Recurrent Tonsillitis/Tonsillectomy

This guidance covers recurrent acute tonsillitis and referral for tonsillectomy.


Signs and Symptoms

Typical features of tonsillitis include:

  • Soreness of the throat especially upon swallowing
  • Swollen neck glands
  • Enlarged erythematous tonsils — with or without exudates
  • Fever
  • Can be associated with small red haemorrhagic spots on the hard and soft palate
  • Nausea, vomiting, and abdominal pain are also common (children only)

History and Examination

Caution with examination of the throat of anyone with suspected epiglottitis (dysphonia, drooling, sepsis or stridor)

Differential Diagnoses

Consider differential diagnoses:

  • Epiglottitis
  • Infectious mononucleosis (glandular fever)
  • Malignancy − be suspicious if there is unilateral enlargement and subacute or chronic symptoms, or if swelling is painless
  • Embedded foreign body:
    • suggestive history
    • unilateral pain
    • abscess formation

Red Flags

Consider immediate admission to hospital if patient presents with:

  • Sore throat associated with stridor or respiratory difficulties, drooling, systemically very unwell, painful swallowing, muffled voice − suspect acute epiglottitis
  • Dehydration or reluctance to take any fluids
  • Severe suppurative complications, e.g.:
    • peritonsillar abscess (also known as quinsy) or cellulitis
    • parapharyngeal abscess
    • retropharyngeal abscess
    • Lemierre's syndrome (fusobacterial pharyngitis associated with IJV thrombosis and high risk of complications)
  • Signs of being markedly systematically unwell
  • Immunosuppressed patients
  • Malignancy − be suspicious if there is unilateral enlargement and subacute or chronic symptoms persist for more than 3 weeks, or if swelling is painless


  • Throat swabs should not be carried out routinely in primary care management of sore throat unless scarlet fever is suspected.

Consider serology for infectious mononucleosis.


Discuss treatment options, including benefits and risks.

Use the Centor clinical prediction score to assist the decision on whether to prescribe an antibiotic − cannot be relied upon for a precise diagnosis:

  • The score gives one point each for:
    • tonsillar exudate
    • tender anterior cervical lymph nodes
    • history of fever
    • absence of cough
    • age less than 15
    • age over 44 subtract 1 point

Antibiotic treatment if:

  • 3 or 4 Centor criteria present
  • systemically very unwell
  • pre-existing co-morbidity that may result in serious complications, e.g:
    • heart
    • lung
    • neuromuscular disease
    • immunosuppression
    • cystic fibrosis
    • prematurely born young children
    • history of rheumatic fever

Formulary Chapter 5: Infections - Upper respiratory tract infections

  • Seek specialist advice if no response to appropriate antibiotics or if there is clinical deterioration:

For pain relief:

  • In adults:
    • consider non-steroidals and simple analgesia
  • In children:
    • paracetamol
    • ibuprofen should be used with caution in children with or at risk of dehydration


Referral Criteria

Tonsillectomy will only be routinely commissioned in adults and children in Devon in the following circumstances:

  • Peritonsillar abscess (Quinsy)
  • Tonsillar enlargement causing or contributing to acute upper airways obstruction
  • Recurrent acute sore throat due to tonsillitis with the following criteria:

Documented evidence of:

  • 7 or more episodes of tonsillitis in the last year; OR
  • 5 or more such episodes per year in the preceding two years; OR
  • 3 or more such episodes per year in the preceding three years;


  • There has been significant impact on quality of life indicated by documented evidence of symptoms that act as a barrier to employment or education or carrying out carer activities; OR
  • Failure to thrive

In line with NHS England guidance (2018), after appropriate specialist assessment tonsillectomy may be considered at a lower threshold than the above for the following indications:

  • Acute and chronic renal disease resulting from acute bacterial tonsillitis (assessment to include renal specialist)
  • As part of treatment of severe guttate psoriasis (assessment to include dermatology specialist)
  • Metabolic disorders where periods of reduced oral intake could be dangerous to health (assessment to include paediatrician or endocrinologist)
  • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) (assessment to include paediatrician)
  • Severe immune deficiency that would make episodes of recurrent tonsillitis dangerous (assessment to include paediatrician, or haematology or immunology specialist)

  • Tonsillectomy/adenotonsillectomy will be funded in children under 16 where obstruction of the airway results in obstructive sleep apnoea syndrome, and the following apply:
    • A significant impact on development, behaviour and/or quality of life demonstrated by supporting evidence such as growth charts, letters from GPs; OR
    • A strong clinical history (± sleep studies) suggestive of sleep apnoea

Tonsillectomy is not routinely commissioned solely for the management of snoring.

Tonsillectomy is not routinely commissioned for the treatment of tonsilloliths (tonsil stones).

Head and Neck cancer services are commissioned by NHS England as part of specialist cancer services; treatment of malignancy is therefore out of scope of this guideline and the policy below.

Click on the link below for the complete Tonsillectomy Commissioning Policy

Tonsillectomy Clinical Commissioning Policy

Referral Instructions

For adults

e-referral selection:

  • Speciality: ENT
  • Clinic type: Throat (inc Voice/Swallowing)
  • Service: DRSS-South Devon & Torbay-ENT- Devon CCG -15N
For children

e-referral selection:

  • Speciality: Children's & Adolescent Services
  • Clinic type: ENT
  • Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon CCG - 15N

Referral Forms

DRSS referral Form

Supporting Information

Patient Information

MyHealth: Tonsillitis


Clinical Knowledge Summary: Sore throat - acute

SIGN guidance on tonsillectomy

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: October 2019

Updated in accordance with the Devon Tonsillectomy Commissioning Policy October 2019


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