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Sore throat - acute - Management
When should I refer or seek advice?

  • 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.
Clarification / Additional information
  • The definition of recurrence is arbitrary and for the purposes of deciding who should be referred is defined as five or more episodes in the previous 12 months. The diagnosis of recurrence does not depend on the underlying cause (viral, bacterial) or on the severity of the sore throat [NICE, 2001].
  • Consider keeping a sore throat diary in order to establish any pattern of recurrence and the impact on the child's day to day activities [NICE, 2001].
  • Discuss the advantages and disadvantages of tonsillectomy including the natural history of resolution [SIGN, 1999].
Basis for recommendation
  • The basis for these recommendations is expert advice from standard textbooks [Jones, 1998; Franco and Har-El, 1999; Dhillon and East, 2006].
  • The National Institute for Health and Clinical Excellence (NICE) advises immediate referral for anyone with suspected leukaemia [NICE, 2005].
  • The basis for these recommendations regarding recurrent episodes of acute sore throat is expert advice from national guidance:
    • The recommendations for referral of children for tonsillectomy are based on expert opinion from the National Institute for Health and Clinical Excellence and apply to people aged up to 15 years with recurrent acute sore throat [NICE, 2001].
    • The recommendations for referral of adults for tonsillectomy are based on expert opinion from the Scottish Intercollegiate Guidelines Network that apply to both children and adults as reasonable indications for consideration of tonsillectomy based on the current level of knowledge, clinical observation in the field and the results of clinical audit [SIGN, 1999].
  • Evidence for the benefits of tonsillectomy is poor. In children surgery may be beneficial in selected cases. In adults, limited evidence suggests that tonsillectomy may benefit people with recurrent infection.
  • The recommendations regarding people who are immunosuppressed on based on national guidelines [British Society for Rheumatology, 2000] and the opinion of our expert reviewers.

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