Tonsillitis

Abstract

Tonsillitis 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.

Full text

Tonsillitis
Tonsillitis 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.
The GP curriculum and tonsillitis
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
Aetiology
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Waldeyer’s ring is a ring of lymphoid tissues within the
pharynx; it consists of the palatine tonsils (‘tonsils’), pha-
ryngeal tonsils (‘adenoids’), tubal tonsils (just posterior to
the eustachian tube opening), and lingual tonsils (on the
posterior aspect of the tongue). Tonsillitis refers to the
inflammation of the palatine tonsils and pharyngitis, an
inflammation of the remainder of the pharynx. Multiple
pathogens can contribute to tonsillitis but, in most (up to
80%) cases, the causative agent is a virus. Table 1 pro-
vides a breakdown of the causes of tonsillitis. It is import-
ant to remember that pathogens such as candida albicans
can cause sore throats and be incorrectly diagnosed as
tonsillitis.
As a GP, it is important to search for patient cues that may,
in some cases, unearth a hidden agenda. It has been sug-
gested that prescribing antibiotics inappropriately may
over-medicalise what is usually a self-limiting condition
(Little et al., 1997). Contrary to popular belief, studies
suggest that the priority for patients attending with
a sore throat is not to acquire antibiotics, but rather to
establish the cause of their symptoms, obtain pain relief,
and receive information regarding the course of the illness
(Butler, Rollnick, Pill, Maggs-Rapport, & Stott, 1998).
The clinical approach
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The aim of the evaluation of patients with sore throat or
acute pharyngitis is to exclude potentially dangerous
causes, to identify any treatable causes, and to improve
symptoms. The evaluation includes a thorough history,
focused physical examination, and investigation in
selected patients.
History
The history provides important information to determine
whether the patient has a sore throat, or whether there is
a deeper pain in the throat or neck pain. Symptoms of
acute sore throat can vary between patients, and will occa-
sionally depend on the cause. Distinguishing between
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a viral and bacterial cause is difficult in practice, as there is
often overlap between the symptoms and signs.
Group A beta-haemolytic streptococcal (GABHS) infec-
tion usually presents with a sudden onset of sore throat,
tonsillar exudate, fever, tender cervical lymphadenopathy
and absence of a cough. Additional symptoms include
halitosis, odynophagia, otalgia and upper airway
obstructive signs, such as snoring or mouth-breathing.
Viral tonsillopharyngitis, on the other hand, may have
additional symptoms relating to a generalised viral
upper respiratory tract infection. This includes coryza,
nasal congestion, sinusitis, and hoarseness.
Children between the ages of 6 and 36 months present-
ing with a ‘barking cough’, hoarseness, stridor, and
respiratory distress may be suffering from laryngotra-
cheobronchitis (croup). Unilateral symptoms, such as
one-sided sore throat and ipsilateral otalgia, may suggest
spread of infection beyond the palatine tonsil capsule,
such as a peritonsillar abscess.
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.
Drooling and an inability to take fluids orally should prompt
urgent referral to secondary care for intravenous
antibiotics. Drooling in children associated with fever, stri-
dor, dysphagia and an upright posture is highly suggestive
of epiglottitis, which although uncommon, can be
life-threatening. In adults, although rare, acute epiglottitis
has similar symptoms along with a muffled or hoarse voice.
The incidence of epiglottitis has dramatically declined
since routine infant vaccination with Haemophilus influen-
zae type b (Hib) vaccines began in 1991. These patients
should not be examined; rather they should be kept calm
and referred urgently to secondary care.
Otherwise, inspect the oral cavity, assessing for trismus
(an inability to open the jaw) on mouth-opening. This
may indicate a peritonsillar abscess or a deep neck
space infection. Although a whitish-yellow membrane
covering both tonsils may suggest glandular fever
(infectious mononucleosis) caused by Epstein– Barr
Virus (EBV) infection and a generalised erythematous,
swollen appearance with exudate is consistent with
GABHS infection (Fig. 1). Viral and bacterial infections
are clinically indistinguishable. The presence of cough
and coryzal symptoms may suggest a viral aetiology.
