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April 2010
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
High quality systematic reviews of case control or cohort studies
2++ High
quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the
relationship is causal
Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the
2+
relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
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impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation.
SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality
aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which
can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign.
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Scottish Intercollegiate Guidelines Network
April 2010
Management of sore throat and indications for tonsillectomy
Contents
1 Introduction................................................................................................................. 1
1.1 The need for a guideline............................................................................................... 1
1.2 Remit of the guideline................................................................................................... 1
1.3 Definitions.................................................................................................................... 1
1.4 Statement of intent........................................................................................................ 2
2 Key recommendations.................................................................................................. 3
2.1 Diagnosis and presentation........................................................................................... 3
2.2 General management.................................................................................................... 3
2.3 Surgical management.................................................................................................... 3
2.4 Postoperative care......................................................................................................... 3
3 Presentation................................................................................................................. 5
3.1 Incidence of sore throat in general practice................................................................... 5
3.2 Reasons for presentation in general practice.................................................................. 5
3.3 Emergency hospital admission...................................................................................... 5
4 Diagnosis of sore throat............................................................................................... 6
4.1 Clinical diagnosis.......................................................................................................... 6
4.2 Throat culture............................................................................................................... 7
4.3 Rapid antigen testing..................................................................................................... 7
5 General management of sore throat............................................................................. 8
5.1 Pain relief in adults....................................................................................................... 8
5.2 Pain relief in children.................................................................................................... 8
5.3 Adjunctive therapy . ..................................................................................................... 9
6 Antibiotics ................................................................................................................... 10
6.1 Antibiotics in acute sore throat...................................................................................... 10
6.2 Antibiotics in recurrent sore throat................................................................................ 11
6.3 Use of antibiotics to prevent rheumatic fever and glomerulonephritis............................ 11
6.4 Use of antibiotics to prevent suppurative complications................................................ 12
6.5 Use of antibiotics to prevent cross infection in sore throat............................................. 12
7 Surgery in recurrent sore throat................................................................................... 13
7.1 Tonsillectomy rates for all surgical indications............................................................... 13
7.2 Evidence for surgery in recurrent tonsillitis.................................................................... 13
7.3 Referral criteria for tonsillectomy for the treatment of recurrent tonsillitis...................... 14
7.4 Otolaryngological assessment....................................................................................... 15
7.5 Postoperative care......................................................................................................... 16
Management
Control of sore
of pain throat
in adults andcancer
with indications for tonsillectomy
8 Provision of information............................................................................................... 19
8.1 Sources of further information....................................................................................... 19
8.2 Checklist for provision of information........................................................................... 20
9 Implementing the guideline.......................................................................................... 21
9.1 Auditing current practice . ............................................................................................ 21
10 The evidence base........................................................................................................ 22
10.1 Systematic literature review........................................................................................... 22
10.2 Recommendations for research..................................................................................... 22
10.3 Review and updating.................................................................................................... 22
11 Development of the guideline...................................................................................... 23
11.1 Introduction.................................................................................................................. 23
11.2 The guideline development group................................................................................. 23
11.3 Acknowledgements....................................................................................................... 24
11.4 Consultation and peer review........................................................................................ 24
Abbreviations............................................................................................................................... 27
Annexes ..................................................................................................................................... 28
References................................................................................................................................... 35
1 INTRODUCTION
1 Introduction
1.1 the need for a guideline
The management of sore throat is a significant burden on health service resources. Most patients
who seek advice see their general practitioner (GP) and in most cases the condition is relatively
minor and self limiting. However, a significant number of patients experience unacceptable
morbidity, inconvenience, and loss of education or earnings due to recurrent sore throat. The
use of antibiotics in patients with recurrent sore throat has been controversial. The indications
for tonsillectomy have long been a matter of debate. Tonsillectomy has a small but significant
complication rate and an outcome that is not clearly defined.
The guideline SIGN 34, Management of sore throat and indications for tonsillectomy, was
published in 1999. Awareness of the guideline among physicians has led to more efficient and
effective use of healthcare resources.1 In 2005 a consultation document identified the need for
an update. This guideline updates SIGN 34 to reflect the most recent evidence.
1.3 definitions
Acute pharyngitis, tonsillitis, or acute exudative tonsillitis may all cause sore throat. For the
purpose of non-surgical management, these are considered together under the term ‘sore
throat’.
No accepted definition of ‘childhood’ exists in Scots law or NHSScotland. Upper cut-off ages
used in studies of children included in this guideline vary from 12 to 16. For the purposes of
this guideline, recommendations concerning tonsillectomy in childhood apply to ages 4-16.
