Mrs Ceilidh Kennedy (left) and Mr Musheer Hussain explain the new SIGN recommendations on management of sore throats and indications for tonsillectomy
The Scottish Intercollegiate Guidelines Network (SIGN) has recently published a guideline on the Management of sore throat and indications for tonsillectomy,1 which updates and supersedes SIGN guideline 34, published in 1999.2 The Guideline Development Group worked from 2008–2010 to incorporate the most recent evidence and to suggest a rational approach to the management of acute sore throat in general practice, as well as to provide the criteria for referral for tonsillectomy when recurrent tonsillitis is seen.
Presentation and diagnosis
Acute pharyngitis, tonsillitis, or acute exudative tonsillitis may cause sore throat. For the purpose of non-surgical management, these conditions are dealt with together under the term ‘sore throat’. Most sore throats can be managed at home by patients. However, patients with a sore throat who seek advice generally attend their GP, and in the majority of cases the condition is relatively minor and self-limiting.1
The management of recurrent sore throats can cause undesirable morbidity, inconvenience, loss of education or earnings, and is a significant strain on health service resources.1 The cost to NHS Scotland of GP consultations for sore throat exceeds £10.9 million per annum, before any treatment or investigation.3
It is essential that GPs are aware of both the underlying psychosocial influences and the medicalising effect of prescribing antibiotics.4 A patient information leaflet would be useful in the management of acute sore throat and would assist in managing future episodes.1
Accurate clinical diagnosis is difficult because clinically it is hard to differentiate between bacterial and viral infections. The most common bacterial pathogen is group A beta-haemolytic streptococcus (GABHS) for which antibiotic treatment may be considered.1 During a consultation no single symptom or sign is helpful when used alone to diagnose a sore throat, however, combinations of factors have been used in several clinical prediction rules. The Centor scoring system should be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for precise diagnosis. The score is not validated for use in children under 3 years of age.1,5
The Centor score gives one point each for:4
- tonsillar exudate
- tender anterior cervical lymph nodes
- history of fever
- absence of cough.
The likelihood of GABHS infection rises with increasing score, and is between 25%–86% certain with a score of 4, and 2%–23% with a score of 1, depending on age, local prevalence, and seasonal variation.4
Streptococcal infection is most likely in those aged 5–15 years and becomes progressively less likely in younger and older patients.5
Hospital admission is necessary for patients with sore throat who have stridor, progressive difficulty with swallowing, increasing pain, or severe systemic symptoms. These patients may have peritonsillar cellulitis or abscess (quinsy) and may require parenteral antibiotics. In young adults, glandular fever (infectious mononucleosis) is a common reason for hospital admission as these patients are often unable to swallow. Patients with severe uncomplicated tonsillitis who develop dysphagia and dehydration may also require admission.1
Assessment of the patient in general practice should take account of other medical conditions and prescribed medication that may suggest an increased susceptibility to infection and, therefore, lower the threshold for antibiotic treatment. Occasionally sore throat may be a presenting symptom of acute epiglottitis or another serious upper airway disease. If the patient is having difficulty breathing, urgent referral to hospital is mandatory and attempts to examine the throat should be avoided.1
Throat swabs are neither sensitive nor specific for serologically confirmed infection. Taking swabs considerably increases costs, may medicalise the illness, and changes few management decisions.6 Throat swabs should not be carried out routinely in the primary care management of sore throat; however, they may be used to establish the aetiology of recurrent severe episodes in adults when considering referral for tonsillectomy.
