Acute/Recurrent Tonsillitis Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • Acute and recurrent Tonsillitis and when to referral for Tonsillectomy
  • Adults and children

Commissioning Statements:


Signs and Symptoms

Typical features of tonsillitis include:

  • Soreness of the throat especially upon swallowing
  • Swollen neck glands
  • Enlarged erythematous tonsils – with or without exudates
  • Headache
  • Fever
  • Can be associated with small red haemorrhagic spots on the hard and soft palate
  • Nausea, vomiting, and abdominal pain are also common (children only)

History and Examination

  • Do not examine the throat of anyone with suspected epiglottitis (dysphonia, drooling, sepsis or stridor)

Differential Diagnoses

  • Tonsillitis – viral or bacterial causes
  • Epiglottitis
  • Quinsy
  • Infectious mononucleosis (glandular fever)
  • Malignancy − be suspicious if there is unilateral enlargement and subacute or chronic symptoms, or if swelling is painless
  • Embedded foreign body:
    • Suggestive history
    • Unilateral pain
    • Abscess formation

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Sore throat associated with stridor or respiratory difficulties, drooling, systemically very unwell, painful swallowing, muffled voice − suspect acute epiglottitis
  • Dehydration or reluctance to take any fluids
  • Severe suppurative complications, e.g.:
    • Peritonsillar abscess (also known as quinsy) or cellulitis
    • Parapharyngeal abscess
    • Retropharyngeal abscess
    • Lemierre's syndrome (fusobacterial pharyngitis associated with IJV thrombosis and high risk of complications)
  • Signs of being markedly systematically unwell
  • Immunosuppressed patients- if patients taking DMARDs or carbimazole and not appropriate for admission take FBC and withhold medication and advise specialist contact, advise them obtain immediate medical advice if systemically unwell
  • Suspected Kawasaki disease
  • Malignancy − be suspicious if there is unilateral enlargement and subacute or chronic symptoms persist for more than 3 weeks, or if swelling is painless


  • Throat swabs should not be carried out routinely in primary care management of sore throat unless scarlet fever is suspected.
  • Consider serology for infectious mononucleosis.


Advice Patient to:
  • Have plenty of rest
  • Drink enough fluids to avoid feeling thirsty
  • Ask local community pharmacist to recommend medicines to help with symptoms or pain (or both)
  • Keep well by eating healthily, including at least five portions of fruit and vegetables every day.
FeverPAIN Score
  • The FeverPAIN clinical score can help prescribers to determine if a sore throat is more likely to be caused by bacteria. Higher scores suggest more 12 severe symptoms and likely bacterial (streptococcal) cause.
  • Each of the FeverPAIN criteria (below) score 1 point (maximum score of 5).
    • Fever
    • Purulence
    • Attend rapidly (3 days or less)
    • Severely Inflamed tonsils
    • No cough or coryza
  • A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus.
  • A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus.
  • A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus
Antibiotic treatment
  • FeverPAIN score of 0 or 1
    • Unlikely to benefit from an antibiotic
    • Do not offer an antibiotic prescription
    • Give advice about managing symptoms and advise to seek medical help if symptoms deteriorate rapidly or significantly, do not improve after 1 week or they become systemically very unwell
  • FeverPAIN score of 2 or 3
    • More likely to benefit from an antibiotic
    • Offer a delayed antibiotic prescription
  • FeverPAIN 2 score of 4 or 5
    • Most likely to benefit from an antibiotic
    • Offer an immediate antibiotic prescription
  • People who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high-risk of complications - Offer an immediate antibiotic prescription
For pain relief:
  • In adults:
    • Consider non-steroidals and simple analgesia
  • In children:
    • Paracetamol
    • Ibuprofen should be used with caution in children with or at risk of dehydration
  • Please refer to the Prescribing Guidelines for up to date guidance - NHS SWYAPC - Upper Respiratory Tract Infection


Referral Criteria

  • Red Flags
  • As per commissioning statement - evidence of recurrent acute sore throat due to tonsillitis as follows:
    • 7 or more, clinically significant, adequately treated episodes of tonsillitis in the last year
    • 5 or more such episodes per year in the preceding two years
    • 3 or more such episodes per year in the preceding three years
    • With significant impact on quality of life OR Failure to thrive
    • Marked tonsillar asymmetry, which there is clinical suspicion sinister pathology
    • Halitosis thought to be caused by tonsils but ONLY where there is clear evidence of tonsillar debris

Referral Requirements

  • Documented evidence that the patient meets the above criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statements:

Referral Instructions

  • e-consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Decision Making Aid - Tonsillectomy – this can also be printed off for the patient

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 09.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 09.2017
  • Publication Date: 09.2017
  • Last Updated: 01.2018
  • Review Date: 01.2020
  • Ref No: ENT9 - 09.2017
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Only the electronic version is maintained, once printed this is no longer a controlled document


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