QuestionSBA
QuestionChoice
In cases where the patient has stridor, respiratory difficulty, dehydration, severe suppurative complications, severe systemic illness, or suspected Kawasaki disease or epiglottitis, an urgent same-day referral to an ENT specialist may be necessary. Referring the patient to a specialist may be required in these instances, but it is not the most appropriate next step in this case.
62327
e
Urgent referral to a specialist
QuestionChoice
The evaluation of patients with tonsillitis involves using the CENTOR score, a scoring system that includes:

- Fever
- Tonsillar exudate
- Tender cervical lymphadenopathy
- Abscence of cough

Each of these factors is assigned one point, and the total score is used to determine the likelihood of *streptococcal* *pharyngitis* or 'strep throat'. NICE guidelines advise commencing antibiotics immediately if the **CENTOR score is 3 or 4**. As her score is 3, and she is allergic to penicillins, clarithromycin is the most appropriate medication.
62323
a
Clarithromycin
QuestionChoice
If the patient has a CENTOR score of 1 or 2, they are unlikely to benefit from an antibiotic, and an antibiotic prescription should not be offered. However, they may consider using the antibiotic if their sore throat has not started to improve within 3-5 days or if their symptoms worsen. They should be given the option of returning for reassessment and be advised to do so if their symptoms continue to worsen despite using the antibiotic prescription.
62326
d
Review after 5-7 days
QuestionChoice
Reassuring the patient may provide temporary relief, but it does not address the underlying cause of the patient's symptoms and would not be sufficient as a standalone treatment.
62325
c
Reassure
QuestionChoice
In cases of tonsillitis, NICE guidelines recommend prescribing antibiotics immediately if the CENTOR score is 3/4, and phenoxymethylpenicillin is the first-line medication as the positive predictive value for *streptococcal* pharyngitis or strep throat is between 32-56%. However, in this case, the patient is allergic to penicillin, so an alternative antibiotic, such as clarithromycin, would be more appropriate.
62324
b
Phenoxymethylpenicillin
QuestionComment
Another question of a similar presentation indicated hospital admission...
29318
User
subscriber
Mike Oxsmall
Concept
Chapter
# Summary
 
 
Tonsillitis is a condition characterised by the inflammation of the tonsils due to infection. The main signs and symptoms include sore throat, headache, fever, and lymphadenopathy. Investigation methods such as throat swabs are not routinely performed, and blood tests are reserved for patients with immunodeficiency. Management strategies primarily include treatment with paracetamol and ibuprofen, with antibiotics prescribed in certain cases.
 
 
# Definition
 
 
Tonsillitis is a medical condition that is characterised by the inflammation of the tonsils, which are the masses of lymphoid tissue located at the back of the throat. This inflammation is primarily due to an infection.
 
 
# Epidemiology
 
 
Sore throat is a very common presenting complaint. Cases are highest in children during the winter months.
 
# Aetiology
 
 
The aetiology of tonsillitis is usually due to a viral or bacterial infection. Common viruses include the Epstein-Barr virus, influenza virus, adenovirus, and rhinovirus. Bacterial tonsillitis can be caused by Group A streptococcus, which is also responsible for strep throat.
 
 
# Signs and Symptoms
 
 
Patients with tonsillitis typically present with the following symptoms:
 
 
 - Sore throat
 - Headache
 - Fever (pyrexia)
 - Enlarged and tender lymph nodes (lymphadenopathy)
 - Enlarged & erythematous tonsils
 - Tonsillar exudate
 - Some people may also experience abdominal pain, and nausea & vomiting
 - There may be signs of dehydration
 
 
# Differential Diagnosis
 
 
When diagnosing tonsillitis, it's important to differentiate it from other conditions with similar symptoms such as: 
 
 - **Pharyngitis:** Symptoms include sore throat, fever, and headache. Unlike tonsillitis, patients do not usually present with lymphadenopathy.
 - **Infectious mononucleosis:** Characterised by fatigue, sore throat, fever, and swollen lymph nodes. A key difference is the presence of severe fatigue and splenomegaly.
 
