Patients who present with bleeding post tonsillectomy (secondary haemorrhage) must be referred to ENT for admission due to the small but significant risk of serious haemorrhage. 

• Glandular Fever
  • hugely swollen symmetrical tonsils and neck glands. 
  • Rule out airway obstruction.
  • Check FBC and monospot (don’t need to wait) – a lymphocyte-white blood cell count (L/WCC) ratio > 0.35 has a specificity of 100% and a sensitivity of 90% for the detection of infectious mononucleosis.
  • Prescribe analgesia and advise GP follow-up for LFT’s etc. 
• Quinsy
  • asymmetrical pain, gross trismus and asymmetric swelling in the peritonsillar tissues. 
  • Refer for aspiration/drainage. 

• Sore throat, drooling, dysphagia, and possibly stridor with minimal tonsillar signs. 
• Do not attempt to examine the throat as this may aggravate the obstruction. 
• Transfer the patient to the resuscitation room and get emergency airway trolley. 
• Give high flow oxygen (humidified if possible) and get senior ED, anaesthetic and ENT immediately.
• Allow patient to assume their most comfortable position.
• Usually diagnosed via nasal scope but clarify whether a portable lateral soft tissue X-ray of the neck will help (patient should not be in extremis and not forced to lie down!). 

• Tachycardia and desaturation – get senior ED, anaesthetist and ENT immediately. 
• Give 02 by mask ± nebulised adrenaline (5mls 1%). 
• If sudden decompensation occurs and intubation is impossible, then cricothyrotomy and minitrach tube insertion, supported with 02 15l/min, might be life-saving. 

• Discomfort - good indicator of the true position of the foreign body - tonsils, tongue (post 1/3) and pyriform fossae are the common sites. 
• An X-ray may be helpful but does not exclude a foreign body as the radio-opacity of (fish) bones is very variable. 
• If you are unable to find the foreign body then ask for ENT help. 
• Do not leave a chicken bone or other similar sharp contaminated fragment overnight but refer immediately.