For prescribing in children, advice in the BNF for Children should be followed.2
1
Management of sore throat and indications for tonsillectomy
2
2 KEY RECOMMENDATIONS
2 Key recommendations
The following recommendations were highlighted by the guideline development group as
the key clinical recommendations that should be prioritised for implementation. The grade of
recommendation relates to the strength of the supporting evidence on which the recommendation
is based. It does not reflect the clinical importance of the recommendation.
D Throat swabs should not be carried out routinely in primary care management of sore
throat.
A In adults with sore throat who are intolerant to ibuprofen, paracetamol 1 g four times
daily when required is recommended for symptom relief.
D Patients should be made aware of the potential for pain to increase for up to 6 days
following tonsillectomy.
Patients/carers should be given written and oral instruction prior to discharge from hospital
;;
on the expected pain profile and the safety profile of the analgesic(s) issued with particular
reference to appropriate dose and duration of use. They should be issued with enough
analgesic to last for a week.
3
Management of sore throat and indications for tonsillectomy
A Routine use of anti-emetic drugs to prevent postoperative nausea and vomiting (PONV)
in tonsillectomy is recommended.
A A single intraoperative dose of dexamethasone (dose range 0.15 to 1.0 mg/kg; maximum
dose range 8 to 25 mg) is recommended to prevent postoperative vomiting in children
undergoing tonsillectomy or adenotonsillectomy.
4
3 PRESENTATION
3 Presentation
3.1 incidence of sore throat in general practice
Most patients with sore throat do not attend their general practitioner (GP) to seek help with their
condition.4 A UK study of 516 women aged 20-44 years found that only one in 18 episodes of
sore throat led to a GP consultation.5 The age distribution of patients and the management of
sore throat which is reported to a GP vary widely across Europe.6
The unit cost of a GP surgery consultation in the UK in 2008-09 was £35.7 In Scotland in 2005-
2006, consultations for any form of sore throat or tonsillitis numbered 313,150, a rate of 58.3
per 1,000 population.8 The cost to NHSScotland of GP consultations for sore throat therefore
exceeds £10.9 million per annum, before any treatment or investigation. In 2006-2007 in
Scotland, 3,605 tonsillectomies were performed for bacterial tonsillitis. NHSScotland spends
approximately £3 million on tonsillectomy operations per year.8
A patient information leaflet may be of value in the management of acute sore throat and may
assist in managing future episodes at home without general practitioner involvement.
;; S ore throat associated with stridor or respiratory difficulty is an absolute indication for
admission to hospital.
5
Management of sore throat and indications for tonsillectomy
C The Centor clinical prediction score should be used to assist the decision on whether
to prescribe an antibiotic, but cannot be relied upon for a precise diagnosis.
In addition to clinical examination, assessment of a patient with sore throat should take account
of other medical conditions and medication which may suggest an increased susceptibility to
infection and lower the threshold for treatment.
Occasionally, sore throat may be a presenting symptom of acute epiglottitis or other serious
upper airway disease.
;; If breathing difficulty is present, urgent referral to hospital is mandatory and attempts to
examine the throat should be avoided.
6
4 DIAGNOSIS OF SORE THROAT
D Throat swabs should not be carried out routinely in primary care management of sore
throat.
Throat swabs may be used to establish aetiology of recurrent severe episodes in adults
;;
when considering referral for tonsillectomy (see section 7.2.2).
7
Management of sore throat and indications for tonsillectomy
Ibuprofen is available over the counter and is only slightly more expensive than paracetamol.
A large blinded randomised controlled trial (RCT) involving 8,633 European adults showed
that ibuprofen is as well tolerated as paracetamol and produces fewer serious gastrointestinal 1++
adverse effects, irrespective of patient age, in short courses for acute pain.27
Ibuprofen should not be routinely given to adults with or at risk of dehydration due to concerns
regarding renal toxicity although this serious adverse effect is rare.
No head to head trials that compared ibuprofen and diclofenac were identified.
A Ibuprofen 400 mg three times daily is recommended for relief of fever, headache and
throat pain in adults with sore throat.
A systematic review has shown that ibuprofen does not exacerbate asthma morbidity in a
paediatric population.28 Caution is advised using ibuprofen in adults with asthma as similar 1+
evidence in adults could not be found.
