Section 2

List two differential diagnoses for the above photograph.

  • Tonsillitis
  • Glandular fever

What investigation should you arrange to help determine this.

Blood test – Mono spot / Paul Bunnel to exclude or diagnose glandular fever

Which antibiotic should you avoid and why?

Avoid amoxicillin or ampicillin as may cause a type IV hypersensitivity rash in patients with glandular fever.

What are the SIGN criteria for tonsillectomy or recurrent tonsillitis?

  • Tonsillectomy if recurrent episodes of acute sore throats due to tonsilitis, which are disabling and prevent normal function.
  • 7 or more episodes of tonsillitis in preceding year
  • 5 or more episode s each year for two preceding years
  • 3 or more episodes each year  for the three preceding years

Describe three other indications for tonsillectomy.

  • More than one quinsy/peritonsillar abscess
  • Suspected cancer
  • Obstructive sleep apnoea
  • As part of another procedure e.g. uvulopalatoplasty

Supporting Information


Portsmouth Tonsillectomy Protocol

Bird JH, Biggs TC, Schulz C, Lower N, Faris C, Repanos C. Implementation of an evidence‐based acute tonsillitis protocol: Our experience in one hundred and twenty‐six patients. Clinical Otolaryngology. 2013 Oct;38(5):410-5. 

Scottish Intercollegiate Guidelines Network (SIGN) – Management of sore throat and indications for tonsillectomy › assets › sign117 


Tonsillitis + glandular fever

  • Organisms- Group A, Beta haemolytic strep – pyogenes, EBV for glandular fever.
  • Presents- fever, otalgia, odynophagia, dehydration, sepsis, halitosis
  • Treatment- analgesia, fluid resus and abx to present secondary infection
  • Investigations
  • Complications– quinsy, retropharyngeal/parapharyngeal abscess, sepsis, Glomerulonephritis, endocarditis, mediastinitis. Necrotising tonsillitis- haemolytic streptococci (scarlet fever), diphtheria and vincent’s angina (fusiform and spirochetes)- necrotising pharyngeal infection.
  • Chronic tonsillitis- crypts with tonsiliths. 

Glandular fever – can cause hepatosplenomegaly – advice to abstain from contact sport for 6 weeks

Tonsillectomy– indications

  1. 7 or more episodes of tonsillitis in preceding year
  2. 5 or more for 2 consecutive years
  3. 3 or more for 3 consecutive years
  4. More than one quinsy- collection pus peritonsillar space- space between tonsillar capsule (lateral aspect of tonsil by condensation of the pharyngobasilar fascia) and the superior constrictor. Treat as tonsillitis with Incision/aspiration.
  5. Suspected cancer
  6. OSA
  7. Part of another procedure- uvulopalatoplasty

Contraindications include acute infection, bleeding disorder, cleft palate. 

Procedure– Boyle-Davis mouth gag held with draffin rods. Dissection using cold steel, diathermy, coblation, guillotine or laser. Haemostasis at the end, check PNS for clot. 


  • Bleeding-
    • Primary in 24 hrs
    • Secondary normally 5-10 days post op
      • It is often from tonsillar arteries or its branches. It occurs in 2-5%. The bleeding can be treated with an adrenaline swab, cautery or return to theatre. Occasionally the pillars need to be stitched over a swab. Diathermy tonsillectomy has the highest risk.
    • Infection, damage to teeth, lips gums, TMJ, change in voice, Otalgia, Trauma to soft palate and pharyngeal wall.
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