Pharyngitis, Tonsillitis, Laryngitis Flashcards
Define
Usually due to viral infection (mainly adenoviruses, enteroviruses and rhinoviruses)
- In older children, Group A b-haemolytic Streptococcus (usually S. pyogenes) is COMMON
Common causes of tonsillitis:
- Group A b-haemolytic streptococci - rare under 3yo or >45 yo, common 3-14 yo
- EBV - (i.e. bacterial or viral) – no amoxicillin treatment (as you can get a generalised maculopapular eruption)
- Tonsillitis is a form of pharyngitis characterised by intense inflammation of the tonsils, often with a purulent exudate
Group A streptococcal infection can cause Scarlet Fever
* It is a reaction to the erythrogenic toxins produced by GAS
* Most common: 2-6 years
(Remember kid with rash all over back)
Spread via respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges (sneezing and coughing)
Symptoms and signs
Remember symptoms get worse before getting better
- Fever
- Sore throat
- Dysphagia/ odynophagia
- Hoarseness
- GORD
- Rhinitis
- Pain referred to ears
Signs:
* Tonsils- erythematous, swollen, enlarged
* Anterior cervical lymphadenopathy
* Lethargy and fatigue
* Post-nasal drip
* Abdominal pain
* N+V
* Scarlatiniform rash
Signs of dehydration (reduced skin turgor, capillary refill > 3 seconds, dry mucus membranes)
Quinsy- this is a peri-tonsillar abscess (may be seen on one side and will cause the uvula to deviate) which poses a risk of airway compromise, aspiration of pus and death due to vascular involvement
Scarlet Fever (GAS (S. pyogenes) infection can progress to this)
- Incubation: 2-4 days
- Fever usually precedes the presence of headache and tonsillitis by 24-48 hours
- Coryza - Malaise, headache, N+V
‘Strawberry tongue’- white and coated, sore, swollen
Sandpaper-like maculopapular ash - REMEMBER KID WHO CAME IN WITH THE RASH ALL OVER THE BACK
Fine, punctate erythema (pinhead) -> first appears on neck and chest then spreads to torso and spares palms and soles
Flushed cheeks, perioral sparing
Desquamation layer in course of illness- particularly fingers + toes
‘Pastia’s lines’ (rash in prominent skin creases)
IF HAVE RED CRACKED LIPS OR CONJUNCTIVAL INVOLVEMENT, THINK KAWASAKI INSTEAD OF SCARLET FEVER!
May progress to Rheumatic Fever with a week latency period
Ix: clinical (also, FBC (polymorphonuclear lymphocytosis, eosinophilia), ELISA, rapid antigen test, etc.)
Mx: phenoxymethylpenicillin (2nd line: azithromycin), notify PHE
Px: S/S resolve after 1 week, exclude for 24hrs from nursery from starting ABx
NOTE: it is difficult to distinguish clinically between bacterial and viral tonsillitis. The surface exudates on the tonsils from EBV are more membranous compared to bacterial tonsillitis.
However, marked constitutional disturbance (e.g. headache, apathy, abdominal pain, white tonsillar exudate and cervical lymphadenopathy) is more common with bacterial infection
Investigations
- Examine fontanelle, cervical lymph nodes, ears, throat
- Basic observations
- Throat swab – culture or rapid antigen test for Streptococci
- Urine dipstick/ urinalysis- anti-streptolysin-O titre
CENTOR Criteria ” determines likelihood of bacterial over viral (if ≤3 days of pharyngitis)
- History of fever > 38oC
- Tonsillar exudate
- Tender anterior cervical adenopathy
- Absence of cough
- Age 3 - 14 yo
(If 5 criteria area met- treat as bacterial, think about treatment with score of 4 or 5, culture (rapid strep test) with 2 and 3, don’t give treatment if 0-1)
NOTE: Viral sore throat (e.g. EBV) can also give exudate
Management
Arrange hospital admission if:
- Difficulty breathing
- Clinical dehydration
- Peri-tonsillar abscess or cellulitis
- Signs of marked systemic illness or sepsis
- A suspected rare cause e.g. Kawasaki disease, diphtheria
Specific cases to watch out for:
- DMARDs- could cause immunodeficiency
- Carbimazole- can cause idiosyncratic neutropaenia
NOTE: take urgent FBC in both cases
Diphtheria - ‘web’/pseudomembrane at back of throat - tx: penicillin + anti-toxin
Medical Management
(if bacterial tonsillitis is confirmed using rapid antigen testing)
- 1st Line: Phenoxymethylpenicillin (Penicillin V) for QDS 10 days
If penicillin allergy: clarithromycin
Treatment length is to eradicate the organism completely (and prevent rheumatic fever)
Symptomatic relief: Paracetamol or ibuprofen
ADVICE
- Adequate fluid intake
- Encourage to continue eating
- Salt water gargling, lozenges or anaesthetic sprays e.g. Difflam, may provide temporary relief of throat pain
- Children can return to school 24 hours after starting antibiotics or after fever has resolved and they are no longer feeling unwell
- Symptoms should settle down after 1 week
- Patients with recurrent tonsillitis may require referral to ENT
No contact sport if EBV is the cause due to risk of splenic rupture
Scarlet fever is a NOTIFIABLE DISEASE (let local Public Health England centre know)
RARELY, children may be admitted to hospital for IV fluids and analgesia if they are unable to swallow solids or liquids
If persistent (>3w) change in voice refer for laryngoscopy
WARNING: Amoxicillin should be AVOIDED because it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis
MANAGEMENT of laryngitis: Secure airway + supportive therapy, corticosteroids (if airway obstruction), antibiotics (if bacterial cause). If diphtheria: phenoxymethylpenicillin + antitoxin
Complications
- Quinsy (peritonsillar abscess)
- Scarlet fever
Non-suppurative (autoimmune):
- Rheumatic fever- arthritis, carditis, erythema marginatum- occurs 20 days after infection
- Acute glomerulonephritis- typically occurs 10 days after infection (coca-cola coloured urine) need to check urine dipstick, U&Es, BP +/- blood gas (check if kidney function is okay)
Suppurative:
- Otitis media- MOST COMMON complication of Scarlet fever
- Acute sinusitis
- Peri-tonsillar abscess (quinsy)
Invasive complications e.g. bacteraemia, meningitis, necrotising fasciitis- RARE
Toxic shock syndrome! response to GAHS/ S. aureus infections where the toxins act as superantigens (causing a cytokine response and vasodilation)
May get an erythematous diffuse macular rash, vomiting, diarrhoea, altered GCS
Rapidly progressive shock and deterioration can occur
(Usually well known for retained tampons, cellulitis or burns etc. but can occur from soft tissue infections such as sore throat)
MANAGEMENT: IV/ IO Clindamycin (in addition to Ceftriaxone for suspected sepsis), fluid resuscitation, escalate to PICU
Prognosis/ Paces
Prognosis
- Self-limiting
- Resolves within 2 weeks
PACES
Explain that this is tonsillitis, Centor score the child
Explain that importance of taking antibiotics correctly for 10 days even if symptoms get better in that time
Avoid school until 24 hours after starting antibiotics (scarlet fever) and the child is feeling well
Advise on the use of paracetamol, lozenges, saltwater gargling and Difflam for symptomatic treatment
When explaining to parents it is not tonsilitis but a viral infection “Ears, nose and throat are connected so if there is a viral infection these areas may be swollen, however as there is no pus on the tonsils, it is not tonsilitis and so AB are not needed; if ___ does develop pus or the symptoms are not getting better, come back again”