There is insufficient evidence to recommend rapid antigen testing as neither it nor throat swab culture can differentiate between the streptococcal carrier state and an invasive infection.1,7
General management of sore throat
Diagnosis of a sore throat does not mean that an antibiotic has to be given. Patients should be advised that it is a treatable condition and be given advice on how to relieve symptoms and manage the pain with sufficient analgesia. In adults diclofenac and ibuprofen are superior to paracetamol and aspirin in reducing throat pain as early as 1 hour post-dose.8,9
Analgesia in adults
Ibuprofen 400 mg three times daily is recommended for the relief of fever, headache, and throat pain. In adults with sore throat who are unable to tolerate ibuprofen, paracetamol 1 g four times daily when required is recommended for symptom relief.1
Analgesia in children
The recognised complications of aspirin therapy, including Reye’s syndrome in children, make it less suitable for general use, and its use as an analgesic is contraindicated in patients under 16 years of age. In children who have a sore throat, an adequate dose of paracetamol should be used as the first-line treatment for pain relief.1
Ibuprofen can be used as an alternative to paracetamol in children.1 A systematic review and meta-analysis of ibuprofen and paracetamol use in febrile children and the occurrence of asthma-related symptoms showed that there is a low risk of asthma-related morbidity associated with ibuprofen in children.10 Ibuprofen should not be given routinely to children with or at risk of dehydration as recent case reports have highlighted concern about renal toxicity.11,12
There is inadequate evidence to choose between ibuprofen, paracetamol, or their combination for pain relief in children. There is also insufficient evidence to establish safety of diclofenac in children with a sore throat.1
There is no good quality evidence on the effectiveness of non-prescription throat sprays, lozenges, gargles, or echinacea purpurea. Evidence on the use of corticosteroids for pharyngitis is conflicting and no recommendations were made. However, in patients with acute glandular fever (infectious mononucleosis) who require hospitalisation, corticosteroids may have a role when pain and swelling threaten the airway or where there is very severe dysphagia.1
Antibiotics in acute sore throat
It is important to note the limitations of performing throat swabs and of isolating, or failing to isolate, GABHS. The significance of the presence of bacterial pathogens in cases of sore throat remains in doubt, and the superiority of antibiotics over simple analgesics is negligible in reducing duration or severity of symptoms.13,14
With the increase in healthcare-acquired infections and antibiotic resistance in the community, unnecessary prescribing of antibiotics for minor self-limiting illness should be avoided. The general use of antibiotics is associated with:1
- promotion of Candida infections
- the risk of developing resistant bacteria
- the risk of adverse effects including allergic reactions
- increased prescribing costs.
In severe cases where the practitioner is concerned about the clinical condition of the patient, antibiotics should not be withheld. The dose used in most studies is penicillin V 500 mg four times daily for 10 days. A macrolide can be considered as an alternative first-line treatment, in line with local guidance. Patients must be advised to complete the course of antibiotics.1
In certain circumstances, such as epidemics, more widespread prescription of antibiotics may be recommended and the relevant public health guidance should be followed. Ampicillin-based antibiotics, including co-amoxiclav, should not be used for sore throat because these antibiotics may cause a rash when used in the presence of glandular fever.1
Sore throat should not be treated with antibiotics specifically to prevent the development of rheumatic fever and acute glomerulonephritis,15,16 and the prevention of suppurative complications (e.g. quinsy) is also not a specific indication for antibiotic therapy. Antibiotics may prevent cross infection with GABHS in closed institutions (e.g. barracks, boarding schools) but should not be used routinely to prevent cross infection in the general population.1
Surgery in recurrent sore throat
The literature on surgery for recurrent tonsillitis is limited. Most published studies refer to a paediatric population and yet evidence on exactly which children with sore throats benefit from tonsillectomy is not available. Current evidence suggests that the benefit of tonsillectomy increases with the severity and frequency of sore throats prior to such a procedure. Watchful waiting is more appropriate than tonsillectomy for children with mild sore throats. Apart from in adults with proven recurrent group A streptococcal pharyngitis, evidence on which adults will benefit from tonsillectomy is not available.17
Tonsillectomy is recommended for recurrent severe sore throat in adults. The operation requires a short admission to hospital and a general anaesthetic, is painful, and can occasionally be complicated by bleeding. Return to normal daily activities takes 2 weeks on average, with a corresponding loss of time from education or work.1
Indications for considering tonsillectomy
The following are indications for consideration of tonsillectomy for recurrent acute sore throat in both children and adults:1,18
- Sore throats that are due to acute tonsillitis
- The episodes of sore throat are disabling and prevent normal functioning
- Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or
- Five or more such episodes in each of the preceding 2 years or
- Three or more such episodes in each of the preceding 3 years.