 
# Investigations
 
 
Investigations for tonsillitis typically involve clinical examination and patient history. Additional tests such as throat swabs are only used when an alternative bacterial cause is suspected. Blood tests are primarily reserved for those with suspected immunodeficiency.
 
## Scoring systems to predict the need of antibiotic treatment:
 
 
### Centor Criteria
 
 
The Centor Criteria is a set of clinical predictors used to identify patients with Group A streptococcal pharyngitis:
 
 
 - History of fever
 - Presence of tonsillar exudates
 - Absence of cough
 - Tender anterior cervical lymphadenopathy
 
 
Patients presenting with three or four of these criteria should be considered for antibiotic treatment.
 
FeverPAIN criteria:
 
 - Fever
 - Purulence (exudate)
 - Attended within 3 days of symptom onset
 - Inflamed tonsils
 - No cough or coryza (suggests viral origin)
 
A score of four or five indicates a high probability of streptococcal infection and hence the need for antibiotics.
 
 
# Management
 
 
Management strategies for tonsillitis include:
 
 
 - Symptomatic treatment with paracetamol and ibuprofen
 - Antibiotic therapy in cases featuring (phenoxymethylpenicillin is first-line):
 - Marked systemic upset
 - Three or more Centor criteria, or four or more FeverPAIN criteria
 - Underlying immunodeficiency
 - Increased risk of complications 
 - Clarithromycin can be used if there is penicillin allergy 
 - In some cases a delayed antibiotic prescription may be indicated
 
If a patient appears severely unwell, dehydrated or presents with complications, refer urgently to hospital or for specialist assessment.
 
Patients may be referred to ENT for tonsillitis if they have recurrent episodes of tonsillitis. The criteria for this is:
 
 - 7+ episodes in one year
 - 5+ episodes per year for two years
 - 3+ episodes per year for three years
 
# Complications
 
 
Potential complications of tonsillitis include:
 
 
 - Recurrent Tonsillitis: This is the most common complication. The evidence base for tonsillectomies as a treatment is poor, leading to stricter referral criteria.
 - Retropharyngeal Abscess: A rare complication characterised by soft tissue swelling, more common in young children. Symptoms include a stiff and extended neck and refusal to eat or drink.
 - Peritonsillar Abscess (Quinsy): Presents with sore throat, difficulty swallowing, peritonsillar bulge, uvular deviation, trismus, and muffled voice. Treatment has shifted from surgical drainage to antibiotics and aspiration.
 - Lemierre's Syndrome: In this rare complication, inflammation leads to pharyngotonsilitis, inflammation within the internal jugular vein, and septic emboli. Treatment may require high-dose benzylpenicillin and debridement.
 
 
Complications of streptococcal tonsillitis include:
 
 - Scarlet fever
 - Acute rheumatic fever
 - Post-streptococcal glomerulonephritis
 - Reactive arthritis
 
# NICE Guidelines 
 
[Click here for NICE CKS on sore throat - acute](https://cks.nice.org.uk/topics/sore-throat-acute/)
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An example of a right sided quinsy.
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Bilateral exudate seen on the tonsils of someone with tonsilitis.
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Acute Tonsillitis
Topic
60
General Practice
Condition
670
Tonsillitis
UkmlaTopic
5
Child health
Condition
671
Tonsillitis
UkmlaTopic
9
Ear, nose and throat
Condition
672
Tonsillitis
UkmlaTopic
12
General practice and primary healthcare
12526
Presentation
504
Sore throat
UkmlaTopic
9
Ear, nose and throat
Presentation
505
Sore throat
UkmlaTopic
12
General practice and primary healthcare
Presentation
506
Sore throat
UkmlaTopic
13
Infection
A 10-year-old girl is brought to the GP clinic complaining of a sore throat, neck pain, headache and high-grade fever for the past five days. There are no similar complaints among her family or peers. Her vaccinations are up to date, and she is allergic to penicillin. Her vital signs are normal except for an elevated temperature (39.3°C). On examination, both tonsils are enlarged, hyperaemic tonsils with pus, and tender lymph nodes in the neck.

What is the most appropriate next step in management?
a