Epiglottitis is a rapidly progressive airway emergency — the epiglottis and supraglottic structures become severely oedematous, and stimulation (tongue depressor, crying in a child, anxiety) may worsen distress and airway compromise. The classic presentation is the tripod position: patient sitting upright, leaning forward on hands, with neck extended, mouth open, drooling. This posture maximises the airway calibre — it is an involuntary survival response. Lying the patient flat on an examination couch may worsen airway compromise. The GP's role is entirely supportive: call 999, keep the patient calm and upright, administer high-flow oxygen via mask if available (do not use a tight-fitting mask), and do NOT attempt any examination or investigation. The decline of childhood epiglottitis from H. influenzae type b followed universal Hib vaccination (1992 in UK), but adult epiglottitis (GAS, Streptococcus pneumoniae, H. influenzae non-type b) has filled the epidemiological gap. Lemierre's syndrome deserves specific attention because it is a disease that affects young previously healthy adults (typically 16–30), occurs in the convalescent phase of pharyngitis (after the sore throat seems to be improving), and is frequently not considered. The incidence is approximately 3.6 per million per year — rare but rising. The Fusobacterium necrophorum pathogen is found in 80% of cases and is resistant to many standard antibiotics (notably macrolides). Any young adult with a two-week history of pharyngitis who now presents with fever, neck pain, and chest symptoms needs urgent hospital assessment for Lemierre's syndrome (blood cultures and cross-sectional imaging are hospital investigations).

The FeverPAIN score was specifically developed and validated in UK primary care (Little et al., Lancet Infectious Diseases, 2013) — making it the most applicable scoring tool for UK GP practice. The key insight from this landmark study is that most sore throats are viral (70–80%), and even GAS pharyngitis is largely self-limiting — antibiotics reduce symptom duration by only 16 hours on average (from approximately 7 days to approximately 6.4 days). The modest symptom benefit must be weighed against antibiotic side effects (diarrhoea in 10%, rash in 5%, Clostridioides difficile risk), contribution to antibiotic resistance, and medicalisation of self-limiting illness. The primary indication for antibiotics in streptococcal pharyngitis is prevention of rheumatic fever (acute rheumatic heart disease) — a complication that has become extremely rare in the UK due to improved living conditions and historical antibiotic use, but remains important in high-incidence communities. Secondary indications include prevention of peritonsillar abscess (quinsy) and invasive GAS disease. The NNT for preventing quinsy with antibiotics in a high-risk sore throat is approximately 100 — meaning 100 patients must be treated to prevent one case. The delayed prescription strategy (back pocket prescription) is one of the most evidence-based antibiotic stewardship interventions in primary care — it empowers patients to self-assess, significantly reduces antibiotic consumption, and achieves equivalent clinical outcomes to immediate prescribing for uncomplicated sore throat.

The amoxicillin rash in EBV is one of the most important pharmacological interactions to know — and one of the most easily forgotten in a busy acute consultation. When a patient with EBV (infectious mononucleosis) is given amoxicillin or ampicillin (including co-amoxiclav), a generalised pruritic maculopapular rash is common (estimates vary substantially), usually within 24–72 hours. This is not a true penicillin allergy — it is a specific interaction between EBV-infected B-lymphocytes and the aminopenicillin structure, producing an immune complex-mediated rash. The patient is not allergic to penicillin and can safely take other penicillins in future, but this must be explained carefully to avoid a permanent and incorrect "penicillin allergy" label being added to their records. The practical implication: if a patient presents with exudative tonsillitis in the 15–25 year age group and the diagnosis might be EBV, do NOT prescribe amoxicillin or co-amoxiclav. If antibiotics are warranted (FeverPAIN ≥4), use phenoxymethylpenicillin (penicillin V). Splenomegaly in EBV is present in 50% of patients by the end of the second week — splenic rupture, although rare (0.1–0.5%), is potentially fatal and is precipitated by contact sport, heavy lifting, or trauma. Advise avoidance of contact sports, heavy lifting and activities with a risk of abdominal trauma for at least 4 weeks from symptom onset, followed by an individualised gradual return when clinically recovered. Routine ultrasound to document splenic resolution is not required for everyone; consider specialist assessment or imaging when the patient participates in high-risk sport, has persistent splenomegaly or the timing of return is uncertain.