Look for inflammation, ulcers, masses, exudate and
asymmetry within the pharynx. Persisting ulcers (longer
than 3 weeks) or masses should prompt an ENT sus-
pected cancer pathway referral. Assess the uvula, soft
palate, palatine tonsils and the pharynx. If the base of
the uvula is deviated, along with soft palate oedema and
trismus, suspect a peritonsillar abscess.
Palpate the neck for cervical lymphadenopathy, making a
note of tender lymphadenopathy. This may suggest
GABHS infection. Tender, symmetrical posterior cervical
lymphadenopathy suggests EBV infection (Aronson &
Auwaerter, 2016), especially in teenagers or young adults
with malaise, fatigue and a more persistent sore throat.
Examine the ears, looking for an erythematous, bulging
tympanic membrane suggestive of acute otitis media.
Restriction of neck movements should raise the suspicion
of a deep neck space infection, requiring an immediate
referral to ENT specialists. Abdominal examination may
reveal hepatosplenomegaly in patients with glandular
fever.
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Table 1. Causative organisms of tonsillitis.
Bacterial Viral
Group A Streptococci Rhinovirus
Non-Group A Streptococci Influenza A
Neiserria gonorrhoea Adenovirus
Mycoplasma Pneumoniae Herpes simplex virus
Chlamydia Pneumoniae Epstein– Barr virus
Corynebacterium
Diphtheriae
Metapneumovirus
Respiratory synctial
virus
Parainfluenza
Figure 1. Clinical photograph of acute bacterial tonsillitis
showing enlarged, inflamed tonsils with exudate. The
uvula is central.
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The combination of symptoms and epidemiologic features
has been used to develop clinical scores that can be used
to attempt to predict the likelihood that a sore throat is
caused by GABHS infection (Breese, 1977; Centor,
Witherspoon, Dalton, Brody, & Link, 1981). The absence
of signs and symptoms of viral infections (e.g. coryza,
conjunctivitis, cough, hoarseness, anterior stomatitis, dis-
crete ulcerative lesions or vesicles, diarrhoea) makes a
bacterial rather than a viral infection more likely.
The Centor score is a widely used and accepted clinical
prediction tool that has a reasonable negative predictive
value in excluding GABHS. The scoring criteria are:
Tonsillar exudate; tender anterior cervical lymphadenop-
athy; fever over 38C; and absence of cough. The
Centor score is most useful in identifying patients in
whom neither microbiological tests nor antibiotic treat-
ment are necessary.
The Centor score was initially validated solely in adults,
and thus not in children. It was therefore later modified
(also known as McIsaac score) to incorporate age, and
was validated in about 600 adults and children (3–15
years old) in a Canadian study (McIsaac, Kellner,
Aufricht, Vanjaka, & Low, 2004). To determine a patient’s
total score, points are assigned as detailed in Table 2. The
predicted risk of GABHS infection depends on the total
modified Centor score as shown in Table 3.
Investigations
Patients with sore throat symptoms commonly visit their
GP, but in most cases the cause is viral and only
symptomatic treatment is needed (Hawker et al.,
2014). It is vital to quickly establish that a patient’s symp-
toms are due to tonsillitis and not another, potentially
dangerous cause of sore throat (such as a retropharyn-
geal abscess or acute epiglottitis).
Throat cultures are not recommended for every patient in
general practice (NICE, 2015a), and are unable to differ-
entiate between active infection and carriage (NICE,
2015a; Scottish Intercollegiate Guidelines Network,
2010). When performed properly, the sensitivity of
throat swabs is 90 to 95% for GABHS (Dingle, Abbott, &
Fang, 2014). Ideally when taking a throat swab, both tonsils
and posterior pharyngeal wall should be vigorously
swabbed without touching the tongue or buccal mucosa
(Pichichero, 1995). Results take 48 hours to be reported.
GABHS can be isolated from up to 30% of patients pre-
senting with sore throats (Caserta & Flores, 2010), how-
ever, values of asymptomatic carriage range between 6
and 40% (Little & Williamson, 1996). Both cost and time
limit the merits of throat swabs, but they may be useful in
patients that have failed treatment, or those patients in
whom a decision has been made to delay antibiotics.
