1.1 Background: the need for a guideline

The management of sore throat in general practice and the further progress to tonsillectomy in a number of cases results in significant use of health service resources. In most cases, the condition is relatively minor and self-limiting. Sore throat has few long term adverse health effects. However, a significant number of patients experience unacceptable morbidity, inconvenience, and loss of education or earnings due to recurrent sore throat. As a result, patients present to general practitioners, who may actively treat them with antibiotics of questionable efficacy and considerable aggregate cost.

A proportion of these patients are referred to ENT surgeons, who may recommend surgery on criteria which are based on precedent, personal experience and a belief of benefit, rather than good scientific evidence. Tonsillectomy has an appreciable perioperative morbidity, a complication rate of around 2%, and the outcome is as yet undefined. However, in most cases, patients (or their parents) seem satisfied with the operation and to benefit from it (see section 6.1).² The paucity of good quality literature addressing an area of long established practice does not inevitably mean that that practice is valueless.

A guideline for management of acute and recurrent sore throat based on a systematic review of the literature (see Annex 1) has the potential to benefit patient care in addition to encouraging more efficient and effective use of health service resources. The guideline should consider optimal management, such that patients are not denied effective treatment which may reduce long term morbidity and minimise unproductive time due to illness.

1.2 Aim of the Guideline

This guideline presents evidence-based recommendations for the management of acute and recurring sore throat and indications for tonsillectomy. Note that the guideline considers only tonsillectomy for recurring sore throat. It does not address tonsillectomy for suspected malignancy or as a treatment for sleep apnoea, peritonsillar abscess, or other conditions. The published literature is mainly concerned with a paediatric population and there is little evidence concerning the management of recurring sore throats in adults. The aim of this guideline is to suggest a rational approach to the management of acute sore throat in general practice and to provide reasonable criteria for referral for tonsillectomy. The guideline also provides examples of patient information leaflets which may assist in management and facilitate decision making about operation (see Annexes 2 and 3) and suggests areas where further research could be productive (see section 7.2).

1.3 Definitions

Sore throat may also be described as 'acute pharyngitis', 'tonsillitis', 'acute exudative tonsillitis'. For the purpose of this guideline, these terms are treated as synonymous. There is no agreed definition of 'chronic' or 'recurrent' sore throat. Within this guideline, the term 'sore throat' is used.

1.4 Symptoms and Signs

Symptoms include:

• sore throat (usually lasting more than three days)
  
• anorexia, lethargy, systemic illness
  
• absence of cough (cough commonly occurs in viral upper respiratory infection, often in association with posterior cervical lymphadenopathy).

Abnormal physical signs include:

• inflamed tonsils or pharynx
  
• purulent exudate on tonsils
  
• fever
  
• anterior cervical lymphadenopathy.

Sore throat may be part of the early symptom complex of minor upper respiratory viral infections. This phase usually passes in 24-48 hours. Occasionally, sore throat may be a presenting symptom of acute epiglottitis or other serious upper airway disease.

If breathing difficulty is present, urgent referral to hospital is mandatory and attempts to examine the throat should be avoided.

1.5 Epidemiology

No case-control or population studies of the epidemiology of sore throat in recent UK populations were identified in the literature search undertaken for this guideline (see Annex 1); neither were longitudinal community studies found on the natural history of recurrent sore throat. However, studies of those attending general practice suggest that sore throat affects both sexes and all age groups, but is much more common in children.³ Sore throat is more common in late autumn and early winter.⁴

1.6 Sore Throat in Scotland

General Practice Administration System for Scotland (GPASS) data covers 75% of the practices in Scotland, but the way in which data are entered can vary between practices. The Continuous Morbidity Recording (CMR) practices supply data on doctor/patient contacts from a sample of the Scottish population (282,700 patients from 52 practices). Different codes are used for 'upper respiratory infection', 'sore throat symptoms', 'acute tonsillitis', and 'acute pharyngitis' and it is not clear what the differences are between these diagnoses. 'Acute tonsillitis' is the sixth most common GP presentation for girls, and eighth for boys (aged 0-14 years), but adding up the different definitions would place tonsillitis much higher. For all ages, acute tonsillitis was the eighth most common acute presentation in 1996, with a rate of 32 per 1000 (approx 1 in 30) patients per year. The rate was higher for females in all age bands.⁵

1.7 Natural History of Recurrent Sore Throat

There is no information on the natural history of sore throat which looks at adults and children separately. Most other childhood upper respiratory tract diseases tend to improve with time and this also appears true of sore throat, but there is no epidemiological evidence of this; neither is it known whether recurrent sore throat in adults also improves with time. Importantly with regard to making recommendations for tonsillectomy, the timescale for natural remission is unknown in these two separate groups to balance expected natural resolution rates against the disadvantages of surgery.