Acute Throat Infections

Question 1

What 3 acute infections does the term “sore throat” encompass?

Answer 1

1. Pharyngitis
2. Tonsilitis
3. Laryngitis

Question 2

Tonsillitis is an infection of the palatine tonsils.

What are the signs and symptoms of acute tonsillitis?

Answer 2

Acute tonsillitis is characterised by:

=> pharyngitis

=> fever

=> malaise

=> bilateral cervical lymphadenopathy

=> Odynophagia (painful swallowing) & dysphagia

=> oedematous and yellow / white pustules present on tonsils

=> presence of trismus (lock jaw) = peritonsillar abscess (quinsy)

=> resolves after 5-7 days

Question 3

What causes tonsillitis?

Who does it most commonly affect?

Answer 3

Tonsillitis can be bacterial (30%) or viral (70%):

Bacterial causes:

=> streptococcus pyogenes aka Group A beta haemolytic streptococci (most common organism)

=> Haemophillus influenza

=> Streptococcus pneumonia

=> Staphylococci

Most commonly affects children & young adults

Question 4

What are the complications of tonsillitis?

Answer 4

1. Peritonsillar abscess (quinsy)

=> severe, unusual unilateral pain,

=> “hot potato” voice,

=> trismus (lockjaw),

=> uvula pushed to opposite side by peritonsillar swelling

2. Parapharyngeal and retropharyngeal abscesses - can be life-threatening
3. Otitis media

Question 5

What are the investigations (if needed) for tonsillitis?

Answer 5

FBC, U&E, CRP

Blood cultures (if pyrexial)

Glandular fever screen
*infectious mononucleosis may mimic tonsillitis

Question 6

What is the management for sore throat?

Answer 6

1. Paracetamol / ibuprofen for pain relief

2. Antibiotics are not routinely prescribed

Question 7

What are the indications for antibiotics use in tonsillitis?

Answer 7

1. Features of marked systemic upset secondary to acute sore throat
2. Unilateral peritonsilitis
3. Hx of rheumatic fever
4. Increased risk from acute infections i.e. diabetes or immunodeficiency
5. Patient with acute sore throat / acute pharyngitis / acute tonsillitis when >3 centor criteria are present.

Question 8

What is the Centor criteria?

Describe the scoring system.

Answer 8

Centor criteria is a 4-point clinical scoring system to identify people at high risk of bacterial throat infection + those who will benefit from antibiotics.

One point for each, remember CENT:

C - Cervical lymphadenopathy (tender)/ lympahdenitis
E - exudate of tonsils
N - no cough
T - temperature > 38 in history

2 cents for my opinion (no Abx)
3 cents for antibiotics

=> 0-2 points = low likelihood of streptococci

=> 3-4 points = high likelihood of streptococci + benefit from antibiotics

Question 9

What is the FeverPain criteria?

Answer 9

FeverPain criteria is another criteria to identify a bacterial throat infection.

One point for each:

1. Fever >38degrees
2. Purulence (pharyngeal / tonsillar exudate)
3. Attend rapidly (<3d)
4. Severely inflamed tonsils
5. No cough or coryza

=> 0-1 = low likelihood of streptococcal infection

=> 2-3 = moderate likelihood of streptococcal infection

=> 4-5 = high likelihood of streptococcus infection

Question 10

1. What is the first line of oral antibiotics in bacterial sore throat?
2. What antibiotic is recommended if patient has penicillin allergy?

Answer 10

1. Phenoxymethylpenicillin
2. Erythromycin

A course of 7 or 10 days should be given

Question 11

When is tonsillectomy recommended?

Answer 11

According to NICE, tonsillectomy is recommended when the patient meets all the criteria:

=> sore throats are due to tonsillitis (i.e. not due to recurrent upper respiratory tract infection)

=> >5 episodes per year

=> symptoms occurring for at least a year

=> episodes of sore throat are disabling + prevent normal functioning

Question 12

What are the complications of tonsillectomy?

Answer 12

1. Primary (<24h)

=> haemorrhage mostly due to inadequate haemostasis - occurs within 6-8h post surgery and should be managed immediately in theatre

2. Secondary (>24h-10d)

=> haemorrhage mostly due to wound infection - treated with antibiotics

3. Pain

Question 13

1. What is peritonsillar abscess (quinsy)?
2. What are the clinical features?
3. What is the management?

Answer 13

1. Peritonsillar abscess develops as a complications of bacterial tonsillitis
2. Clinical features:

=> severe throat pain that lateralises to one side

=> deviation of the uvula to the unaffected side

=> trismus (lockjaw) - difficult opening mouth

=> reduced neck mobility

3. Management:

=> needle aspiration or incision & drainage + IV antibiotics

=> tonsillectomy - considered to prevent recurrence