Tonsillitis

Overview

•Sore throat - sudden onset, odynophagia, fever >38°C

•Tonsillar enlargement - erythematous ± white/yellow exudate (does NOT confirm bacterial aetiology)

•Tender anterior cervical lymphadenopathy - characteristic of streptococcal infection

•Absence of cough - cough suggests viral URTI, not GABHS

🚨
Unilateral painless tonsillar enlargement in an adult = urgent 2-week-wait referral for tonsillar carcinoma. In teenagers with massive tonsillitis + generalised lymphadenopathy + splenomegaly + fatigue, suspect infectious mononucleosis (EBV) - avoid amoxicillin/ampicillin (causes maculopapular rash in up to 90%).

Management

•All patients: paracetamol and/or ibuprofen for analgesia and antipyresis - maintain oral hydration especially in children

•First-line antibiotic (Centor 3-4 / FeverPAIN 4-5): phenoxymethylpenicillin (penicillin V) for 5-10 days - narrow spectrum, low resistance

•Penicillin allergy: clarithromycin

•Quinsy or failure on penicillin V: co-amoxiclav

•Low-to-moderate probability: delayed prescribing - issue prescription, patient fills only if symptoms worsen or do not improve after 2-3 days

⚠️
Aspirin must be avoided in children under 16 years - risk of Reye's syndrome (acute hepatic failure and encephalopathy). Use paracetamol or ibuprofen.

Complications

•Peritonsillar abscess (quinsy) - most common suppurative complication; severe unilateral sore throat, trismus, uvular deviation away from affected side, 'hot potato' voice, drooling; treat with IV antibiotics and surgical drainage; consider tonsillectomy 6 weeks later

•Retropharyngeal abscess - rare; young children; neck stiffness/hyperextension, drooling, high fever; IV antibiotics and surgical drainage

•Post-streptococcal complications - scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis

Scoring criteria

Centor vs FeverPAIN scoring
FeatureCentorFeverPAIN
ComponentsTonsillar exudate; tender anterior cervical nodes; fever history; absence of coughFever; purulence; attends rapidly (<3 days); severely inflamed tonsils; no cough/coryza
Low probability - no antibioticsScore 0-2Score 0-3
High probability - consider antibioticsScore 3-4Score 4-5

Feature	Centor	FeverPAIN
Components	Tonsillar exudate; tender anterior cervical nodes; fever history; absence of cough	Fever; purulence; attends rapidly (<3 days); severely inflamed tonsils; no cough/coryza
Low probability - no antibiotics	Score 0-2	Score 0-3
High probability - consider antibiotics	Score 3-4	Score 4-5

🎯
GABHS is more likely in 5-15 year olds. A Centor 4 child with exudate, lymphadenopathy, fever, and no cough should receive antibiotics.

Tonsillectomy referral

•Refer to ENT if episodes are documented and have caused sufficient morbidity (e.g. missed school/work):

•7 or more episodes in one year, OR

•5 or more episodes per year for two consecutive years, OR

•3 or more episodes per year for three consecutive years

🧠
The 7/5/3 rule - tonsillectomy is now performed much less frequently than in the past; the evidence base is modest and criteria have become stricter.

Post-tonsillectomy haemorrhage

Primary vs secondary post-tonsillectomy haemorrhage
FeaturePrimary (reactionary)Secondary
TimingWithin 24 hours (most often first 6-8 hours)5-10 days post-op
CauseSurgical / vascularWound infection (majority)
ManagementImmediate return to theatreAdmit for IV antibiotics

Feature	Primary (reactionary)	Secondary
Timing	Within 24 hours (most often first 6-8 hours)	5-10 days post-op
Cause	Surgical / vascular	Wound infection (majority)
Management	Immediate return to theatre	Admit for IV antibiotics

🚨
Any post-tonsillectomy bleed within 24 hours = immediate return to theatre regardless of apparent haemodynamic stability. Young patients can compensate and lose significant blood before decompensating. Do not watch and wait.