Sore Throat (pharyngitis and tonsillitis)

Question 1

Denition of acute pharyngitis and tonsilitis

Answer 1

Acute pharyngitis- Inflammation of the part of the throat behind the soft palate (oropharynx).
Tonsilitis- inflammation of the tonsils. Local lymph nodes may become enlarged and tender.

Question 2

Causes of sore throat in children

Answer 2

Usually caused by viral infection- adenovirus, enterovirus and rhinovirus
In older children group A beta-haemolytic streptococcus is common
* Accounts for 15-20% of pharyngitis in children aged 5-15 years- more common in school aged children
* The incidence of strep throat peaks during winter and early spring

Question 3

Causes of tonsilitis

Answer 3

Tonsilitis is a form of pharyngitis characterised by intense inflammation of the tonsils, often with purulent exudate: Most commonly caused by GAS, EBV (leading to infectious mononucleosis)
* It is uncertain why some children suffer from recurrent tonsilitis
* The GAS responsible for the tonsilitis may release toxins leading to development of scarlet fever

Question 4

Complications of streptococcal pharyngitis

Answer 4

Aside from scarlet fever, suppurative complications of streptococcal pharyngitis include otitis media, acute sinusitis, peri-tonsillar abscess. Non-suppurative complications include rheumatic fever and glomerulonephritis.

Question 5

Presentation of pharyngitis/tonsillitis

Answer 5

• Pain on swallowing
• Tonsillar exudate: particularly seen in Group A beta-haemolytic streptococci
• Difficult to distinguish between bacterial and viral causes in reality
• Marked constitutional disturbance (apathy, headache, abdo pain, lymphadenopathy) indicates bacterial infection is more likely
• Non-specific symptoms may include: Headache, fever, nausea, vomiting and abdominal pain.
• May result in significantly reduced fluid intake (significant= 50-75% normal volume), ask about wet nappies and examine for signs of dehydration

Question 6

Investigations for pharyngitis/tonsilitis

Answer 6

Centor criteria- each criteria scores 1 point (score of 3-4 gives 56% likelihood of isolating streptococcus)
* Tonsillar exudate
* Tender anterior cervical lymphadenopathy or lymphadenitis
* History of fever (over 38°C)
* Absence of cough

FeverPAIN score- 1 point each (4-5 indicates strep)
* Fever over 38°C.
* Purulence (pharyngeal/tonsillar exudate).
* Attend rapidly (3 days or less)
* Severely Inflamed tonsils
* No cough or coryza

If the diagnosis of GAS needs to be confirmed with certainty arrange a rapid antigen test for group A streptococcus (should be followed up by a throat culture)

Question 7

What condition needs to be ruled out

Answer 7

Need to be aware of possibility of epiglottitis suggested by severe and acute onset of sore throat and fever, muffled voice, drooling, tripod position, and stridor. These children require urgent hospital admission and should not be examined.

Question 8

When should a child be admitted to hospital with pharyngitis/tonsilitis

Answer 8

• Breathing difficulty
• Clinical dehydration
• Peri-tonsillar abscess or cellulitis
• Signs of marked systemic illness or sepsis
• A suspected rare cause for the pharyngitis such as Kawasaki disease, diphtheria, or yersinial pharyngitis

CAUTIONS: If the patient is taking disease-modifying anti-rheumatic drugs (DMARDs) or carbimazole, take an urgent FBC and seek specialist advice

Question 9

How should GAS throat be managed

Answer 9

If GAS been confirmed as the cause of sore throat by rapid antigen testing or is strongly suspected due to high FeverPAIN (4-5) or Centor score (3-4), prescribe immediate or back-up antibiotics (only decrease symptom duration by less than 1 day):
* 1st line= Phenoxymethylpenicillin (5 to 10 days)
* Clarithromycin is the alternative, in case of true penicillin allergy
* (amoxicillin is avoided since it may cause a widespread maculopapular rash due to mononucleosis)

Question 10

General management of pharyngitis/tonsilits

Answer 10

• Adequate fluid, paracetamol or ibuprofen when necessary, salt water gargling should all be encouraged
• Children can return to school after fever has resolved and they are no longer feeling unwell and/or after taking antibiotics for 24 hours
• Children with recurrent tonsillitis (7 or more episodes in 12 months) or its complications (e.g. peritonsillar abscess – quinsy) and those with sleep disordered breathing (e.g. obstructive sleep apnoea) may benefit from tonsillectomy and/or adenoidectomy