Indications of referral for tonsillectomy in recurrent tonsillitis has been added.
Date: 21 November 2025
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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)
Environmental irritants (e.g. smoke, air pollution)
GORDGastro-oesophageal reflux disease
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 GASGroup A Streptococcal 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
Fever >38°C
Absence of cough
Tonsillar exudate
Tender anterior cervical lymphadenopathy
3 or 4 = 32-56%
0 or 1 or 2 = 3-17%
FeverPAIN
Fever (during previous 24 hours)
Purulence (tonsillar exudate)
Attend rapidly (<3 days onset of symptoms)
Inflamed tonsils
No cough / coryza
4 or 5 = 62-65%
2 or 3 = 34-40%
0 or 1 = 13-18%
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
Approach for other patients:
All patients should be offered self-care management
Do not routinely offer antibiotics – use the Centor or FeverPAIN score to guide antibiotic prescription (see below)
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
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 prescriptionOnly take antibiotics if there is no improvement after 3-5 days or if symptoms worsen
3 / 4
4 / 5
Consider antibiotics (immediate / back-up prescriptionOnly take antibiotics if there is no improvement after 3-5 days or if symptoms worsen)
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
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