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 2 WW 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