One RCT showed that aspirin and paracetamol are both equally effective, and superior to
placebo, at reducing fever, headache, achiness and throat pain for up to six hours.29 The 1++
recognised complications of aspirin therapy make this agent less suitable for general use.
A In adults with sore throat who are intolerant to ibuprofen, paracetamol 1 g four times
daily when required is recommended for symptom relief.
Ibuprofen and paracetamol are often used together. Evidence concerning the safety and efficacy
of this combination in adults is lacking, but is available in children (see section 5.2).
;; In children with sore throat, an adequate dose of paracetamol should be used as first
line treatment for pain relief.
A systematic review and meta-analysis of ibuprofen and paracetamol use in febrile children
and occurrence of asthma-related symptoms showed that there is a low risk of asthma-related 1+
morbidity associated with ibuprofen use in children.28
Recent case reports have highlighted concern about renal toxicity in dehydrated children given
ibuprofen.30, 31 3
8
5 GENERAL MANAGEMENT OF SORE THROAT
5.3.1 corticosteroids
Three trials of varying quality on the effectiveness of a single dose of oral dexamethasone for 1++
pharyngitis in children produced conflicting results.34-36 Larger, well designed trials are required. 1+
The evidence is insufficient to support a recommendation. 1-
One RCT looking at effectiveness of prednisone in pharyngitis was carried out on a relatively
small number of patients (n=79) and the follow up was short.37 1+
5.3.2 echinacea
A double blind placebo controlled RCT of Echinacea purpurea therapy for throat pain in
common cold (n=128) found that the treatment did not reduce symptom scores or duration 1+
of symptoms.38
9
Management of sore throat and indications for tonsillectomy
6 Antibiotics
6.1 antibiotics in acute sore throat
In the UK, the significance of the presence of bacterial pathogens in cases of sore throat remains
in doubt (see section 4).39 It is therefore illogical to treat all sore throats with antibiotics. There
is a favourable outcome in the majority of cases even when antibiotics are withheld.
An open study of prescribing strategy in over 700 patients randomised to antibiotic versus no
prescription versus delayed prescription for three days showed no difference in duration of
illness, proportion of patients better by day 3, days missed from work or school, or proportion
1+
of patients satisfied with treatment.40 The exclusion criteria in this trial were: other explanations
of sore throat, very ill, suspected or previous rheumatic fever, multiple attacks of tonsillitis,
quinsy, or pregnancy.
Even if the sore throat persists, a throat swab to identify GABHS may not be helpful, as the poor
specificity and sensitivity of throat swabs limit their usefulness (see section 4.2). Nevertheless,
randomised controlled trials of antibiotic therapy in patients with acute sore throat in whom
GABHS has or has not been isolated (whether or not causative) have been reported. There is
no evidence of clear clinical benefit from the use of any particular antibiotic.
6.1.1 use of antibiotics in sore throat in which gabhs has been detected
Most trials have compared penicillin with a variety of other antibiotics, notably cephalosporins.
Although optimum elimination of GABHS is secured with intramuscular long-acting penicillin,41
oral penicillin V given 6-hourly for 10 days is widely regarded as the gold standard treatment
in such trials, with the advantages of cheapness and tolerability.42,43 Other more expensive
antibiotics, mainly cephalosporins, have been shown to be statistically significantly more
successful in eradicating the organism, although the clinical advantage is much less clear.44, 45
Some cephalosporins offer a more convenient dosage regimen46 but twice and three times daily
dosage for oral penicillin V have also been shown to be effective in eliminating GABHS.42, 47, 48 A
ten day course of penicillin appears to be more effective than five days.42 There is no convincing
evidence of advantage for any individual cephalosporin.
In severe cases, where the practitioner is concerned about the clinical condition of the
;;
patient, antibiotics should not be withheld. (Penicillin V 500 mg four times daily for 10
days is the dosage used in the majority of studies. A macrolide can be considered as an
alternative first line treatment, in line with local guidance.)
10
6 ANTIBIOTICS
;; mpicillin-based antibiotics, including co-amoxiclav, should not be used for sore throat
A
because these antibiotics may cause a rash when used in the presence of glandular
fever.
C Sore throat should not be treated with antibiotics specifically to prevent the development
of rheumatic fever and acute glomerulonephritis.
11
Management of sore throat and indications for tonsillectomy
C Antibiotics may prevent cross infection with GABHS in closed institutions (such as
barracks, boarding schools) but should not be used routinely to prevent cross infection
in the general community.