Rapid antigen detection testing (RADT) is not recom-
mended as a routine investigation for acute sore throats
by NICE (NICE, 2015a), however, NHS England has
recently planned to roll out a ‘sore throat test and
treat’ service across pharmacies in the country over the
next year. Patients will be able to visit pharmacies for
RADT, and if positive, pharmacists will provide appropri-
ate antibiotics without patients needing to see their GPs
(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-
nosis of GABHS tonsillitis, but a negative RADT does not
rule it out; in these cases throat culture swabs would be
beneficial (Pichichero, 1995).
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Table 2. Modified Centor scoring.
Criterion Points
Fever (greater than or equal
to 38.3C)
1
Absence of symptoms of a viral
upper respiratory infection
(conjunctivitis, rhinorrhoea,
or cough)
1
Tender cervical lymphadenopathy 1
Tonsillar erythema, oedema 1
Age
3–14 years 1
15–44 years 0
Greater than or equal to 45 years 1
Adapted from McIsaac, Kellner, Aufricht, Vanjaka, & Low (2004).
Table 3. Pre-test probabilities of
Streptococcal infection in respect to the
Modified Centor Score.
Modified Centor Score Probability of
Streptococcal
tonsillitis (%)
Less than or equal to 0 1–2.5
1 5–10
2 11–17
3 28–35
Greater than or equal to
4
51–53
Adapted from McIsaac et al. (2004).
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A full blood count may be helpful in patients with sus-
pected infectious mononucleosis, in immunocomprom-
ised patients, and in patients with signs or symptoms of
severe infection. Raised white cell count with lymphocy-
tosis and atypical lymphocytes is suggestive of infectious
mononucleosis (IM). A positive monospot test in patients
with suspected IM is diagnostic of EBV infection, how-
ever, due to low sensitivity, a negative monospot test
does not rule out the diagnosis of IM. In these instances,
EBV-specific antibody testing may be carried out to con-
firm the diagnosis.
Vaginal and cervical, or penile and rectal swabs should be
considered if there is a suspicion of a gonococcal throat
infection, especially in sexually active adolescents and
those engaging in oral-genital sex. A human immune
deficiency virus (HIV) viral load assay is indicated for
patients at risk of HIV infection who have persistent ton-
sillopharyngitis accompanied by severe constitutional
symptoms.
Red flags and serious
diagnosis
...........................................................
Box 1 summarises the red flag symptoms that should
prompt an urgent referral to secondary care.
Differential diagnosis
...........................................................
Scarlet fever
Scarlet fever is caused by toxin-producing strains of
Streptococcus Pyogenes, a beta-haemolytic bacterium
that is classified as a Group A Streptococcus. Scarlet
fever is highly contagious, and is transmitted via drop-
lets. Outbreaks in schools and other institutions where
there is close contact between individuals can occur.
The incubation period is usually 2–3 days. The blanch-
ing rash usually appears on the second day of the ill-
ness, beginning on the chest and spreading to the
abdomen and extremities. The rash is prominent in
skin creases and has a sandpaper-like texture, due to
the occlusion of sweat glands. The rash persists for
several days, and later (up to 3 weeks) will result in
desquamation. There is an exudative tonsillopharyngitis,
and there may be small red haemorrhagic spots on the
hard and soft palate. The face is flushed, with circu-
moral pallor and a red strawberry tongue
Glandular fever (infectious mononucleosis)
EBV is the causative agent in patients typically present-
ing with a triad of sore throat, fever and lymphadenop-
athy. There is muscle ache and severe malaise out of
proportion to the clinical picture (Caserta and Flores,
2010). Lymphocytosis may be apparent on full blood
count and a positive monospot test is diagnostic.
Ampicillin-based antibiotics should be avoided, as they
may precipitate a rash. There may be splenomegaly in
up to 50% of patients (Fisher & Boyce, 2005) due to
lymphocytic infiltration, rendering the organ susceptible
to rupture, either spontaneously or traumatically. Splenic
rupture is rare (less than 0.5% of patients with IM), but
its consequences can be severe (Turner and Gard,
2008). Therefore, patients should be advised to avoid
activities that increase intra-abdominal pressure and
contact sport for at least 4–6 weeks (Becker and
Smith 2014).
