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Non-infective Sore Throat

This guideline applies to children, young people and adults.

 

Introduction

Most sore throats are due to viral infections. Non-infectious causes are uncommon. This guideline applies to patients when an infective cause for sore throat is not suspected. If an infective cause is suspected, please follow the Acute Infective Sore Throat guideline.

 

Red Flag Features

Sore throat in the context of:

  • Unexplained, persistent (more than 4 weeks) sore or painful throat (especially with otalgia)
  • Un-investigated unexplained palpable neck lump
  • Unexplained, persistent hoarseness (more than 3 weeks) in adult aged 45yr or over
  • Suspicious mass
  • Features of Kawasaki disease
  • Stridor/upper airway obstruction
  • Constitutional symptoms i.e. anorexia, weight loss, easy bruising/bleeding
  • Risk factors for malignancy (known malignancy, smoking, alcohol)

 

Investigations

No investigations are required routinely prior to treatment and/or referral.

If oral mucositis or ulceration, consider blood tests: FBC U&E B12 Folate Ferritin CRP HbA1c EBV HIV

 

Management Optimisation

In context of no red flag features, manage according to likely underlying cause:

 

Advice and Guidance

In the absence of red flags, consider seeking ENT Advice and Guidance if:

  • diagnostic uncertainty
  • patient falls outside the referral criteria

 

Referral

Emergency assessment:

Call 999 if patient has life-threatening symptoms, such as acute airway obstruction, acute breathing difficulties, impending or suspected sepsis (not an exhaustive list).

 

Same-day assessment:

  • Kawasaki disease
  • Stridor/upper airway obstruction

*Not an exhaustive list

In adults, discuss with ENT first on-call to arrange assessment.

In children, discuss with Paediatric first on-call who will liaise with ENT if required.

 

Fast Track ENT Suspected Cancer:

This service is only for adults aged 16 years and over.

  • Unexplained, persistent (more than 4 weeks) sore or painful throat (especially with otalgia)
  • Un-investigated unexplained palpable neck lump (including thyroid, parotid and submandibular glands), excluding scalp and posterior neck lumps
  • Unexplained, persistent hoarseness (more than 3 weeks) in adult aged 45yr or over

Refer via Fast Track ENT Suspected Cancer Referral Form.

 

Urgent Throat Symptoms Clinic or Routine ENT (Neck and Throat) Referral:

This service is only for adults, aged 16 years and over.

An option for adults with:

  • Intermittent sore/painful throat
  • Throat discomfort
  • Tonsil asymmetry* – include a photo if possible

*Tonsil asymmetry, which is not longstanding and stable, should be sent via the Urgent Throat Symptoms Clinic using the Fast Track ENT Suspected Cancer Referral Form. It would be reasonable to refer all other symptoms (which are considered to be low risk) routinely to the Adult ENT (Neck and Throat) Service via e-RS.

 

Routine ENT (Neck and Throat) Referral:

Tonsillectomy for recurrent sore throat is subject to strict commissioning criteria. On the NHS, it is only commissioned when the following criteria are met2:

  • Sore throats are due to acute tonsillitis

AND

  • The episodes are disabling and prevent normal functioning

AND

  • 7 or more, documented, clinically significant, adequately treated sore throats in the preceding year

OR

  • 5 or more such episodes in each of the preceding two years

OR

  • 3 or more such episodes in each of the preceding three years

 

AND

  • The risks of tonsillectomy versus active monitoring have been discussed with the adult or child and their family or carers, and a shared decision has been made on whether to have the procedure. This discussion should be documented.* 

*The responsibility for full tonsillectomy counselling remains with the responsible surgeon.

 

Referrals that do not clearly evidence how the commissioning criteria are met will be returned.

 

There are a number of medical conditions where episodes of tonsillitis can be damaging to health or tonsillectomy is required as part of the ongoing management. In these instances, tonsillectomy may be considered beneficial at a lower threshold after specialist assessment2:

  • Acute and chronic renal disease due to bacterial tonsillitis
  • Severe guttate psoriasis
  • Metabolic disorders, where reduced oral intake could be harmful to health
  • Periodic Fever, Aphthous stomatitis, Pharyngitis, cervical Adenitis (PFAPA)
  • Severe immunodeficiency
  • 2 or more episodes of quinsy 
  • Children with obstructive sleep apnoea or sleep disordered breathing
  • Suspected malignancy
  • Emergency presentations e.g. treatment of parapharyngeal abscess
  • Tonsillar enlargement causing a previous episode of acute upper airways obstruction or chronic upper airway obstructive symptoms 

In adults (16 and over), send the referral to the Adult ENT (Neck and Throat) Service.

In children (15 and under), send the referral to the Paediatric ENT (Neck and Throat) service.

 

Exclusions:

  • Suspected Obstructive Sleep Apnoea in adults – do NOT refer to ENT; unlike in children, surgical intervention is rarely, if ever, indicated for OSA in adults – refer to Respiratory Sleep Service
  • Tonsillectomy for tonsilloliths (tonsil stones), halitosis and snoring is not routinely commissioned2

 

Supporting Information

For professionals:

For patients:

 

References

  1. NHS Cornwall ICB Treatment Policies
  2. NHS CIOS Commissioning Policies and Evidence-based interventions

 

Page Review Information

Review date

15th May 2025

Next review date

15th May 2026

GP speciality lead

Dr Laura Vines

Contributors

Mr Venkat Reddy, Consultant ENT Surgeon