12
7 SURGERY IN RECURRENT SORE THROAT
7.2.1 children
No study demonstrated clear clinical benefit of tonsillectomy in children. A Cochrane review
showed modest benefit of tonsillectomy or adenotonsillectomy in the treatment of recurrent
acute tonsillitis.75 In this review, in those children with severe recurring tonsillitis the benefit was
a reduction in the number of sore throats by three episodes in the first postoperative year, one
of those episodes being moderate to severe. The reduction in sore throats in the severe group 1++
is accompanied by one episode of sore throat as a direct consequence of the surgery itself. In
the case of less severely affected children, the benefit of tonsillectomy or adenotonsillectomy
is more modest, with a reduction by one episode of sore throat in the first postoperative year,
reducing the number of sore throat days from 22 to 17 on average.
No recent studies evaluated tonsillectomy in children with severe sore throats, the group that
is assumed to be the most likely to benefit from surgical intervention.
An RCT conducted in the Netherlands of 300 children aged 2 to 8 years with mild to moderate
sore throat found that adenotonsillectomy was not cost effective in mild to moderate sore throat 1+
and did not result in significant clinical benefit.76
In 328 children with moderate sore throat, an RCT of tonsillectomy or adenotonsillectomy
versus watchful waiting found a statistically significant reduction in the incidence of mild sore
throats in the surgical group, but the clinical significance of this reduction has to be balanced 1++
against the risk of complication of the procedure.77
In a pragmatic randomised controlled trial with a parallel non-randomised preference study
of tonsillectomy and adenotonsillectomy in 729 children (268 in the randomised trial group
and 461 in the cohort group), the estimated effect of surgery over two years of follow up was a
reduction of 3.5 episodes of sore throat (95% CI 1.8 to 5.2) compared to medical management. 1+
This difference was not statistically significant. Children and parents both exhibited a strong
preference for surgical management, but the health of all the children with recurrent sore
throat was noted to improve with time. The study did not provide clear-cut evidence of clinical
effectiveness or cost effectiveness.78
13
Management of sore throat and indications for tonsillectomy
A Watchful waiting is more appropriate than tonsillectomy for children with mild sore
throats.
Adenotonsillectomy in children with obstructive sleep apnoea and in patients with rare
conditions such as periodic fever is outwith the scope of this guideline.
7.2.2 adults
A Cochrane review found limited evidence of benefit of tonsillectomy in adults.75 1++
In adults with proven recurrent group A streptococcal pharyngitis (GAHSP), a small well
conducted RCT demonstrated benefit for tonsillectomy in adults. Tonsillectomy reduced the
1++
incidence of GAHSP in the 90-day postoperative period with a number needed to treat (NNT)
of 5.86
14
7 SURGERY IN RECURRENT SORE THROAT
15
Management of sore throat and indications for tonsillectomy
D Patients should be made aware of the potential for pain to increase for up to 6 days
following tonsillectomy.
;; atients/carers should be given written and oral instruction prior to discharge from
P
hospital on the expected pain profile and the safety profile of the analgesic(s) issued with
particular reference to appropriate dose and duration of use. They should be issued with
enough analgesic to last for a week.
16
7 SURGERY IN RECURRENT SORE THROAT
A Cochrane review concluded that a single intraoperative dose of dexamethasone (dose range
0.15 to 1.0 mg/kg; maximum dose range 8 to 25 mg) is effective, relatively safe and inexpensive
for reduction of paediatric emesis after tonsillectomy and adenotonsillectomy. Treating four 1++
children will prevent one episode of emesis (NNT=4). No complications were found as a result
of dexamethasone administration.112
A A single intraoperative dose of dexamethasone (dose range 0.15 to 1.0 mg/kg; maximum
dose range 8 to 25 mg) is recommended to prevent postoperative vomiting in children
undergoing tonsillectomy or adenotonsillectomy.
One RCT (n=215) of dexamethasone published after the Cochrane review showed a dose
dependent reduction in PONV in children undergoing tonsillectomy. The study reported
an increase in postoperative bleeding, which has not been seen in other studies. Three 1+
different methods of tonsillectomy were used, which adds to the uncertainty regarding the
conclusion.113
One well conducted double blind RCT on the effectiveness of dexamethasone for preventing
PONV in adults was identified. The study involved 72 patients (80% female) aged 16 to 42 with
a completion rate of 64%. Those treated with dexamethasone 10 mg intravenously at induction 1+
of anaesthesia had significantly less PONV on the day of operation (p=0.001), although on
subsequent days there was no significant difference between the groups.88
17
Management of sore throat and indications for tonsillectomy
No studies on the effectiveness of fasting for prevention of PONV in adults were identified. A
Cochrane review on preoperative fasting in children included a wide variety of operations and
it is not clear how many studies included tonsillectomies.117 Of the 23 RCTs included, only one
reported on postoperative vomiting and none reported on nausea. The fasting regimens favoured
in the Cochrane review are already adopted in many paediatric centres for all operations.