Asymmetric tonsillar enlargement in an adult is one of the most important and most missed signs of oropharyngeal malignancy — lymphoma (particularly NHL) and SCC can both present as unilateral tonsillar enlargement without ulceration or an obvious mass. The key clinical question is: is one tonsil consistently and persistently larger than the other on separate examinations? Transient asymmetry during acute tonsillitis is common — but tonsillar asymmetry that persists weeks after an acute infection, or that is noted incidentally in a patient without acute infection, must be investigated. Unexplained unilateral tonsillar enlargement in an adult warrants urgent ENT referral (clinical practice; not a specific NICE NG12 criterion). The monospot (Paul-Bunnell / heterophile antibody) test has a known false-negative rate of 20% in the first week of EBV illness (before sufficient heterophile antibodies are produced) — a negative monospot in the first 4–5 days does not exclude EBV. EBV-specific antibodies (VCA-IgM) are more sensitive in early infection and should be requested when clinical suspicion remains high despite a negative monospot. LFTs are reasonable in EBV with significant systemic illness, jaundice or abdominal symptoms — EBV hepatitis (transaminitis, with ALT often elevated 3–10× ULN) is present in 80% of EBV cases but is usually subclinical and resolves spontaneously within 4–6 weeks. Severe jaundice or ALT >10× ULN warrants gastroenterology review. Avoid alcohol if there is hepatitis, abnormal LFTs or significant systemic illness; advise according to clinical findings.

The tonsillectomy criteria (7-5-3 rule, adapted from the Paradise criteria — originally in SIGN 117, now withdrawn; for UK practice use the NHS England Evidence-Based Interventions programme, the ENT UK 2021 commissioning guide, the ENT UK decision aid and local criteria) provide the evidence-based threshold for tonsillectomy referral — ≥7 clinically significant episodes in 1 year, ≥5 per year for 2 consecutive years, or ≥3 per year for 3 consecutive years, where episodes must be documented and clinically significant (not just "a sore throat"). The evidence base for tonsillectomy in recurrent tonsillitis was established by the Burton and Paradise trials — tonsillectomy reduces the frequency of sore throats for 2 years post-procedure, but the benefit is modest (approximately 3 fewer throat infections per year) and most patients improve without surgery within 3–4 years. Therefore, tonsillectomy is reserved for patients meeting the frequency criteria AND experiencing significant functional impact (time off school/work, hospitalisation, analgesia dependence). The suspected cancer pathway referral for suspected head and neck cancer is one of the highest-yield cancer safety-net decisions in GP practice — oropharyngeal SCC (largely HPV-associated) is the most rapidly rising cancer in the UK, with incidence increasing 200% since the late 1990s. It typically affects non-smoking middle-aged adults (the "new" head and neck cancer profile) and presents as a unilateral tonsillar mass, sore throat with referred otalgia, or neck mass. The 5-year survival is 80% at Stage I–II but falls to 40% at Stage IV — early suspected cancer pathway referral is critical. Clinical red flags and the local pathway — not HPV epidemiology — determine the referral threshold.

The single-dose dexamethasone evidence shows only a modest benefit. The TOAST trial (Hayward et al., JAMA, 2017) — a UK primary care RCT in adults not given immediate antibiotics — found that a single dose of dexamethasone did not significantly increase complete symptom resolution at 24 hours, but did at 48 hours (35.4% vs 27.1% placebo, NNT approximately 12), with no significant increase in adverse effects. NICE NG84 (2018) nevertheless does not recommend corticosteroids for acute sore throat, citing its self-limiting course and the risks of repeated steroid courses. This is a clinical stewardship intervention — the steroid reduces the inflammatory pain without promoting bacterial proliferation (antibiotics decision remains based on FeverPAIN/Centor). The choice of phenoxymethylpenicillin (penicillin V) over amoxicillin as first-line for GAS tonsillitis is specifically because amoxicillin causes the florid rash in EBV — since EBV cannot be excluded clinically in every case, penicillin V is the safer default. Phenoxymethylpenicillin is narrow-spectrum, effective, cheap, and spares the broader spectrum for other indications. Clarithromycin and erythromycin (used for penicillin allergy) are associated with macrolide resistance in GAS and Streptococcus pneumoniae — they should only be used when genuine penicillin allergy exists.

