred urgently to ENT.
• Low grade sore throat with unilateral otalgia

Management

• Encourage smoking cessation
• Encourage weight loss (if appropriate)
• A sore throat is most often a self-limiting disease and most often viral in origin. Usually simple OTC the counter remedies are all that is required for pain relief.
• Centor score is helping in determining when to prescribe antibiotics.
   

Centor criteria

• The Centor criteria was developed to predict bacterial infection (GABHS) in people with acute sore throat. The four Centor criteria are:
  • Presence of tonsillar exudate.
  • Presence of tender anterior cervical lymphadenopathy or lymphadenitis.
  • History of fever.
  • Absence of cough.
• The presence of three or four of these clinical signs (Centor score 3 or 4) suggests that the person may have GABHS (40–60% chance) and may benefit from antibiotics treatment.
• The absence of three or four of these signs suggests that the person is unlikely to have an infection (80% chance), and antibiotics treatment is unlikely to be necessary.
• In the UK throat swabs are not usual practice as for a simple sore throat the specificity of a swab is 70% and the sensitivity is 30%.
• Consider other non-infective causes of the persistent sore throat.
• 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 persistent consider swab to rule out unusual bacteria or fungal infection.
• Discuss smoking and alcohol and reflux (consider treatment with sodium alginate – e.g. Peptac®. This can be purchased OTC).

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: Rare but if associated with airway compromise
• Recurrent/Chronic: See tonsillitis document for recurrent tonsillitis. Persistent and not responding to above treatment and conservative measures.
   

Information to include in referral letter

• Timing, effect on quality of life, any nasal features, previous and current treatment.
• Relevant past/ medical surgical history.
• Current regular medication.
• BMI/ Smoking status/ Alcohol status/ Employment.
• MUST include a completed tonsillectomy referral form click here

Patient information leaflets/ PDAs

• Rightcare Recurrent Sore Throat Decision Aid
• Patient Information Recurrent Sore Throat Decision Aid
   

References

• https://cks.nice.org.uk/sore-throat-acute#!topicsummary 
• https://www.nice.org.uk/guidance/CG69
• North Yorkshire Antibiotic Guidance (May 2017)
• http://bestpractice.bmj.com/best-practice/monograph/598/diagnosis/criteria.html 
• https://cks.nice.org.uk/sore-throat-acute#!scenario 
• https://www.oxford.dec.nihr.ac.uk/reports-and-resources/horizon-scanning-reports/point-ofcare-tests-for-group-a-streptococcus