HIV
HIV can cause ulcerative tonsillitis and pharyngitis with
fever. It occurs after an incubation period of 3–5 weeks
with symptoms of myalgia, arthralgia, lethargy, and
in some people a non-itchy maculopapular rash.
Lymphadenopathy develops a week later (Caserta &
Flores, 2010).
Herpes simplex virus pharyngitis
Herpes simplex virus (HSV) pharyngitis presents with
red, swollen tonsils that may have aphthous ulcers on
their surfaces. Herpetic gingival stomatitis, herpes labia-
lis, and hypopharyngeal and epiglottic lesions may be
seen.
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Box 1. Red flag symptoms.
NICE recommends urgent referral for anyone with:
.An unexplained sore throat persistent for longer
than 3–4 weeks (refer within 2 weeks) to rule out
malignancy
.Presence of red or white patches/ulceration/
swelling of the oral/pharyngeal mucosa for
more than 3 weeks
.Pain on swallowing or dysphagia for more than
3 weeks
The following features may suggest another more
serious diagnosis:
.Stridor or respiratory difficulty (respiratory dis-
tress, drooling, systemically unwell, painful swal-
lowing and muffled voice: suspect epiglottitis)
.Suppurative complications (e.g. peri-tonsillar or
parapharyngeal abscess) as there is a risk of
airway compromise
.At risk of immunosuppression
.Suspected Kawasaki disease
.Diphtheria
.Signs of being severely unwell and with either the
cause being unknown or a rare cause is suspected,
such as Stevens–Johnson syndrome (high fever,
arthralgia, myalgia, extensive bullae in the mouth
followed by erosion and a grey–white membrane)
Source: NICE (2015c).
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Complications
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Peri-tonsillar abscess/quinsy
A spread of infection beyond the tonsil may lead to an
abscess formation and collection of pus within the poten-
tial space between the tonsil and its containing fossa.
Clinical features include unilateral sore throat, trismus,
‘hot-potato’ voice, referred otalgia and odynophagia.
Treatment is in the form of aspiration/incision and drain-
age, and intravenous antibiotics. Rarely, these can pro-
gress to a parapharyngeal/retropharyngeal abscess,
which can cause airway obstruction and mediastinal
infection. Suspicion of any extracapsular spread of infec-
tion should prompt an immediate referral to ENT.
Airway obstruction
Airway obstruction is a rare complication and requires
immediate referral to secondary care, where surgical
intervention may be considered as an emergency. This
may occur because of oedema of the soft palate and
tonsils following a deep neck space infection, peritonsillar
abscess or in rare circumstances, EBV infection. Common
features include stridor, muffled voice, increased work of
breathing and tachypnoea.
Post-Streptococcal glomerulonephritis
Post-streptococcal glomerulonephritis is an inflammatory
disorder of the kidneys that can manifest 1–2 weeks after
a streptococcal throat infection. Common features
include dark urine, periorbital oedema, general malaise
and anorexia.
Rheumatic fever
Rheumatic fever is a rare, but serious, complication of an
untreated or partially treated streptococcal sore throat.
Clinical features include polyarthritis affecting the larger
joints, and cardiac involvement which manifests as chest
pain, shortness of breath and a new murmur; typically
mitral regurgitation. Valvular damage can persist long term.
Treatment options
...........................................................
The medical treatment of sore throats does not necessarily
need to focus on the administration of antibiotics, as has
historically been the case. Between 50 and 80% are due to
a viral cause, and therefore, the use of antibiotics should
be discouraged to reduce the risk of antibiotic resistance.
In a 2013 meta-analysis, sore throat lasted between 2 and
7 days among children who received control, placebo, or
over-the-counter treatment; the sore throat resolved by
day 3 in approximately 60–70% of cases (Thompson
et al., 2013). The duration of symptoms was similar in
children with and without GABS tonsillitis. Treatment
with antibiotics improved symptoms 16 hours earlier
compared with those treated with supportive care only
(Spinks, Glasziou, & Del Mar, 2013). Symptom resolution
was much more likely if antibiotic treatment was insti-
gated within 2 days of symptom onset (Randolph,
Gerber, DeMeo, & Wright, 1985).
