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Management of sore throat and indications for tonsillectomy

Presentation and diagnosis in general practice

  • Practitioners should be aware of underlying psychosocial influences in patients presenting with sore throat
  • Sore throat associated with stridor or respiratory difficulty is an absolute indication for admission to hospital
  • The Centor clinical prediction score should be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for a precise diagnosis
  • The Centor score gives one point each for:
    • tonsillar exudate
    • tender anterior cervical lymph nodes
    • history of fever
    • absence of cough
  • The likelihood of group A beta-haemolytic streptococcus (GABHS) infection increases with increasing score, and is between 25–86% with a score of 4, and 2–23% with a score of 1, depending upon age, local prevalence, and seasonal variation
  • Streptococcal infection is most likely in the 5–15 year old age group and gets progressively less likely in younger or older patients. The score is not validated for use in children under 3 years
  • Throat swabs should not be carried out routinely in primary care management of sore throat
  • Throat swabs may be used to establish aetiology of recurrent severe episodes in adults when considering referral for tonsillectomy
  • If breathing difficulty is present, urgent referral to hospital is mandatory and attempts to examine the throat should be avoided

General 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

Analgesia in adults

  • Ibuprofen 400 mg three-times daily is recommended for relief of fever, headache, and throat pain in adults with sore throat
  • In adults with sore throat who are intolerant to ibuprofen, paracetamol 1 g four-times daily when required is recommended for symptom relief

Analgesia in children

  • In children with sore throat, an adequate dose of paracetamol should be used as first-line treatment for pain relief
  • Ibuprofen can be used as an alternative to paracetamol in children
  • Ibuprofen should not be given routinely to children with or at risk of dehydration

Adjunctive therapies

  • Echinacea purpurea is not recommended for treatment of sore throat
  • In patients with acute glandular fever (infectious mononucleosis) requiring hospitalisation, corticosteroids may have a role when pain and swelling threaten the airway or where there is very severe dysphagia

Antibiotics in acute and recurrent sore throat

  • Antibiotics should not be used to secure symptomatic relief in sore throat
  • Antibiotic prophylaxis for recurrent sore throat is not recommended
  • In view of increases in healthcare-acquired infections and antibiotic resistance in the community, unnecessary prescribing of antibiotics for minor self-limiting illness should be avoided
  • In severe cases, where the practitioner is concerned about the clinical condition of the patient, antibiotics should not be withheld
  • In certain unusual 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
  • Sore throat should not be treated with antibiotics specifically to prevent the development of rheumatic fever and acute glomerulonephritis
  • Antibiotics may prevent cross infection with GABHS in closed institutions (such as barracks, boarding schools) but should not be used routinely to prevent cross infection in the general community

full guideline available from…
Scottish Intercollegiate Guidelines Network, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB (Tel–01316234720)
www.sign.ac.uk/sign-117-management-of-sore-throat-and-indications-for-tonsillectomy.html

Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. Edinburgh: SIGN; 2010. (SIGN Guideline No. 117).
First included: May 2015.