There is insufficient evidence to make a recommendation on fasting prior to tonsillectomy for
the prevention of PONV.
18
8 PROVISION OF INFORMATION
8 Provision of information
This section reflects the issues likely to be of most concern to patients and their carers. These
points are provided for use by health professionals when discussing recurrent sore throat and
tonsillectomy with patients and carers and in guiding the local production of information
materials.
19
Management of sore throat and indications for tonsillectomy
Diagnosis
Advise that recurrent sore throat is a treatable condition
Explain the different treatment options available
Advise patients and carers to monitor time lost from education/work because of sore
throat
Provide an information leaflet to help patients manage sore throat at home and advise
patients to contact their GP or NHS 24 if they have the following symptoms:
-- any difficulty in breathing
-- any difficulty swallowing saliva or opening their mouth
-- a persistent high temperature
-- a particularly severe illness, especially with symptoms mainly on one side of
the throat
-- a sore throat which has been worsening for several days.
Treatment
Advise patients/carers how to relieve symptoms and manage pain
Inform patients that if antibiotics are prescribed the course should be completed
Inform patients that most sore throats can be self-managed and that persistent sore
throats can be managed in primary care. Inform patients of referral criteria for
tonsillectomy
Inform patients that there is no guarantee that tonsillectomy will prevent ALL sore
throats in the future; inform patients of the difference between bacterial and viral sore
throat
Advise patients of length of stay, the need for general anaesthetic and potential
complications, ie bleeding.
Post-surgery
Advise on recovery time and expected loss of time from education/work
Inform patients of foods that may cause discomfort and the importance of adequate
fluid intake.
Discharge
E nsure patients are aware that pain may increase for up to 6 days following
tonsillectomy and that they should continue to take adequate analgesia
Provide written information advising whom to contact and at what hospital unit or
department to present if they have postoperative problems or complications.
20
9 IMPLEMENTING THE GUIDELINE
21
Management of sore throat and indications for tonsillectomy
22
11 DEVELOPMENT OF THE GUIDELINE
23
Management of sore throat and indications for tonsillectomy
11.3 acknowledgements
SIGN is grateful to the following former member of the guideline development group who
contributed to the development of this guideline.
Dr Fiona Bisset Consultant in Public Health Medicine, Directorate of Health
and Wellbeing, Scottish Government
SIGN would like to acknowledge the guideline development group responsible for SIGN 34:
Management of Sore Throat and Indications for Tonsillectomy, on which this guideline is
based.
Mr William McKerrow Consultant Otolaryngologist, Raigmore Hospital, Inverness
(Chair)
Dr Ann Bisset Senior Registrar in Public Health Medicine, Grampian
Health Board
Mr Robin Blair Consultant Otolaryngologist, Ninewells Hospital and
Medical School, Dundee
Professor George Browning Consultant Otolaryngologist, Glasgow Royal Infirmary
Mr John Dempster Consultant Otolaryngologist, Crosshouse Hospital,
Kilmarnock
Dr Jill Morrison General Practitioner, Department of General Practice,
Glasgow University
Dr Barney Reilly General Practitioner, Whitefriars Surgery, Perth
Ms Susan Renton Ward Sister, ENT Ward, Royal Hospital for Sick Children,
Edinburgh
Dr George Russell Consultant Paediatrician, Royal Aberdeen Children’s
Hospital
Mr David Sim Consultant Otolaryngologist, St John’s Hospital at Howden,
Livingston
24
11 DEVELOPMENT OF THE GUIDELINE
SIGN is very grateful to all of these experts for their contribution to the guideline.