Both suppurative and non-suppurative complications are
uncommon, and clinical scoring does not predict the like-
lihood of acquiring these complications (Howie & Foggo,
1985; Little et al., 2013; Taylor & Howie, 1983). Reducing
suppurative and non-suppurative complications requires
treating many patients with antibiotics (Spinks et al.,
2013). For example, the complication rate of acute otitis
media (AOM) among those with sore throats is estimated
at 0.7%, implying a number needed to benefit (NNTB) of
nearly 200 to prevent one case of AOM. In low-income
countries, complications are much more common, and
therefore, the NNTB may be lower (Spinks et al., 2013).
In both instances, there is a balance between modest
levels of symptom reduction and the risk of antimicrobial
resistance. In most cases, supportive management may
be all that is required in the form of adequate analgesia:
paracetamol and ibuprofen. Patients should also be
advised to maintain adequate hydration and to rest.
Occasionally, antibiotics are recommended at first pres-
entation to treat: marked systemic upset, those with
valvular heart disease or existing rheumatic heart disease,
patients with scarlet fever and for complications of ton-
sillitis. Patients with or without suppurative complications
of tonsillitis, and who are unable to swallow, will require
admission to secondary care for administration of paren-
teral antibiotics and fluids.
Antibiotics are recommended for patients at high risk of
complications, including patients who are immunocom-
promised or have significant heart, lung, renal, liver or
neuromuscular disease. The high-risk group includes
patients with cystic fibrosis, and young children born
prematurely.
Antibiotics may also be considered in patients scoring
three or more on the modified Centor criteria. These
patients may be provided with a prescription for delayed
antibiotics, or with no antibiotics if no risk factors of
severe infection are present.
The antibiotic of choice is Phenoxymethylpenicillin for 10
days. A macrolide can be used as an alternative if an
allergy to penicillin exists. Ampicillin-based antibiotics
should be avoided in the treatment of sore throats, as
these may precipitate a widespread non-blanching macu-
lopapular rash in the presence of glandular fever.
NICE (NICE 2015b) suggests a delayed antibiotic pre-
scription as an alternative prescribing strategy. In this
case, patients can be offered:
.Reassurance that antibiotics are not needed immedi-
ately, as they are likely to make little difference to
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symptoms and may have side effects, such as diar-
rhoea, vomiting and rashes
.Advice about using the delayed prescription if symp-
toms do not settle within the expected time frame, or
if a worsening occurs in the patient’s clinical status or
symptoms
.Advice about seeking medical advice if there is a
worsening in the clinical condition, despite using the
delayed prescription
Ultimately, a clear explanation regarding the expected
course of illness should be provided to the patient. It
should be emphasised that symptoms will resolve
within 7 days, and that if there is worsening of symptoms
or no improvement patients should re-present for review.
The use of glucocorticoids has increased recently, but is
controversial. The Infectious Disease Society of America
advises against the use of steroids, however, in patients
with severe throat pain and/or inability to swallow, there
may be a role (Shulman et al., 2012).
In cases of recurrent tonsillitis, referral to secondary care
should be discussed for consideration of tonsillectomy.
Although tonsillectomy has been shown to reduce the
number of sore throats and improve general health, the
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
a tonsillar haemorrhage rate of 3.5% (British Association of
Otorhinolaryngologists—Head and Neck Surgeons, 2005).
It is important to note that although tonsillectomy can pre-
vent recurrent episodes of tonsillitis, it will not affect recur-
rent sore throats from other causes. Therefore, it is vital to
confirm a diagnosis of recurrent tonsillitis and rule out sore
throats from other aetiologies prior to consideration of
surgical management.
The Scottish Intercollegiate Guidelines Network (SIGN)
published guidelines in 1999 on the management of sore
throat and indications for tonsillectomy. These advise on
the indications for tonsillectomy in both adults and chil-
dren and can be used to guide ENT referral in primary
care; they are listed in Box 2.
