URTI (tonsillitis / pharyngitis)

Question 1

What is tonsillitis?

Answer 1

Tonsillitis is a form of pharyngitis presenting with intense acute inflammation of the tonsils
=> purulent exudate in bacterial tonsillitis

Question 2

What causes tonsillitis?

Answer 2

1. Strep. pneumoniae = most common causative pathogen especially recurrent tonsillitis in children
2. Epstein-barr virus
   * The common cold i.e. rhinovirus, coronavirus, parainfluenza virus accounts for 25% of all sore throat

Question 3

How do you differentiate between bacterial and viral tonsillitis?

Answer 3

Bacterial tonsillitis is assoc. with cervical lymphadenopathy

Viral tonsillitis is assoc. with headache, apathy and abdominal pain

Question 4

Which criteria is used to give an indication that tonsillitis is most likely bacterial?

Describe the criteria below.

Answer 4

CENTOR criteria

1. Tonsillar exudate
2. Tender anterior cervical lymphadenopathy
3. Fever over 38
4. Absence of cough

*Each centor criteria scores 1 point (max 4 points)

Score of 0, 1, 2 is assoc. with a low risk of bacterial tonsillitis (3-17%)

Score of 3 or 4 is assoc. with a high risk of bacterial tonsillitis (32-56%)

Question 5

How do you manage bacterial tonsillitis?

Answer 5

1. Centor criteria of 3 or 4 => prescribe antibiotics

=> 1st line: Penicillin V 500mg PO QDS for 5-10 days

=> Alternative in pen allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days

*Avoid amoxicillin because it causes pathogenic rash in all whose pharyngitis is from EBV

2. Symptom relief: regular ibuprofen ± paracetamol to relieve pain and fever
   => consider mouthwashes / mouth sprays (benzydamine e.g. difflam)

Question 6

What are the complications of tonsillitis?

Answer 6

1. Otitis media
2. Sinusitis
3. Peritonsillar abscess (quinsy)
4. Parapharyngeal abscess
5. Lemierre syndrome

Question 7

What is peritonsillar abscess (quinsy)?

Answer 7

Quinsy presents with:
=> severe sore throat which lateralises to one side,
=> dysphagia,
=> peritonsillar bulge,
=> uvular deviation to the unaffected side,
=> trismus (lockjaw)
=> muffled voice

Urgent review by ENT:
IV Antibiotics and needle aspiration preferred to surgical drainage and needed immediately.

Question 8

Tonsillectomy should be considered only if all the criteria are met. What are the 4 criteria for tonsillectomy?

Answer 8

1. Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
2. Person has >7 episodes of clinically significant, adequately treated sore throat in the preceding year
   >5 episodes/year in last 2 years
   >3 episodes/year in the last 3 years
3. Symptoms have been occurring for at least a year
4. Episodes of sore throat are disabling and prevent normal functioning

Question 9

What are the complications of tonsillectomy?

Answer 9

1. Primary <24h:
   => haemorrhage in 2-3% most commonly due to inadequate haemostasis
   => pain
2. Secondary 24h-10days:
   => haemorrhage most likely due to infection
   => pain

*Both are ENT emergencies

Management:

1. Refer to ENT
2. ABCDE approach - gain IV access, fluid bolus

Question 10

What causes scarlet fever?

How does it present?

What are the signs?

How is it treated?

Answer 10

1. Scarlet fever is caused by exotoxins released from Strep pyogenes (group A beta-haemolytic streptococcus).
2. Rash develops on chest, axillae or behind ears 12-48h after initial sore throat and fever
3. Signs:
   => Red pin-prick blanching rash
   => Facial flushing circumoral pallor
   => strawberry tongue
4. Treatment:
   => Penicillin V for 10d (clarithromycin if pen allergy)
5. Complications:

=> Sydenham’s chorea (rapid, irregular, aimless involuntary movements caused by neurological disorder from an infection)

=> Post infection de-myelinating disorder e.g. acute disseminated encephalomyelitis

*scarlet fever used to be a major cause of infant mortality but now it is self-limiting in developed countries.