Professional Documents
Culture Documents
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Tonsillitis
T
onsillitis is a condition that is commonly encountered in primary care. On
average 50 per 1000 patients consult their GP each year with a sore throat.
Tonsillitis is a significant economic burden, with 35 000 000 days lost from
work or school. Acute tonsillitis commonly affects children from the age of
4 years (highly prevalent between 4 and 8 years old) and young adults aged
between 15 and 25 years old. With the emergence of multi-resistant pathogens,
antimicrobial stewardship has become central to the strategies adopted by the
National Institute for Health and Care Excellence in the UK.
Clinical module 3.15: Care of people with ENT, oral and facial problems lists the core competencies a GP
should acquire, to appropriately manage tonsillitis in the community. In particular, GPs should be able to:
. Manage primary contact with patients who have a common/important ENT, oral or facial problem, e.g. vertigo or
tinnitus
. Demonstrate knowledge of the scientific backgrounds of symptoms, diagnosis and treatment of ENT, oral and
facial conditions
. Understand how to recognise rarer but potentially serious conditions such as oral, head and neck cancer
. Understand when urgent (or semi-urgent) referral to secondary care may be indicated, e.g. in trauma, epistaxis,
quinsy (peritonsillar abscess), severe croup or stridor
. Understand when watchful waiting and the use of delayed prescriptions are indicated
. Demonstrate an evidence-based approach to antibiotic prescribing
. Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions, such as recurrent
tonsillitis or otitis media with effusion, e.g. explain why antibiotics are not always indicated
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life-threatening. In adults, although rare, acute epiglottitis
Table 1. Causative organisms of tonsillitis.
has similar symptoms along with a muffled or hoarse voice.
Bacterial Viral The incidence of epiglottitis has dramatically declined
since routine infant vaccination with Haemophilus influen-
Group A Streptococci Rhinovirus zae type b (Hib) vaccines began in 1991. These patients
should not be examined; rather they should be kept calm
Non-Group A Streptococci Influenza A and referred urgently to secondary care.
Examination
It is important to appreciate that patients presenting with
a sore throat may be seriously unwell and septic. As part
the examination, one should inspect the patient, obser-
ving for a ‘toxic’ appearance and signs of dehydration.
Vital signs and a thorough, systematic examination of the
ear, nose and throat (ENT) should guide the clinician
towards a diagnosis.
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Table 2. Modified Centor scoring. Table 3. Pre-test probabilities of
Streptococcal infection in respect to the
Criterion Points Modified Centor Score.
The Centor score was initially validated solely in adults, Rapid antigen detection testing (RADT) is not recom-
and thus not in children. It was therefore later modified mended as a routine investigation for acute sore throats
(also known as McIsaac score) to incorporate age, and by NICE (NICE, 2015a), however, NHS England has
was validated in about 600 adults and children (3–15 recently planned to roll out a ‘sore throat test and
years old) in a Canadian study (McIsaac, Kellner, treat’ service across pharmacies in the country over the
Aufricht, Vanjaka, & Low, 2004). To determine a patient’s next year. Patients will be able to visit pharmacies for
total score, points are assigned as detailed in Table 2. The RADT, and if positive, pharmacists will provide appropri-
predicted risk of GABHS infection depends on the total ate antibiotics without patients needing to see their GPs
modified Centor score as shown in Table 3. (Desmond, 2016). RADT has a specificity of greater than
95% and a varying sensitivity between 70 and 90% for
GABHS. Given its high specificity and limited sensitivity,
a positive RADT can be useful in establishing the diag-
Investigations nosis of GABHS tonsillitis, but a negative RADT does not
Patients with sore throat symptoms commonly visit their rule it out; in these cases throat culture swabs would be
GP, but in most cases the cause is viral and only beneficial (Pichichero, 1995).
