Ear Nose and Throat Infections

Tonsillitis, otitis media and rhinosinusitis are most commonly caused by a viral infections and do not require antibiotics. These infections will resolve without treatment over 1-3 weeks.

Antibiotics should be reserved for immunocompromised patients, those with significant co-morbidities, severe infections or infections that fail to resolve. NICE guidelines are supportive of considering a delayed prescription in the community where patients can collect antibiotics if the symptoms don’t improve or get worse after 3 days.



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
  • Morazella catarrhalis
  • Staphylococcus aureus



Tonsillitis is most commonly viral and does not require antibiotics.

The Centor Criteria are used to estimate the probability that tonsillitis is due to a bacteria infection, and therefore requires antibiotics. A score of < 3 indicates they are unlikely to benefit from an antibiotic and antibiotics should not routinely be given. A score of ≥ 3 gives a 40 – 60 % probability of bacterial tonsillitis and it is appropriate to offer antibiotics. One point is given for each of the following:

  • Fever > 38ºC
  • Tonsillar exudates
  • Absence of cough
  • Tender anterior cervical lymph nodes (lymphadenopathy)

Penicillin V (also called phenoxymethylpenicillin) for a 10 day course is typically first line.

Alternatives antibiotics and for a broader spectrum of activity:

  • Co-amoxiclav
  • Clarithromycin
  • Doxycycline


Otitis Media

It is difficult to distinguish between bacterial and viral otitis media. It presents with ear pain. Examination will reveal a bulging red tympanic membrane. If the ear drum perforates there can be discharge from the ear.

Otitis media usually resolves within 3-7 days without antibiotics. If systemically unwell consider admission.

An appropriate initial antibiotic in the community:

  • Amoxicillin

Alternatives in penicillin allergy:

  • Clarithromycin
  • Erythromycin

Second line if not responding to amoxicillin after 2 days:

  • Co-amoxiclav



Again sinusitis can be bacteria or viral. NICE recommend providing an antibiotic if the patient is systemically very unwell however most patients do not require an antibiotic.

Sinusitis usually last 2-3 weeks and resolves without treatment.

NICE guidelines suggest the following management:

  • Symptoms for less than 10 days: No antibiotics.
  • No improvement after 10 days: 2 weeks of high-dose steroid nasal spray
  • No improvement after 10 days and likely bacterial cause: consider delayed or immediate prescription of antibiotics

Penicillin V (also called phenoxymethylpenicillin) for a 5 day course is typically first line.

Alternatives in penicillin allergy:

  • Clarithromycin
  • Erythromycin (pregnancy)
  • Doxycycline

Second line if not responding after 2 days:

  • Co-amoxiclav


Last updated March 2019