Guideline 34 Summary

Management of Sore Throat and Indications for Tonsillectomy
Summary

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.

PRESENTATION

Sore throat associated with stridor or respiratory difficulty is an absolute indication for admission to hospital.

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

Practitioners should be aware of underlying psychosocial influences in patients presenting with sore throat.

DIAGNOSIS OF SORE THROAT

Clinical examination should not be relied upon to differentiate between viral and bacterial sore throat.

Throat swabs should not be carried out routinely in sore throat.

Rapid antigen testing should not be carried out routinely in sore throat.

MANAGEMENT OF SORE THROAT

Diagnosis of a sore throat does not mean that an antibiotic has to be administered. Adequate analgesia will usually be all that is required.

Taking account of the increased risks associated with non steroidal anti-inflammatory agents (NSAIDs), their routine use in management of sore throat is not recommended.

Paracetamol is the drug of choice for analgesia in sore throat, taking account of the increased risks associated with other analgesics.

ANTIBIOTICS IN ACUTE SORE THROAT

The limited information available is insufficient to support a recommendation on the routine use of antibiotics in acute sore throat.

In severe cases, where the practitioner is concerned about the clinical condition of the patient, antibiotics should not be withheld.

Antibiotics should not be used to secure symptomatic relief in sore throat.

Sore throat should not be treated with antibiotics specifically to prevent the development of rheumatic fever or acute glomerulonephritis.

Antibiotics may prevent cross-infection with group A beta-haemolytic streptococcus (GABHS) in closed institutions (such as barracks, boarding schools) but should not be used routinely to prevent cross infection in the general community.

The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat.

Practitioners should be aware that infectious mononucleosis may present with severe sore throat with exudate and anterior cervical lymphadenopathy, and should avoid prescription of ampicillin-based antibiotics, including co-amoxiclav, as first line treatment.

ANTIBIOTICS IN RECURRENT SORE THROAT

There is no evidence to support a recommendation on the use of antibiotics in recurrent non streptococcal sore throat.

In cases of recurrent sore throat associated with GABHS (not necessarily causal) the limited evidence of benefit available suggests that a 10-day course of antibiotic may reduce the number and frequency of attacks. However, diagnosis of GABHS is not reliable.

INDICATIONS FOR TONSILLECTOMY

The following are recommended as reasonable indications for consideration of tonsillectomy in both children and adults, based on the current level of knowledge, clinical observation in the field and the results of clinical audit. Patients should meet all of the following criteria:

sore throats are due to tonsillitis
five or more episodes of sore throat per year
symptoms for at least a year
the episodes of sore throat are disabling and prevent normal functioning.

A six month period of watchful waiting is recommended prior to tonsillectomy to firmly establish the pattern of symptoms and allow the patient to consider fully the implications of operation.

Once a decision is made for tonsillectomy, this should be performed as soon as possible, to maximise the period of benefit before natural resolution of symptoms might occur (without tonsillectomy).

Management of Sore Throat and Indications for Tonsillectomy Summary

Management of Sore Throat and Indications for Tonsillectomy
Summary