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A full blood count may be helpful in patients with sus-
pected infectious mononucleosis, in immunocomprom- Differential diagnosis
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ised patients, and in patients with signs or symptoms of
severe infection. Raised white cell count with lymphocy- Scarlet fever
tosis and atypical lymphocytes is suggestive of infectious Scarlet fever is caused by toxin-producing strains of
mononucleosis (IM). A positive monospot test in patients Streptococcus Pyogenes, a beta-haemolytic bacterium
with suspected IM is diagnostic of EBV infection, how- that is classified as a Group A Streptococcus. Scarlet
ever, due to low sensitivity, a negative monospot test fever is highly contagious, and is transmitted via drop-
does not rule out the diagnosis of IM. In these instances, lets. Outbreaks in schools and other institutions where
EBV-specific antibody testing may be carried out to con- there is close contact between individuals can occur.
firm the diagnosis. The incubation period is usually 2–3 days. The blanch-
ing rash usually appears on the second day of the ill-
Vaginal and cervical, or penile and rectal swabs should be ness, beginning on the chest and spreading to the
considered if there is a suspicion of a gonococcal throat abdomen and extremities. The rash is prominent in
infection, especially in sexually active adolescents and skin creases and has a sandpaper-like texture, due to
those engaging in oral-genital sex. A human immune the occlusion of sweat glands. The rash persists for
deficiency virus (HIV) viral load assay is indicated for several days, and later (up to 3 weeks) will result in
patients at risk of HIV infection who have persistent ton- desquamation. There is an exudative tonsillopharyngitis,
sillopharyngitis accompanied by severe constitutional and there may be small red haemorrhagic spots on the
symptoms. hard and soft palate. The face is flushed, with circu-
moral pallor and a red strawberry tongue
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with antibiotics improved symptoms 16 hours earlier
Complications
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compared with those treated with supportive care only
(Spinks, Glasziou, & Del Mar, 2013). Symptom resolution
Peri-tonsillar abscess/quinsy was much more likely if antibiotic treatment was insti-
A spread of infection beyond the tonsil may lead to an gated within 2 days of symptom onset (Randolph,
abscess formation and collection of pus within the poten- Gerber, DeMeo, & Wright, 1985).
tial space between the tonsil and its containing fossa.
Clinical features include unilateral sore throat, trismus, Both suppurative and non-suppurative complications are
‘hot-potato’ voice, referred otalgia and odynophagia. uncommon, and clinical scoring does not predict the like-
Treatment is in the form of aspiration/incision and drain- lihood of acquiring these complications (Howie & Foggo,
age, and intravenous antibiotics. Rarely, these can pro- 1985; Little et al., 2013; Taylor & Howie, 1983). Reducing
gress to a parapharyngeal/retropharyngeal abscess, suppurative and non-suppurative complications requires
which can cause airway obstruction and mediastinal treating many patients with antibiotics (Spinks et al.,
infection. Suspicion of any extracapsular spread of infec- 2013). For example, the complication rate of acute otitis
tion should prompt an immediate referral to ENT. media (AOM) among those with sore throats is estimated
at 0.7%, implying a number needed to benefit (NNTB) of
Airway obstruction nearly 200 to prevent one case of AOM. In low-income
Airway obstruction is a rare complication and requires countries, complications are much more common, and
immediate referral to secondary care, where surgical therefore, the NNTB may be lower (Spinks et al., 2013).
intervention may be considered as an emergency. This In both instances, there is a balance between modest
may occur because of oedema of the soft palate and levels of symptom reduction and the risk of antimicrobial
tonsils following a deep neck space infection, peritonsillar resistance. In most cases, supportive management may
abscess or in rare circumstances, EBV infection. Common be all that is required in the form of adequate analgesia:
features include stridor, muffled voice, increased work of paracetamol and ibuprofen. Patients should also be
breathing and tachypnoea. advised to maintain adequate hydration and to rest.
The medical treatment of sore throats does not necessarily The antibiotic of choice is Phenoxymethylpenicillin for 10
need to focus on the administration of antibiotics, as has days. A macrolide can be used as an alternative if an
historically been the case. Between 50 and 80% are due to allergy to penicillin exists. Ampicillin-based antibiotics
a viral cause, and therefore, the use of antibiotics should should be avoided in the treatment of sore throats, as
be discouraged to reduce the risk of antibiotic resistance. these may precipitate a widespread non-blanching macu-
lopapular rash in the presence of glandular fever.
