What's New

This pathway has been published following concerns from secondary care regarding the number of referrals for tonsillectomy that do not meet the CCG commissioning criteria and therefore are not funded. The CCG has a clear policy in place for Tonsillectomy that requires patients to meet defined access criteria.

The pathway is based on the Scottish Intercollegiate Guidelines Network (SIGN) guidance on the management of sore throat and indications for tonsillectomy, the Royal College of Surgeon and ENT UK’s commissioning guide for tonsillectomy, BMJ best practice guidance, and the current CCG commissioning policy on Tonsillectomy.

Tonsillectomy Care Pathway Overview

Please click the relevant flowchart box to be taken directly to textual information.


Presentation of Acute Tonsillitis

Tonsillitis is inflammation due to infection of the tonsils. It is a very common condition, most frequent in children aged 5-10 years and young adults between 15 and 25 years.

  • Pain in the throat is sometimes severe and may last more than 48 hours, along with pain on swallowing.
  • Pain may be referred to the ears.
  • Small children may complain of abdominal pain.
  • Headache.
  • Loss of voice or changes in the voice.
Red Flags
  • Quinsy – peri-tonsillar abscess
  • Neck swelling
  • Unable to drink
  • Airway concern
  • Systemically unwell

Practice Point

Please see the Urgent Care: general section to SWAST's guidance on Requesting Ambulance Transport (999 or Urgent).



There is no evidence that bacterial sore throats are more severe than viral ones or that the duration of the illness is significantly different in either case. Between 50% and 80% of sore throat is of viral cause, including influenza and primary herpes simplex. An additional 1% to 10% of cases are caused by Epstein-Barr virus. The most commons bacterial organism identified is group A beta-haemolytic streptococcus (GABHS), which causes 5% to 36% of infections.


  • The throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them.
  • Possibly a high temperature.
  • Swollen regional lymph glands.
  • Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and dysphagia.
  • Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior cervical glands.

Precise clinical diagnosis is difficult in practice. Distinguishing between viral and bacterial aetiology is one of the main considerations, as anti-biotic treatment may be considered for the most common bacterial pathogen GABHS. The Centor scoring system can be used to assist in deciding whether to prescribe antibiotics but cannot be relied upon to give a precise diagnosis. The Centor score gives one point each for:

  • Tonsillar exudate
  • Tender anterior cervical lymph nodes
  • History of fever
  • Absence of cough

The likelihood of GABHS infection increases with increasing score, and is between 25% and 86% with a score of 4 and 2% to 23% with a score of 1, depending upon age local prevalence and seasonal variation. Streptococcal infection is most likely in the 5-15 age group and becomes progressively less likely in younger or older patients. The Centor score is not validated for use in children under 3 years old.

A positive throat culture for GABHS makes the diagnosis of streptococcal sore throat likely but a negative culture does not rule out the diagnosis. Throat swabs are neither sensitive nor specific for serologically confirmed infection, considerably increase costs, may medicalise illness, and alter few management decisions. Therefore, swabs should not be carried out routinely in primary care management of sore throat.
GP Management

Diagnosis of a sore throat does not mean that an antibiotic has to be administered, indeed anti-biotics for recurrent sore throat is not recommended. Adequate analgesia will usually be all that is required.

In adults, diclofenac and ibuprofen are superior to paracetamol and aspirin in reducing throat pain as early as one hour post dose. Ibuprofen 400 mg three times daily is recommended for relief of fever, headache and throat pain in adults with sore throat.

In adults who are intolerant to ibuprofen, paracetamol 1 g four times daily when required is recommended for symptom relief.

In children with sore throat, an adequate dose of paracetamol should be used as first line treatment for pain relief. Ibuprofen can be used as an alternative to paracetamol in children, but should not be given routinely to children with or at risk of dehydration.
When to Refer

In Gloucestershire access to tonsillectomy for recurrent tonsillitis is restricted to patients who meet defined access criteria, which take into account factors such as the frequency of episodes of tonsillitis and the impact of the episodes.  The current referral criteria for tonsillectomy are as follows:

- Sore throats are due to acute tonsillitis and symptoms have been occurring for at least a year.


- the frequency of episodes of acute tonsillitis is confirmed by the patients’ GP as follows: 

  • seven or more well documented, clinically significant, adequately treated sore throats in the preceding year


  • five or more such episodes in each of the preceding two years


  • three or more such episodes in each of the preceding three years. 


- The episodes of sore throat are disabling and cause significant functional impairment.

Significant functional impairment is defined as:

  • symptoms prevent the patient fulfilling routine work or educational responsibilities
  • symptoms prevent the patient carrying out routine domestic or carer activities 


Generally GPs are not expected to refer patients that do not meet the above criteria. However, as some patients who do not meet the above criteria may have more complex problems or specific clinical conditions that may require tonsillectomy as part of their ongoing management, based on clinical judgement GPs may therefore consider a referral to ENT for a specialist opinion, even if the above criteria are not met. Alternatively, GP's may wish to consider seeking specialist advice via the Advice and Guidance service.

Referral to ENT for assessment and subsequent tonsillectomy can be made following two confirmed and documented cases of quinsy.

Referral to ENT for assessment and subsequent tonsillectomy can be made for children with symptoms of persistent significant obstructive sleep apnoea (OSA) which can be diagnosed with a combination of the following clinical features:

  • A clear history of an obstructed airway at night: witnessed apnoeas, abnormal postures, increased respiratory effort, loud snoring or stertor.
  • Evidence of adeno-tonsillar hypertrophy: direct examination, hot potato or adenoidal speech, mouth breathing / nasal obstruction
  • Significant behavioural change due to sleep fragmentation: daytime somnolence or hyperactivity
  • OSA may also cause morning headache, failure to thrive, night sweats and enuresis 

Referral to ENT should be made where there is concern over potential malignancy under the 2ww pathway
Ongoing Primary Care Management

For patients that do not meet the criteria for onward referral for tonsillectomy primary care management should continue. For patients with recurrent tonsillitis the GP should ensure that additional cases are documented to support potential future referral/re-referral.


Patient Resources

Please see the Patient & Carer Information & Leaflets section.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

Significant Variations for this Pathway

There are no significant variations from the national standards.

Other Online Resources

Pathway Leads

Name Role Organisation Email
Tira Galm ENT Consultant Gloucestershire Hospitals NHS Foundation Trust Tira.Galm@glos.nhs.uk
Malcolm Gerald GP Gloucestershire Clinical Commissioning Group malcolm.gerald@nhs.net
Richard Thorn Commissioning Manager, Planned Care Gloucestershire Clinical Commissioning Group richard.thorn@nhs.net

Reason for Pathway Selection

Following concerns from secondary care regarding the number of referrals for tonsillectomy that do not meet the CCG commissioning criteria and therefore are not funded

Completion Date

May 2016

Reviewed and updated

March 2018

Annual Review Date

Feb/March 2019