Pharyngitis / Tonsillitis
Pharyngitis / tonsilitis is an acute upper respiratory tract infection, affecting the oropharynx and tonsils. It most commonly manifest as a sore throat, which is a symptom rather than a diagnosis, referring to pain, irritation, or discomfort in the throat.
This updated UKMLA guide to pharyngitis and tonsillitis is based on NICE NG84 and NICE CKS, which covers causes, assessment, and management.
Definition
Pharyngitis and tonsillitis are acute upper respiratory tract infections (URTIs)
- Pharyngitis: inflammation of the oropharynx
- Tonsillitis: inflammation of the tonsils (may occur in isolation or as part of pharyngitis)
Causes
Most common overall cause: viral infection
| Category | Organisms |
|---|---|
| Viral |
|
| Bacterial |
|
Clinical Features
Sore throat (pain, irritation, or discomfort in the throat) is the predominant symptom in tonsillitis and pharyngitis.
Associated symptoms:
| Viral pharyngitis / tonsillitis | Bacterial pharyngitis / tonsillitis |
|---|---|
|
|
Signs:
- Inflamed tonsils and/or pharynx
- Features more suggestive of bacterial pharyngitis / tonsillitis
- Pharyngeal and/or tonsillar exudates (appear as white spots on the red tonsils or mucosa)
- Tender cervical lymphadenopathy
Differential Diagnosis
The main differential diagnoses of pharyngitis / tonsilitis are non-infective causes of sore throat:
- Post-nasal drip (excess mucus from the nose and sinuses drains down the pharynx, causing irritation)
- Allergic rhinitis
- Physical irritation (e.g. nasogastric tube, post-intubation)
- Environmental irritants (e.g. smoke, air pollution)
- GORD
- Vocal strain (e.g. professional singer)
- Dry air
- Oral mucositis secondary to radiotherapy or chemotherapy
- Kawasaki disease (in children)
Complications
Viral pharyngitis is often uncomplicated.
Complications mainly arise from Group A streptococcus / Streptococcus pyogenes infection, but are rare:
- Acute otitis media – most common
- Acute sinusitis (rare)
- Quinsy (peritonsillar abscess)
- Immune-mediated complications (rare in developed countries)
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Reactive arthritis
Scarlet fever is technically NOT considered a complication of streptococcal pharyngitis. It is a direct clinical syndrome due to an erythrogenic (pyrogenic) toxin-producing Group A streptococcus.
Pharyngitis is simply part of the clinical presentation of scarlet fever, along with additional toxin-mediated features (e.g. rash, skin desquamation, strawberry tongue).
Diagnosis
Assessment and Diagnosis
Pharyngitis / tonsillitis is primarily a clinical diagnosis
Perform a clinical examination to:
- Exclude signs of lower respiratory tract infection (pneumonia or acute bronchitis)
- Calculate the Centor / FeverPAIN score to estimate the probability of GAS pharyngitis and guide management (see below for more details)
- Check temperature
- Specifically ask if the patient experiences a cough
- Check for exudates
- Perform a lymph node examination
A throat swab or Group A Streptococcus antigen test is not recommended in the context of a sore throat.
Centor and FeverPAIN Score
| Score | Components | Likelihood of streptococcus pharyngitis |
|---|---|---|
| Centor |
|
|
| FeverPAIN |
|
|
Both Centor and FeverPAIN scores are used to determine the likelihood of streptococcus pharyngitis, to reduce unnecessary antibiotic prescription.
In summary, bacterial pharyngitis is more likely if there is:
- NO cough
- NO coryza (e.g. rhinorrhoea, congestion)
- High fever (>38°C)
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
Management
If the patient has possible sepsis or signs of severe complications (e.g. airway obstruction, drooling, muffled or “hot potato voice”, displaced uvula, difficulty opening the jaw) → refer to the hospital
Self-Care Management
Advise the patient to:
- Drink adequate fluids
- Consider paracetamol / ibuprofen for pain or fever
- Patients may wish to try medicated lozenges (containing e.g. local anaesthetic, NSAID, antiseptic)
Antibiotic Therapy
DO NOT routinely offer antibiotics to treat acute sore throat / pharyngitis / tonsillitis.
Indications for Antibiotics
Offer immediate antibiotic prescription if any of the following:
- Systemically very unwell
- Features of a more serious illness / condition (e.g. quinsy)
- High risk of complications (e.g. diabetes, heart failure, chronic respiratory disease, history of rheumatic fever)
Otherwise, the Centor (more commonly used) or FeverPAIN score should be used to guide antibiotic prescription:
| Centor score | FeverPAIN | Recommended management |
|---|---|---|
| 0 / 1 | 0 / 1 / 2 | Do not offer antibiotics |
| n/a | 2 / 3 | Consider no antibiotics or back-up prescription |
| 3 / 4 | 4 / 5 | Consider antibiotics (immediate / back-up prescription) |
NICE has a high threshold for prescribing antibiotics because antibiotics make little difference in the duration or improvement of symptoms for most sore throats. Additionally, withholding antibiotics rarely leads to complications.
On the other hand, antibiotics can cause adverse effects, such as diarrhoea and nausea, and their use contributes to antibiotic resistance.
Choice of Antibiotics
1st line: phenoxymethylpenicillin (penicillin V)
- 500mg QDS or 1g BD
- For 5-10 days (5 days may be enough for symptomatic cure, but 10 days may increase the chance of microbiological cure)
2nd line (penicillin alternatives):
- Clarithromycin 250-500 mg BD for 5 days
- If pregnant: erythromycin 250-500mg QDS / 500-1000mg BD for 5 days
Avoid amoxicillin and co-amoxiclav in acute sore throat / tonsillitis / pharyngitis.
This is because if the illness is due to EBV infection, they can trigger a widespread maculopapular rash.
The choice of antibiotics in the paediatric population remains the same. The only difference is the dose adjustment.
Recurrent Tonsillitis
Patients with recurrent tonsillitis may benefit from tonsillectomy
Refer the following patients to ENT for consideration of tonsillectomy:
- Past 1 year, with 7 or more episodes of clinically significant tonsillitis
- Past 2 years, with 5 or more episodes in each year
- Past 3 years, with 3 or more episodes in each year
References
Related Articles
Infectious Mononucleosis (Glandular Fever)
Quinsy (Peritonsillar Abscess)