This guidance is for recurring tonsillitis, any concern regarding the appearance of the tonsil or other red flag symptoms should be referred urgently.

Management of acute tonsillitis as per NICE/Local guidance (click here for FEVER-Pain shortcut).

It uses the FEVER-PAIN or Centor score for assessing symptoms and deciding initial management. This primarily is trying to
determine if the sore throat is likely bacterial in origin.

GPs should have an awareness of the potential local and systemic complications of tonsillitis and when to refer to ENT.

Assess the airway and if any compromise refer as below:

• Look for signs of a deep neck space infection, altered voice, torticollis, trismus, sepsis and refer as below.
• Is the patient able to swallow and consider a trial of oral analgesia and antibiotics as per NICE guidance.
• Is the sore throat associated with significant acute lymphadenopathy or abdominal pain. If so there is a high chance of glandular fever and liver function tests as well as EBV glandular fever antibodies should be sent.
  If glandular fever is confirmed please see the patient advice leaflet regarding abstaining from alcohol and contact
  sports.
• Consider HIV testing if persistant lymphoid tissue enlargement or lymphadenopathy without acute infective cause

Emergency referral to ENT:

• If there is concern regarding the patients airway then immediate referral to A+E via an ambulance
• If the patient is unable to swallow, is septic or concern regarding an acute complication of tonsillitis (referral to on call
  ENT team)

Chronic or recurrent tonsillitis, as per the SIGN guidelines the episodes need to be:

• Due to acute tonsillitis, be disabling and prevent normal function (i.e. off school or work)
• The patient should have been adequately treated for each episode (seen or discussed with GP)
• Number of episodes requiring antibiotics:
  • 7 in 1 year
  • 5 in the 2 preceding years
  • 3 in the 3 preceding years
• When in doubt a period of watchful waiting with a symptom diary should be kept for 6 months.

What is not accepted?

Following discussion across the ENT surgical profession in NHS Scotland and considering the above evidence and risks, there is a consensus that the provision of surgical tonsillectomy for patients presenting with tonsils stones or crypt debris without recurrent tonsillitis is not evidence based.

ENT Scotland in consultation with the office of the Chief Medical Officer in Scotland concludes therefore that this procedure should not be offered on the NHS in Scotland.