Tonsillitis refers to infection of the tonsils. Otitis media refers to an infection in the middle ear. Rhinitis refers to inflammation in the nose. Sinusitis refers to inflammation of the paranasal sinuses in the face. Infections in the ear, nose and throat are most commonly caused by viruses. They usually resolve without treatment within 1-3 weeks.
Antibiotics are reserved for immunocompromised, significant co-morbidities, severe infections or infections that fail to resolve. A backup prescription may be considered, where patients can collect antibiotics if the symptoms do not improve or worsen after 3 days.
Bacteria
Bacterial tonsillitis is most commonly caused by group A streptococcus (GAS) infections, mainly streptococcus pyogenes.
Otitis media, sinusitis and tonsillitis not caused by GAS are most commonly caused by:
- Streptococcus pneumoniae
Other causes of otitis media, sinusitis and tonsillitis:
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
Tonsillitis
The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics. A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present:
- Fever over 38ºC
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymph nodes (lymphadenopathy)
The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis:
- Fever during the previous 24 hours
- P – Purulence (pus on tonsils)
- A – Attended within 3 days of the onset of symptoms
- I – Inflamed tonsils (severely inflamed)
- N – No cough or coryza
Penicillin V (phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.
Clarithromycin is the usual first-line choice in true penicillin allergy.
Complications of tonsillitis include:
- Peritonsillar abscess, also known as quinsy
- Otitis media, if the infection spreads to the inner ear
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
Otitis Media
Otitis media presents with reduced hearing and pain in the affected ear. Otoscopy will reveal a bulging red tympanic membrane. A perforated tympanic membrane can result in discharge from the ear.
Otitis media usually resolves within 3 to 7 days without antibiotics. Systemically unwell may need admission.
The NICE clinical knowledge summaries (updated May 2023) suggest:
- Amoxicillin for 5-7 days first-line
- Clarithromycin (if penicillin allergic)
- Erythromycin (in pregnant women allergic to penicillin)
Co-amoxiclav is a second-line option if the infection is not responding to amoxicillin.
Sinusitis
Sinusitis is usually viral. Only around 2% of acute sinusitis is bacterial. Sinusitis typically last 2-3 weeks and resolves without treatment.
NICE CKS (May 2023) recommend for patients with symptoms that are not improving after 10 days, the options of:
- High-dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)
- A backup antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)
The options for chronic sinusitis (lasting more than 12 weeks) are:
- Saline nasal irrigation
- Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
- Functional endoscopic sinus surgery (FESS)
Last updated July 2023
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