It should also be noted whether the frequency of episodes is increasing or decreasing as there are situations in which tonsillectomy may be appropriate outside the criteria listed above. This judgement should be made following a discussion with the patient, covering all the diagnostic and treatment choices available.1
When unsure as to whether tonsillectomy would be beneficial, a 6-month period of watchful waiting is recommended prior to consideration of surgery to establish firmly the pattern of symptoms and allow the patient to consider fully the implications of an operation. Patients should be informed that there is no guarantee that tonsillectomy will prevent all sore throats in the future and they should also be advised of the length of stay, the need for general anaesthetic, and the possible complications (e.g. bleeding).1
Patients frequently experience significant morbidity following tonsillectomy. This can include:
- throat and ear pain
- poor oral intake
- decreased activity levels.
Pain and poor oral intake can have an impact on the recovery of tonsil beds and lead to a secondary bleed. At the time of discharge, patients/carers should be provided with written information advising them who to contact and at what hospital unit or department to present if they have post-operative problems. Studies have shown that in most cases pain will reduce in the first few days following tonsillectomy, but is likely to increase around day 5 before finally tailing off from day 6 onwards.1
Following discharge, a letter should be sent to the GP giving details of the hospital admission and the discharge medication given.
Implementation of the guideline
Guideline implementation is the responsibility of each NHS Board and is an essential part of clinical governance. The key priorities for implementation in general practice are to make all members of the team aware of any new guidelines and review their current practice. The reasons for any differences should be assessed and addressed where appropriate. A further audit of clinical practice after 6 months would assess whether the guidelines had been successfully followed.
A patient information leaflet explaining the diagnosis and treatment of sore throat would be useful in general practice. Patient information leaflets about paediatric and adult tonsil surgery are routinely provided at ear, nose, and throat outpatient clinics in conjunction with ENT·UK (see www.entuk.org)—GPs could familiarise themselves with the content of these leaflets so that they can provide accurate information during the consultation. GPs should also be aware of who to contact locally in the event of postoperative problems.
- Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. SIGN 117. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/guidelines/fulltext/117/index.html
- Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. SIGN 34. Edinburgh: SIGN, 1999.
- NHS Quality Improvement Scotland. Tonsillectomy for recurrent bacterial tonsillitis. Available at: www.nhshealthquality.org/files/Procedures_23_Tonsillectomy_APR08.pdf (cited 8 April 2010).
- Little P, Gould C, Williamson I et al. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997; 315 (7104): 350–352.
- Ebell M, Smith M, Barry H et al. The rational clinical examination. Does this patient have strep throat? JAMA 2000; 284 (22): 2912–2918.
- Del Mar C. Managing sore throat: a literature review I. Making the diagnosis. Med J Aust 1992; 156 (8): 572–255.
- Scheeler R, Little P. Rapid streptococcal testing for sore throat and antibiotic resistance. Clin Microbiol Infect 2006; 12 (suppl 9): 3–7.
- Boureau F, Pelen F, Verriere F et al. Evaluation of ibuprofen vs paracetamol analgesic activity using a sore throat pain model. Clin Drug Investig 1999; 17 (1): 1–8.
- Gehanno P, Dreiser R, Ionescu E et al. Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat. Clin Drug Investig 2003; 23 (4): 263–271.
- Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms. Clin Ther 2007; 29 (12): 2716–2723.
- Moghal N, Hegde S, Eastham K. Ibuprofen and acute renal failure in a toddler. Arch Dis Child 2004; 89 (3): 276–277.
- Buck M. Ibuprofen-associated renal toxicity in children. Pediatr Pharmacotherapy 2000; 6 (4).
- Little P, Williamson I, Warner G et al. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997; 314 (7082): 722–727.
- Del Mar C. Managing sore throat: a literature review II. Do antibiotics confer benefit? Med J Aust 1992; 156 (9): 644–649.
- Howie J, Foggo B. Antibiotics, sore throats and rheumatic fever. J R Coll Gen Pract 1985; 35 (274): 223–224.
- Taylor J, Howie J. Antibiotics, sore throats and acute nephritis. J R Coll Gen Pract 1983; 33 (257): 783–786.
- Alho O, Koivunen P, Penna T et al. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: Randomised controlled trial. BMJ 2007; 334 (7600): 939–941.
- Paradise J, Bluestone C, Bachman R. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984; 310 (11): 674–678.G