Mr Martin J Burton Consultant Otolaryngologist, Oxford Radcliffe NHS Trust
Senior Clinical Lecturer, University of Oxford
Dr George Crooks Medical Director NHS 24 and the Scottish Ambulance
Service, Glasgow
Dr Jon Dowell Director of Undergraduate Studies, Community Health
Sciences Education, Dundee
Dr Haytham Kubba Consultant Paediatric Otolaryngologist, Royal Hospital for
Sick Children, Glasgow
Mr T H J Lesser Consultant ENT/Skull Base Surgeon, Aintree University
Hospitals NHS Foundation Trust, Liverpool
Dr Helen Lewis Consultant Paediatrician, Royal College of Paediatrics and
Child Health, London
Dr Peter Macfarlane Consultant Paediatrician, Royal College of Paediatrics and
Child Health, London
Dr Graham MacKenzie Consultant in Public Health, Deaconess House, Edinburgh
Dr Una McFadyen Consultant Paediatrician, Stirling Royal Infirmary
Mr John McGarva Consultant ENT Surgeon, Stirling Royal Infirmary
Dr Andrew Power Medical Prescribing Adviser, Victoria Infirmary, Glasgow
Mr Peter J Robb Consultant ENT Surgeon, Epsom & St Helier University
Hospitals NHS Trust
Dr Grant Rodney Consultant Anaesthetist, Ninewells Hospital, Dundee
Ms Mandy Sim Pain Management Nurse Specialist, Royal Hospital for Sick
Children, Edinburgh
Dr Geeta Subramanian Consultant Paediatrician, Royal College of Paediatrics and
Child Health, London
Dr Avril Washington British Paediatric Mental Health Group, Royal College of
Paediatrics and Child Health, London
Dr Graham Wilson Scottish Representative, Council of the Association of
Paediatric Anaesthetists of Great Britain and Ireland
Professor Janet Wilson Professor of Otolaryngology Head and Neck Surgery,
Freeman Hospital, Newcastle upon Tyne
25
Management of sore throat and indications for tonsillectomy
26
ABBREVIATIONS
Abbreviations
A&E accident and emergency
BNF British National Formulary
CI confidence interval
ENT ear, nose and throat
GABHS group A beta-haemolytic streptococcus
GAHSP group A streptococcal pharyngitis
GP general practitioner
LA local anaesthesia
MTA multiple technology appraisal
NHS QIS NHS Quality Improvement Scotland
NICE National Institute for Health and Clinical Excellence
NNT number needed to treat
NSAID non-steroidal anti-inflammatory drug
OR odds ratio
PCR polymerase chain reaction
PONV postoperative nausea and vomiting
RAT rapid antigen testing
RCT randomised controlled trial
SIGN Scottish Intercollegiate Guidelines Network
SMC Scottish Medicines Consortium
27
Management of sore throat and indications for tonsillectomy
Annex 1
Key questions used to develop the guideline
The following questions were used to inform the process of identifying, sifting, and including or
excluding evidence for use in the guideline development process. Key questions are structured
(where appropriate) according to the PICO format, specifying patient group or population,
intervention, comparison, and outcome.
THE KEY QUESTIONS USED TO update SIGN 34
DIAGNOSIS
Key question Inclusion/exclusion criteria See guideline section
1. What is the evidence of Consider gastro-oesophageal
burden of disease caused reflux and H. pylori
by misdiagnosis of cause
of sore throat?
2. What is the evidence to 4.3
support the use of rapid
antigen testing [compared
to throat swabbing] in the
diagnosis of streptococcal
sore throat? How does it
affect patient outcomes?
3. Is there any evidence that Consider: fever, tonsillar exudate/ 4.1
the clinical picture/features pus, cervical lymphadenopathy,
can help differentiate cough, absence of cough, duration
between viral and bacterial of symptoms eg pain, dysphagia,
sore throat? pharyngeal erythema, spots and
rashes, centor criteria, breese
scale, other clinical scales
MANAGEMENT
Key question Inclusion/ exclusion criteria See guideline section
4. A. Which analgesic Include: paracetamol, ibuprofen, 5.1 and 5.2
(or combination of adjuvant compounds to painkillers
analgesics) is most (eg caffeine), topical sprays,
effective in adults with Chinese medicines; consider
sore throat in terms of gastrointestinal bleeding, nausea,
speed and duration of diarrhoea
pain relief?
Exclude aspirin and diclofenac
B. Which analgesic (or
combination of analgesics)
is most effective in children
with sore throat in terms of
speed and duration of pain
relief?
5. Which adjunctive Benzydamine (topical agents), 5.3
therapies are useful in sore sprays, lozenges (eg Fisherman’s
throat in terms of pain Friends), gargles, steroids
relief and dysphagia?
(consider harms and adverse
effects from long term use)
28
ANNEXES
6. D
oes the use of the Include: Penicillin V, macrolides, 6.1
following antibiotics in cefalexin, amoxicillin, co-
acute sore throat (a) relieve amoxiclav
symptoms (b) prevent
(consider dose and duration of
sequelae (c) prevent
treatment)
complications (eg abscess
formation, breathing
problems, quinsy/
peritonsillar abscess)?
