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10 May 2017

The Tin Man opened his mouth wide and showed me the familiar white spots

It was difficult to assess his complexion because of the silver face paint blending his skin in with the metallic material of his outfit.

By Phil Whitaker

I was consulted by the Tin Man from The Wizard of Oz recently. He hadn’t come about rusted-up joints, though; he had a sore throat.

“When did he become unwell?” I asked his mother.

“Yesterday,” she said. “I looked in his throat this morning and saw white spots. I think he’s got tonsillitis.”

The term “tonsillitis” literally means “inflamed tonsils”, but both doctors and patients/parents use it to mean something different – a throat infection that needs an antibiotic. Patients with that kind of problem are usually poorly: high fever, flushed, achy all over, lacking in energy, and often with a characteristic facial rash and tongue coating.

I looked at my patient. It was difficult to assess his complexion because of the silver face paint blending his skin in with the metallic material of his outfit. Nevertheless, he didn’t seem too unwell. I checked his temperature – mildly elevated – and established that he also had the typical viral symptom of a runny nose.

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“Can you open wide, George?” I said.

Obligingly, he gave me an unobstructed view: big tonsils, with scattered blobs of exudate, but pink rather than angry red. I checked his neck: no serious gland swelling.

“I think this one will get better on its own,” I told his mum.

She looked nonplussed. “But what about the white spots?”

Until a few years ago, no one ever examined their own or their child’s tonsils, but these days complaints of “white spots” are a common occurrence. This has arisen because of the Centor criteria – a set of four clinical signs, devised to help doctors target antibiotic use more appropriately. The presence of tonsillar exudate is one of the criteria, along with a high fever, tender neck glands and the absence of viral symptoms.

If someone scores 4, there’s a roughly 50/50 chance that antibiotics might help. Score 2 or less, and it’s virtually certain that they won’t. The criterion to do with white exudate seems to have taken on a life of its own, though, out there in the big wide world. For many patients and parents it equates to an automatic need for antibiotics.

I explained all this to mum. She seemed satisfied, and took George back to school to enjoy the rest of World Book Day.

Even when a patient scores 4 on the Centor criteria, it remains a moot point whether antibiotics should be used. There’s an old medical adage: treat a patient for a sore throat once, and you create a patient for life. Many doctors, faced with a recurrently consulting patient, assume that they’re demanding antibiotics and go along with it for a quiet life, thereby reinforcing the pattern.

Moreover, by repeatedly treating people, we might even be preventing their immune system from “learning” how to mount an effective response to common throat bacteria. Most cases of tonsillitis get better within a week or so, and during that time the immune system develops “memory” for the infecting germ, so that the body rapidly attacks it when it crops up again. Keep killing the germs off with antibiotics and the immune response never properly develops.

The Centor criteria – helpful as they are as a first step in reducing unnecessary antibiotic use – should never supplant clinical judgement. Most Centor 4 cases can safely be allowed to self-limit, but there will be a few where the patient is very unwell and antibiotics are justified. The worst cases of tonsillitis can progress to severe complications, including quinsy – an abscess in the tonsillar bed that can obstruct breathing and swallowing.

Besides reappraising the role for antibiotics, medicine is increasingly reluctant to perform tonsillectomies. A very small subset of patients – those who suffer full-blown tonsillitis multiple times every year – do derive benefit from having their tonsils removed. But an operation that was once routinely performed in fact makes very little difference to how often most of us will come down with the next sore throat. 

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This article appears in the 03 May 2017 issue of the New Statesman, The Russian Revolution