Tonsillar Disorders
Acute infective sore throat
Most infective sore throats, due to pharyngitis / tonsillitis, are viral:
- 82% will resolve in 7 days without antibiotics
- Pain will only be reduced by 16 hours with antibiotics
In all patients advise self-care, and use the FPAIN online tool to help decide which patients will benefit from antibiotics:
https://www.mdcalc.com/feverpain-score-strep-pharyngitis
Referral pathways for tonsillar disorders
Urgent throat symptoms assessment clinic
This is available as an alternative pathway on the ENT 2WW referral form for adults meeting criteria below. Patients will be seen within 4 weeks - if cancer is suspected or detected at that point, cases will be appropriately prioritised.
Inclusion criteria:
Adults >16 yr old
With one or more of the following symptoms:
Exclusion criteria:
Children </=16 yr old
Any paediatric queries should be addressed to the paediatric neck and throat service.
Tonsillectomy
Tonsillectomy is commissioned where patients meet the criteria below. The referral letter and patient’s medical record need to clearly evidence how these criteria are met.
Tonsillectomy for tonsil stones, tonsilloliths or halitosis is NOT routinely commissioned.
Indications for tonsillectomy
1. 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 2 years, OR
- 3 episodes per year in the preceding 3 years
- AND there has been significant severe impact on quality of life indicated by documented evidence of absence from school/work
- AND/OR faltering growth in children that has been assessed by their GP/HV
There are a number of medical conditions where episodes of tonsillitis can be especially damaging to health & tonsillectomy may be required. In these instances tonsillectomy may be considered beneficial at a lower threshold than the above criteria. These particular conditions are:
- Acute and chronic renal disease resulting from acute bacterial tonsillitis
- As part of the treatment of severe guttate psoriasis
- Metabolic disorderswhere periods of reduced oral intake could be dangerous to health
- PFAPA (Periodic Fever, Apthous stomatitis, Pharyngitis, cervical Adenitis)
- Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous
2. Peri-tonsillar abscess (Quinsy), 2x episodes
3. Tonsillar enlargement causing acute upper airways obstruction
4. Suspected tonsillar malignancy
- In adults only, refer via Urgent Throat Symptoms Assessment Clinic
5. Obstructive Sleep Apnoea in children:
- Often associated with snoring, though not always
- Observed episodes of apnoea, often followed by a gasp, snort or choking sound
- Sometimes restlessness, laboured breathing or sudden arousal from sleep
- These episodes occur throughout the night, every night i.e. not just with URTIs
- If apnoeas are only a transient problem, referral is not necessary
- Associated with or without a significant impact on quality of life demonstrated by growth charts or letters from school
- Where possible, it is useful if the parents/carers can provide a video recording of the episodes causing concern
Suspected obstructive sleep apnoea in adults should be referred to the sleep clinic, not ENT:
https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/respiratory/sleep_apnoea
https://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/ent/nose/snoring_adults
Red flags
In adults only, refer via 2WW if:
-
Previously un-investigated, unexplained PALPABLE lump in the neck (including thyroid, parotid and submandibular glands)
-
Unexplained persistent (>4 weeks) sore or painful throat (especially with otalgia)
(NOT for globus or throat discomfort)
- Persistent (>3weeks) unexplained hoarseness and age ≥ 45yrs
Any paediatric queries should be addressed to the paediatric neck and throat service.
References
NHS Kernow Commissioning Policies 2021-22- click here
Microguide: RCHT Primary Care Antibiotic Guide: Upper Respiratory Tract Infections: Pharyngitis / sore throat / tonsillitis
Review Date August 2022
Next Review Date August 2023
GP Sifter Dr Laura Vines
Contributor Mr Venkat Reddy
Version 2.0