ENT

Tonsillitis

Acute sore-throat inflammation involving the tonsils, usually viral and self-limiting; clinical scoring targets antibiotics to people more likely to benefit while airway compromise, quinsy and deep-neck infection require urgent escalation.

In a nutshell

Most acute tonsillitis is a self-limiting viral sore throat. Use FeverPAIN or Centor to target antibiotics, avoid amoxicillin when glandular fever is plausible, and treat quinsy, airway compromise and deep-neck infection as urgent problems.

Classic presentation

A child, adolescent or adult with sore throat, fever, odynophagia, inflamed or exudative tonsils and cervical nodes; marked fatigue, posterior nodes or splenomegaly should raise glandular fever.

Key points

Exudate does not prove streptococcal disease; use FeverPAIN or Centor alongside the clinical assessment.
FeverPAIN 0 or 1 and Centor 0 to 2: no antibiotic. FeverPAIN 2 or 3: no or back-up. FeverPAIN 4 or 5 and Centor 3 or 4: immediate or back-up can be considered.
Phenoxymethylpenicillin is first-choice when an antibiotic is indicated; use clarithromycin for penicillin allergy or intolerance and erythromycin if a macrolide is needed in pregnancy.
Suspected glandular fever is a classic amoxicillin trap because of the associated widespread rash.
Trismus, uvular deviation, muffled voice, drooling, stridor or unilateral swelling suggests quinsy or deeper infection and needs urgent assessment.
Recurrent, documented, disabling episodes may justify ENT tonsillectomy assessment using the UK 7/5/3 framework, with shared decision-making.

First-line investigation

Clinical assessment with FeverPAIN or Centor plus airway, hydration and alternative-diagnosis assessment; routine throat swabbing is not needed for the standard pathway.

Management

Protect the airway and identify deep infection

Same-day hospital assessment is needed for suspected quinsy, deep-neck infection, Lemierre syndrome, severe systemic infection or airway compromise. Trismus, unilateral swelling, uvular deviation, drooling, stridor, inability to swallow fluids or a muffled voice must not be managed as uncomplicated tonsillitis.^1,2
Assess fever in children under 5 using the NICE fever pathway and reassess rapidly deteriorating or systemically unwell people for sepsis and other serious illness.^1,12,11

Score the episode and support recovery

Use FeverPAIN or Centor as a clinical decision aid, but also assess hydration, airway, comorbidity, alternative diagnoses and previous antibiotics. Give paracetamol or suitable ibuprofen, encourage fluids and explain the approximately one-week course.^1,2
Marked fatigue, posterior cervical lymphadenopathy or splenomegaly should raise glandular fever; avoid amoxicillin while the diagnosis is uncertain and provide appropriate advice about the expected course and activity.^3,4,2

Use antimicrobial stewardship

Do not offer antibiotics for FeverPAIN 0 or 1 or Centor 0, 1 or 2. For FeverPAIN 2 or 3, consider no or back-up treatment; use back-up if symptoms do not start to improve within 3 to 5 days or worsen rapidly or significantly.^1,2
For FeverPAIN 4 or 5 or Centor 3 or 4, consider an immediate or back-up antibiotic after clinical review. If prescribing, use phenoxymethylpenicillin first choice; use age- and population-specific NICE and BNF/BNFc tables for doses and duration.^1,5,6

Choose antibiotics safely

Use clarithromycin for penicillin allergy or intolerance when not pregnant; use erythromycin if a macrolide is needed in pregnancy and the antibiotic benefit outweighs harm. Do not choose amoxicillin when glandular fever is plausible because it may provoke a widespread rash.^1,7,8,3,4
Offer immediate antibiotics for people who are systemically very unwell, have signs of serious illness or are at high risk of complications, but arrange hospital assessment when there is quinsy, severe suppurative infection, sepsis or airway risk.^1,2

Avoid low-value testing and document recurrence

Routine throat swabs are not needed for the standard score-based pathway. Document episodes carefully, including clinical diagnosis, functional impact and treatment, because recurrence decisions depend on clinically significant episodes rather than a number copied from an undocumented history.^1,2,9

Consider ENT review for recurrent disabling disease

Discuss ENT referral for tonsillectomy assessment when episodes are documented, clinically significant and disabling, commonly using the UK 7 episodes in 1 year, 5 per year for 2 years or 3 per year for 3 years framework; recurrent quinsy and individual circumstances may justify referral outside the count.^9,10
Give clear safety-netting: seek help for rapid worsening, failure to improve after a week, systemic illness, dehydration, airway symptoms or a new unilateral swelling. Reassess the diagnosis and consider glandular fever or deep infection when the trajectory is atypical.^1,2,3

Exam traps

Tonsillar exudate and tender nodes do not automatically mean streptococcal infection; viral disease and glandular fever can look identical.
The current back-up window is 3 to 5 days for acute sore throat, while symptoms can last around a week.
A high score does not make quinsy safe for primary-care oral treatment: trismus, uvular deviation and a muffled voice require urgent assessment.
The 7/5/3 tonsillectomy thresholds require documented, clinically significant and disabling episodes; do not refer on episode count alone.
A rash after amoxicillin during glandular fever is not automatically proof of IgE-mediated penicillin allergy.

Illustrations

Exudative tonsillitisEnlarged tonsils with white exudate in acute exudative tonsillitis; exudate is not by itself proof of bacterial infection.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Centor and FeverPAIN criteriaTeaching diagram summarising FeverPAIN and Centor components and their antibiotic decision branches; thresholds are referenced to current NICE NG84.PassFinals · original

Waldeyer's ring anatomyDiagram of the palatine, lingual and pharyngeal tonsils forming Waldeyer's ring at the entrance to the pharynx.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.