In a 2013 meta-analysis, sore throat lasted between 2 and
7 days among children who received control, placebo, or NICE (NICE 2015b) suggests a delayed antibiotic pre-
over-the-counter treatment; the sore throat resolved by scription as an alternative prescribing strategy. In this
day 3 in approximately 60–70% of cases (Thompson case, patients can be offered:
et al., 2013). The duration of symptoms was similar in . Reassurance that antibiotics are not needed immedi-
children with and without GABS tonsillitis. Treatment ately, as they are likely to make little difference to
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symptoms and may have side effects, such as diar- It is interesting to note that a cross-sectional observa-
rhoea, vomiting and rashes tional study of trends in emergency hospital admission
. Advice about using the delayed prescription if symp- for sore throats in the context of the number of tonsillec-
toms do not settle within the expected time frame, or tomies, found a 44% reduction in the overall tonsillec-
if a worsening occurs in the patient’s clinical status or tomy rate between 1991 and 2011. During the same
symptoms study period, the admission rate to hospital for tonsillitis
. Advice about seeking medical advice if there is a rose by 310%, for peritonsillar abscess by 31% and for
worsening in the clinical condition, despite using the retro/parapharyngeal abscess by 39% (Lau, Upile, Wilkie,
delayed prescription Leong, & Swift, 2014).
Ultimately, a clear explanation regarding the expected Tonsillectomy may be considered on a case-by-case basis
course of illness should be provided to the patient. It after careful consideration of the risks and benefits and a
should be emphasised that symptoms will resolve thorough discussion of the options with the patient. In
within 7 days, and that if there is worsening of symptoms cases where the diagnosis is uncertain, or there is a
or no improvement patients should re-present for review. doubt as to the clinical significance of the sore throats,
a period of active monitoring over a minimum of
The use of glucocorticoids has increased recently, but is 6 months can be beneficial, with patients recording epi-
controversial. The Infectious Disease Society of America sodes and symptoms in a ‘sore throat diary’.
advises against the use of steroids, however, in patients
with severe throat pain and/or inability to swallow, there Tonsillectomy is performed under a general anaesthetic,
may be a role (Shulman et al., 2012). and may involve an overnight stay in hospital. Recovery
takes up to 2 weeks and patients are advised to rest;
In cases of recurrent tonsillitis, referral to secondary care taking time off work/school. They will require regular
should be discussed for consideration of tonsillectomy. analgesia and should maintain a good oral intake, as
Although tonsillectomy has been shown to reduce the this has been shown to reduce recovery time and pre-
number of sore throats and improve general health, the vent infections.
procedure is not without risks. A study of 33 921 patients
undergoing adenotonsillar surgery in the UK between
2003 and 2004 reported a readmission rate of 3.9% and
Key points
a tonsillar haemorrhage rate of 3.5% (British Association of . Diagnosis of acute tonsillitis is clinical, and it can
Otorhinolaryngologists—Head and Neck Surgeons, 2005). be difficult to distinguish viral from bacterial
It is important to note that although tonsillectomy can pre- infections
vent recurrent episodes of tonsillitis, it will not affect recur- . GABHS accounts for up to 30% of the cases of
rent sore throats from other causes. Therefore, it is vital to tonsillitis in children and adolescents
confirm a diagnosis of recurrent tonsillitis and rule out sore . The modified Centor score is a useful validated
throats from other aetiologies prior to consideration of clinical prediction tool for diagnosing GABHS
surgical management. tonsillitis
. Complications of tonsillitis include peritonsillar and
The Scottish Intercollegiate Guidelines Network (SIGN) neck space abscesses, rheumatic fever and post-
published guidelines in 1999 on the management of sore streptococcal glomerulonephritis
throat and indications for tonsillectomy. These advise on . Most cases of tonsillitis are self-limiting and do not
the indications for tonsillectomy in both adults and chil- require antibiotics
dren and can be used to guide ENT referral in primary . Patients who fulfil the SIGN criteria, may be
care; they are listed in Box 2. referred to secondary care for consideration of
surgical management
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. British Association of Reattendance and complications in a randomised
Otorhinolaryngologists—Head and Neck trial of prescribing strategies for sore throat: The
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audit final report. London, UK: The Royal College 7104.350
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. Caserta, M. T., & Flores, A. R. (2010). Pharyngitis. agement in general practice. Family Practice, 13(3),
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. SIGN. (2010). Management of sore throat and indi- . Thompson, M., Vodicka, T., Blair, P., Buckley, D.,
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Mr Hussein Walijee
Speciality Trainee in ENT, Alder Hey Children’s NHS Foundation Trust, Liverpool
Email: hwalijee@gmail.com
Dr Chirag Patel
GP, Tanunda Medical Centre, South Australia
Mr Pranter Brahmabhatt
Speciality Trainee in ENT, Morriston Hospital, Swansea
Mr Madhankumar Krishnan
ENT Consultant, Alder Hey Children’s NHS Foundation Trust, Liverpool
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