7. Will prescribing antibiotics 6.2
to treat sore throat reduce
subsequent episodes in
recurrent sore throat?
8. What is the evidence that Include: Penicillin V, macrolides, 6.2
antibiotic prophylaxis cefalexin, amoxicillin, co-
reduces recurrent episodes amoxiclav
of sore throat?
(consider dose and duration of
treatment)
SURGERY IN RECURRENT SORE THROAT
Key question Inclusion/exclusion criteria See guideline section
9. In children with consider: (a) reducing episodes of 7.2
recurrent sore throat, recurrence (b) improving general
is tonsillectomy health (c) improving quality
(compared to non-surgical of life (d) long term harms of
intervention) clinically- tonsillectomy
and cost-effective?
29
Management of sore throat and indications for tonsillectomy
30
Your child may have sore ABOUT
ears Surgery
This is normal. It happens because the throat and ears have
CHILDREN’S
Annex 2
the same nerves. It does not usually mean that your child
has an ear infection. TONSIL SURGERY
Your child’s throat will look ENT.UK is the professional association for Ear, Nose
and Throat Surgeons and related professionals in the
white UK. This information leaflet is to support and not to
replace the discussion between you and your specialist.
Before you give your consent to the treatment, you
This is normal while the throat heals. You may also see should raise any concerns with your specialist.
small threads in your child’s throat - sometimes these are
used to help stop the bleeding during the operation, and
they will fall out by themselves.
ENT.UK
Bleeding can be serious The Royal College of Surgeons of England
If you notice any bleeding from your child’s throat, you 35-43 Lincoln’s Inn Fields
must see a doctor. Either call your GP, call the ward, or go London WC2 3PE
to your nearest hospital casualty department. www.entuk.org
Disclaimer
This publication is designed for the information of patients. Whilst every effort has been
made to ensure accuracy, the information given may not be comprehensive and patients
should not act upon it without seeking professional advice.
Reproduced with permission from ENT-UK (British Association of Otorhinolaryngology – Head and Neck Surgery)
06002
Example patient information leaflet: About Children’s Tonsil
31
ANNEXES
32
You may change your mind about the operation at any
What are tonsils? time, and signing a consent form does not mean that your Possible complications
child has to have the operation.
Tonsils are small glands in the throat, one on each side. Tonsil surgery is very safe, but every operation has a
They are there to fight germs when you are a young child. If you would like to have a second opinion about the small risk.
After the age of about three years, the tonsils become less treatment, you can ask your specialist. He or she will not
important in fighting germs and usually shrink. Your body mind arranging this for you. You may wish to ask your own The most serious problem is bleeding. This may need a
can still fight germs without them. GP to arrange a second opinion with another specialist. second operation to stop it. About two children out of
every 100 who have their tonsils out will need to be taken
back into hospital because of bleeding, but only one child
Why take them out? Before your child’s out of every 100 will need a second operation. Please let
us know before surgery if anyone in the family has a
We only take tonsils out if they are doing more harm than operation bleeding problem.
good. We will only take your child’s tonsils out if he or she
is getting lots of sore throats, which are making him or her Arrange for your child to have a couple of weeks off During the operation, there is a very small chance that we
lose time from school. Sometimes small children have school. Let us know if he or she has a sore throat or cold may chip or knock out a tooth, especially if it is loose,
tonsils so big that they block their breathing at night. in the week before the operation - it will be safer to put it capped or crowned. Please let us know if your child has
off for a few weeks. It is very important to tell us if your any teeth like this.
child has any unusual bleeding or bruising problems, or if
Are there alternatives to this type of problem might run in the family. Some children feel sick after the operation. We may need
to give your child some medicine for this, but it usually
having the tonsils removed? settles quickly.
Your child will not always need to have his or her tonsils
How is the operation done?
out. You may want to just wait and see if the tonsil problem Your child will be asleep. We will take his or her tonsils out Your child’s throat will be
gets better by itself. Children often grow out of the through the mouth, and then stop the bleeding. This takes
problem over a year or so. The doctor should explain to about 20 minutes. Your child will then go to a recovery sore
you why he or she feels that surgery is the best treatment. area to be watched carefully as he or she wakes up from
the anaesthetic. He or she will be away from the ward for Your child’s throat will get better day-by-day. Give him or
Antibiotics may help for a while, but frequent doses of about an hour in total. her painkillers regularly, half an hour before meals for the
antibiotics can cause other problems. A low-dose first few days. Do not give more than it says on the label.
antibiotic for a number of months may help to keep the Do not give your child aspirin - it could make your child
infections away during an important period such as during How long will my child be bleed. (Aspirin is not safe to give to children under the age
examinations. There is no evidence that alternative of 16 years at any time, unless prescribed by a doctor).