Acute rheumatic fever (ARF) is rare in the UK (approximately 100 cases/year) but is the historical reason why GAS tonsillitis is treated with antibiotics — the original therapeutic rationale was preventing ARF and its devastating valvular heart disease consequence (rheumatic heart disease). ARF still occurs in the UK and causes significant morbidity, particularly in children from lower socioeconomic backgrounds and immigrants from high-prevalence regions. GPs should be aware of the Jones Criteria for ARF diagnosis (major criteria: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) and should consider ARF in any child presenting with migratory joint pain, fever, or cardiac symptoms 2–4 weeks after a sore throat. Secondary prophylaxis with penicillin V for 5–10 years prevents further streptococcal infections and further cardiac damage in patients who have had ARF. The documentation of tonsillitis episodes for tonsillectomy criteria is a practical GP task — if patients are attending out-of-hours, walk-in centres, or A&E with tonsillitis, the GP records may not capture all episodes. Advising patients to keep a symptom diary and providing written documentation at each GP consultation (including objective findings — temperature, tonsillar appearance, investigation results) creates an accurate record. A referral without documented episodes with objective features is unlikely to be accepted for tonsillectomy. Patient self-reported frequency alone is insufficient — all episodes must be clinician-documented.

The RCGP TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) toolkit provides excellent free patient-facing antibiotic stewardship resources — the "When should I worry?" and "Treating your infection" leaflets are validated tools that improve patient understanding and reduce antibiotic expectations. These should be available in every GP consulting room and given to patients who request antibiotics that are not clinically indicated. Multiple RCTs show that providing written patient information alongside an explanation of natural history reduces antibiotic prescribing for URTI by 20–30% without reducing patient satisfaction. The single most evidence-based message is: "Antibiotics will not make you better faster for a viral sore throat — your body will do that on its own, usually within about a week. Antibiotics have side effects and can cause resistant bacteria. Here's what to do to manage your symptoms, and here's exactly when you should come back or seek urgent care." Oral health and sore throat have a stronger connection than is often recognised — periodontal disease and poor oral hygiene increase the oropharyngeal bacterial load and are independent risk factors for recurrent pharyngitis and for Vincent's angina. The ANUG presentation specifically requires urgent dental referral for professional debridement — without this, the necrotising process continues despite antibiotic therapy. GPs managing ANUG should prioritise the dental referral (emergency dental, NHS 111) as the definitive treatment.

Written safety-netting instructions for sore throat are particularly important because the most dangerous complications (epiglottitis, quinsy, Lemierre's syndrome) can develop or worsen days after the initial GP consultation, often at night or over a weekend when access to primary care is limited. Patients and parents need written, specific, unambiguous instructions about which symptoms require calling 999 immediately vs which require same-day GP contact. The TARGET toolkit provides validated safety-netting advice sheets for respiratory infections that are free to download and print. The key signs to include are: cannot open mouth, voice becoming muffled, can hear noisy breathing, neck swelling, unable to swallow water. There is no routine fixed review interval for EBV (NICE CKS): acute symptoms usually improve over about 2–4 weeks and fatigue may persist for weeks to months. Follow-up matters when symptoms persist because: (1) individualised advice on return to contact sport (imaging only if high-risk sport, persistent splenomegaly or uncertain timing); (2) persistent fatigue beyond 12 weeks requires formal CFS/ME assessment (overlap with post-viral fatigue is well-documented — 10–15% of EBV patients develop CFS/ME); (3) persistent cervical lymphadenopathy beyond 6 weeks requires lymphoma exclusion, as EBV is causally associated with Hodgkin's lymphoma and several non-Hodgkin lymphomas. Agree when the patient should come back if symptoms are not settling — and review earlier for deterioration, jaundice, airway symptoms, abdominal pain or diagnostic uncertainty. This prevents the "lost to follow-up" scenario that delays diagnosis of both post-viral fatigue and EBV-associated lymphoma.