Tonsils

Overview

ENT Clinics are currently under extreme pressure as a result of COVID recovery and increased demand for appointments.

Please consider using primary care management pathways where possible and only refer patients if these options have been exhausted. When referring, please also warn patients of long waits for outpatient appointments. The ENT service kindly requests that if patients approach referrers requesting an appointment to be expedited not to ask them to ring the hospital as they will not be able to help. Only submit written requests to expedite if there is clinical deterioration or concern. Do not submit another eRS referral in this situation as these requests will be returned.

Current waits for outpatient clinics in ENT are as follows (January 2024):

• Otology- 8 months
• Rhinology- 6 months
• Head and Neck- 5 months

Acute Tonsillitis

See Sore throat - acute /CKS  for advice on management  of sore throat and acute tonsillitis. This includes advice on red flags that would indicate urgent admission to hospital.

The BNSSG formulary also has advice on antibiotic prescribing.

The FeverPAIN score can be a useful guide to prescribing.

Recurrent Tonsillitis

Recurrent tonsillitis may need consideration for ENT referral if funding criteria are met. See Referral section below for details.

Tonsilloliths

A tonsillolith or tonsillar stone is material that accumulates on the tonsil in crypts or scars caused by previous episodes of tonsillitis. They can range up to the size of a peppercorn and are white/cream in colour. The main substance is mostly calcium, but they can have a strong unpleasant odour.

Tonsilloliths can quite often be removed with a toothbrush and good oral hygiene measures, but they will tend to recur. In addition, patients recurrently manually removing these can cause inflammation and pain themselves.

Although unpleasant and distressing for the patient, they are not an indication for surgical removal of the tonsils and tonsillectomy is not commissioned for these patients.

Please see the Tonsillectomy - Referral for Assessment Prior Approval Policy

Red Flags

Unilateral Tonsillar Enlargement or Asymmetry 

Local ENT specialists advise the following:

Tonsillar asymmetry is not an unusual finding and is often due to apparent asymmetry with the tonsils actually being the same size. 

True unilateral tonsillar enlargement without associated symptoms is very low risk for cancer. Therefore, in the absence of any symptoms (localised or systemic eg B symptoms*) then consider referring these patients urgently to ENT for further assessment. This does not need to be on a fast track cancer (2WW) pathway. If there are additional concerns eg older age (over 40), smoking history, previous head/neck cancer then please highlight this in the referral.

A 2WW referral should be made if there are symptoms or signs that raise concerns about malignancy such as those listed in the Head and Neck 2WW pathway:

* [If there is tonsillar enlargement (or unexplained enlargement of neck nodes) and B symptoms then consider using the Head and Neck 2WW pathway (free text concerns if no suitable tick box).

If there are widespread palpable lymph nodes and B symptoms, then consider the Haematology 2WW pathway.]

Referral

Referral for Recurrent Tonsillitis

The decision to refer to consider tonsillectomy depends on the severity and frquency of infections or other concerns and if funding criteria are met.

A decision making aid can help patients or parents to decide on their options:

NHS England » Decision support tool: making a decision about recurrent tonsillitis in children and adults

Referral should only be made if funding criteria are met as outlined in the policy:

Tonsillectomy - Referral for Assessment Prior Approval Policy

Referrals should be made via eRS with a completed prior approval form attached. Referrals where criteria for referral are not met or PA form is not attached, will be returned by the Referral Service or by providers. 

Referral for Tonsillectomy for other indications

Other indications for consideration of tonsillectomy where criteria are met are outlined in the Tonsillectomy - Referral for Assessment Policy

Advice and Guidance

Advice can be obtained via the ENT A&G service via eRS, but please note that funding criteria still need to be met if referral to consider tonsillectomy is advised. 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.