Management of sore throat and indications for tonsillectomy
off work
Make sure you rest at home away from crowds and smoky SURGERY
places. Keep away from people with coughs and colds.
Your may feel tired for the first few days. ENT.UK is the professional association for Ear, Nose
and Throat Surgeons and related professionals in the
UK. This information leaflet is to support and not to
replace the discussion between you and your specialist.
Bleeding can be serious Before you give your consent to the treatment, you
should raise any concerns with your specialist.
If you notice any bleeding from your throat, you must see
a doctor. Call your GP, call the ward, or go to your nearest
hospital casualty department.
ENT.UK
The Royal College of Surgeons of England
35-43 Lincoln’s Inn Fields
London WC2 3PE
www.entuk.org
Disclaimer
This publication is designed for the information of patients. Whilst every effort has been
made to ensure accuracy, the information given may not be comprehensive and patients
should not act upon it without seeking professional advice.
Reproduced with permission from ENT-UK (British Association of Otorhinolaryngology – Head and Neck Surgery)
06001
Example patient information leaflet: About Adult Tonsil
33
ANNEXES
34
better by itself. The doctor should explain to you why he
What are tonsils? or she feels that surgery is the best treatment. Possible complications
Tonsils are small glands in the throat, one on each side. You may change your mind about the operation at any Tonsil surgery is very safe, but every operation has a small
They are there to fight germs when you are a young child. time, and signing a consent form does not mean that you risk. The most serious problem is bleeding. This may need
As you get older, the tonsils become less important in have to have the operation. a second operation to stop it. As many as five adults out of
fighting germs and usually shrink. Your body can still fight every 100 who have their tonsils out will need to be taken
germs without them. If you would like to have a second opinion about the back into hospital because of bleeding, but only one adult
treatment, you can ask your specialist. He or she will not out of every 100 will need a second operation.
mind arranging this for you. You may wish to ask your
Why take them out? own GP to arrange a second opinion with another During the operation, there is a very small chance that we
specialist. may chip or knock out a tooth, especially if it is loose,
We only take them out if they are doing more harm than capped or crowned. Please let us know if you have any
good. We take tonsils out if they cause recurrent sore teeth like this.
throats despite treatment with antibiotics. The other main Before your operation
reason for removing tonsils is if they are large and block
the airway. A quinsy is an abscess that develops alongside Arrange for two weeks off work. Let us know if you have Your throat will be sore
the tonsil, as a result of tonsil infection, and is most a chest infection or tonsillitis before your admission date
unpleasant. People who have had a quinsy therefore often because it may be better to postpone the operation. It is Your throat will sore for approximately ten days. It is
choose to have a tonsillectomy to prevent having another. very important to tell us if you have any unusual bleeding important to take painkillers regularly, half an hour before
Tonsils are also removed if we suspect there is a tumour in or bruising problems, or if this type of problem might run meals for at least the first week. Do not take aspirin
the tonsil. A rapid increase in the size of a tonsil or in your family. because it may make you bleed.
ulceration or bleeding occurs if a tumour of the tonsil
develops. Tumours of the tonsil are rare.
How is the operation done? Eat normal food
You will be asleep under general anaesthetic. We take the Eating food will help your throat to heal. It will help the
tonsils out through the mouth, and then stop the bleeding. pain too. Drink plenty of water and stick to bland non
This takes about 30 minutes. spicy food. Chewing gum may also help the pain.
The removal of have the same nerves. It does not mean that you have an
enlarged tonsils like In most hospitals, surgeons prefer tonsillectomy patients to ear infection.
this can relieve stay in hospital for one night. In some hospitals tonsil
airway obstruction.
surgery is done as a day case, if your home is close to the
hospital. Either way, we will only let you go home when Your throat will look white
you are eating and drinking and feel well enough.
Do I have to have my tonsils This is normal while your throat heals. You may also see
small threads in your throat - they are used to help stop the
out? bleeding during the operation, and they will fall out by
themselves.
You will not always need to have your tonsils out. You
may want to just wait and see if the tonsil problem gets
Some people get a throat infection after surgery, usually if
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ISBN 978 1 905813 62 9
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