• Admit immediately anyone who has:
• Stridor or respiratory difficulty.
• Respiratory distress, drooling, systemically very unwell, painful swallowing, muffled voice: suspect acute epiglottis. Do not examine the throat of anyone who has suspected epiglottitis.
• Upper airway obstruction.
• Dehydration or reluctance to take any fluids.
• Severe suppurative complications (e.g. peri-tonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre syndrome) as there is a risk of airway compromise or rupture of the abscess.
• Signs of being markedly systemically unwell and is at risk of immunosuppression.
• Suspected Kawasaki disease.
• Diphtheria: characteristic tonsillar or pharyngeal membrane.
• Signs of being profoundly unwell and the cause is unknown or a rare cause is suspected, for example:
• Stevens–Johnson syndrome: high fever, arthralgia, myalgia, extensive bullae in the mouth followed by erosion and a grey–white membrane.
• Yersinial pharyngitis: fever, prominent cervical lymphadenopathy, abdominal pain with or without diarrhoea.

In depth

• If the person may be immunosuppressed:
• If taking a disease-modifying anti-rheumatic drug (DMARD) and immediate admission is not appropriate then:
• Take blood for a full blood count (FBC). Arrange to contact them later with the result.
• Withhold the DMARD whilst awaiting the result and until discussed with the hospital rheumatology service (or follow local protocols).
• Seek urgent specialist advice/referral if the person has a low white cell count or deteriorates.
• Provide symptomatic relief.
• Consider prescribing an antibiotic taking into account potential interactions with DMARDs.
• If the person is taking carbimazole (which can cause idiosyncratic neutropenia) take an urgent FBC and withhold the drug until the result is available. Seek specialist advice. Consider prescribing an antibiotic.
• If the person is on chemotherapy, has known or suspected leukaemia, asplenia, aplastic anaemia or HIV/AIDS, or is taking an immunosuppressive drug following a transplant:
• Seek immediate specialist advice or referral.
• Meanwhile check the FBC urgently.
• Refer or seek urgent specialist advice for anyone who has severe oral mucositis. For further information, see the CKS topic on Palliative cancer care - oral.
• Identify people who may need non urgent referral for consideration of tonsillectomy:
• Confirm the diagnosis of recurrent tonsillitis by history and examination, if possible differentiating it from pharyngitis. In practice this may be difficult to do because people do not always consult when they have sore throat and there may be uncertainty about whether previous sore throats were due to acute tonsillitis or pharyngitis.
• Note whether the frequency of episodes is increasing or decreasing.
• In most children only consider referral for tonsillectomy if all of the following criteria are met:
• The child has five or more episodes of acute sore throat per year, documented by the parent or clinician.
• Symptoms have been occurring for at least a year.
• The episodes of sore throat have been severe enough to disrupt the child's normal behaviour or day to day functioning.
• Refer if the child has guttate psoriasis which is exacerbated by recurrent tonsillitis.
• Refer if the child has a history of sleep apnoea, daytime drowsiness, and failure to thrive.
• Refer adults if they have had five or more episodes per year of sore throat due to tonsillitis. The episodes should have been disabling and have prevented normal functioning.

In depth