It is interesting to note that a cross-sectional observa-
tional study of trends in emergency hospital admission
for sore throats in the context of the number of tonsillec-
tomies, found a 44% reduction in the overall tonsillec-
tomy rate between 1991 and 2011. During the same
study period, the admission rate to hospital for tonsillitis
rose by 310%, for peritonsillar abscess by 31% and for
retro/parapharyngeal abscess by 39% (Lau, Upile, Wilkie,
Leong, & Swift, 2014).
Tonsillectomy may be considered on a case-by-case basis
after careful consideration of the risks and benefits and a
thorough discussion of the options with the patient. In
cases where the diagnosis is uncertain, or there is a
doubt as to the clinical significance of the sore throats,
a period of active monitoring over a minimum of
6 months can be beneficial, with patients recording epi-
sodes and symptoms in a ‘sore throat diary’.
Tonsillectomy is performed under a general anaesthetic,
and may involve an overnight stay in hospital. Recovery
takes up to 2 weeks and patients are advised to rest;
taking time off work/school. They will require regular
analgesia and should maintain a good oral intake, as
this has been shown to reduce recovery time and pre-
vent infections.
Key points
.Diagnosis of acute tonsillitis is clinical, and it can
be difficult to distinguish viral from bacterial
infections
.GABHS accounts for up to 30% of the cases of
tonsillitis in children and adolescents
.The modified Centor score is a useful validated
clinical prediction tool for diagnosing GABHS
tonsillitis
.Complications of tonsillitis include peritonsillar and
neck space abscesses, rheumatic fever and post-
streptococcal glomerulonephritis
.Most cases of tonsillitis are self-limiting and do not
require antibiotics
.Patients who fulfil the SIGN criteria, may be
referred to secondary care for consideration of
surgical management
References and further information
.Aronson, M. D., & Auwaerter, P. G. (2016).
Infectious mononucleosis in adults and adoles-
cents. Retrieved from https://www.uptodate.
com/contents/infectious-mononucleosis-inadults-
and-adolescents
.Becker, J. A., & Smith, J. A. (2014). Return to play
after infectious mononucleosis. Sports Health,
6(3), 232–238. doi: 10.1177/1941738114521984
.Breese, B. (1977). A simple scorecard for the ten-
tative diagnosis of streptococcal pharyngitis.
Archives of Pediatrics & Adolescent Medicine,
131(5), 514–517
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Box 2. SIGN criteria for surgical intervention
in secondary care.
.Sore throats attributable to acute tonsillitis
.These episodes prevent normal functioning
.Seven or more clinically significant, documented
and appropriately treated episodes of sore throat
in the preceding year, or
.Five or more such episodes per year in the pre-
ceding 2 years, or
.Three or more such episodes per year in the
preceding 3 years
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.British Association of
Otorhinolaryngologists—Head and Neck
Surgeons (2005) The Royal College of Surgeons
of England, national prospective tonsillectomy
audit final report. London, UK: The Royal College
of Surgeons of England, London, UK
.Butler, C., Rollnick, S., Pill, R., Maggs-Rapport, F.,
& Stott, N. (1998). Understanding the culture of
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tioners’ and patients’ perceptions of antibiotics
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.Caserta, M. T., & Flores, A. R. (2010). Pharyngitis.
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.Desmond, S. (2016). Sore throats to be tested by
pharmacists instead of GPs under NHS move.
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2016/nov/12/sore-throat-test-pharmacists-
instead-of-gps-under-nhs-move
.Dingle, T., Abbott, A., & Fang, F. (2014). Reflexive
culture in adolescents and adults with group A
streptococcal pharyngitis. Clinical Infectious
Diseases,59(5), 643–650. doi: 10.1093/cid/ciu400
.ENT UK. (2009). Position paper ENT UK 2009:
Indications for tonsillectomy. Retrieved from
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09.pdf on 04/12/16
.Fisher, R. G., & Boyce, T. G. (2005). Infectious
mononucleosis and mononucleosis-like syn-
dromes. In Moffet’s pediatric infectious diseases,
fourth edition. London, UK: Lippincott Williams &
Wilkins.
.Hawker, J., Smith, S., Smith, G., Morbey, R.,
Johnson, A., Fleming, D., ...Hayward, A. (2014).
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02441.d8
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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