Acute Tonsillopharyngitis
Definitions
- Inflammation of pharynx and tonsils.
- Recurrent acute tonsillitis: Repeated episodes with asymptomatic periods.
- Carrier state: Positive pharyngeal culture of Group A beta-hemolytic streptococcus without acute symptoms or immunologic response.
Etiology
| Category | Pathogens |
|---|---|
| Viral (70-95%) | Adenovirus, influenza, parainfluenza, enterovirus, Epstein-Barr virus, measles, rubella. |
| Bacterial | Group A beta-hemolytic streptococcus, Mycoplasma, Candida. |
| Environmental | Irritant fumes, smoke. |
Clinical Features
Differentiating Viral And Bacterial Infections
| Feature | Viral Infection | Group A Streptococcal Infection |
|---|---|---|
| Onset | Gradual. | Sudden onset, winter/early spring. |
| Symptoms | Hoarseness, cough, diarrhea. | Fever, headache, nausea, abdominal pain. |
| Signs | Conjunctivitis, coryza, ulcerative stomatitis, viral exanthema. | Patchy tonsillopharyngeal exudates, palatal petechiae, tender anterior cervical adenitis, scarlet-fever rash. |
| Age | Any age. | 5-15 years, history of exposure. |
Red Flags
- Toxic appearance, respiratory distress, stridor.
- Trismus, drooling, muffled voice.
- Torticollis, neck stiffness/fullness.
Complications
- Local suppurative: Parapharyngeal abscess, peritonsillar abscess, retropharyngeal abscess, sepsis.
- Nonsuppurative: Acute rheumatic fever, acute post-streptococcal glomerulonephritis, reactive arthritis, pediatric autoimmune neuropsychiatric disorders.
Diagnostic Evaluation
- Clinical evaluation combined with laboratory testing.
- Rapid antigen detection test: Point of care, high specificity (98.4%), sensitivity (89.7%).
- Throat swab culture: Indicated if rapid test negative with strong clinical suspicion.
- Antistreptococcal antibody titers: Not routinely recommended.
- Blood tests/cultures: Not indicated routinely.
Mcisaac Score
| Clinical Finding | Points |
|---|---|
| Temperature > 38Β°c | 1. |
| Absence of cough | 1. |
| Cervical lymph node swelling | 1. |
| Tonsillar swelling or exudation | 1. |
| Age 3-14 years | 1. |
| Age 15-44 years | 0. |
| Age > 44 years | -1. |
Interpretation: Score 0-1: Do not test/treat. Score 2: Treat if rapid test positive. Score 3: Treat if positive or treat empirically. Score 4: Treat empirically.
Management
Supportive Care
- Analgesics and antipyretics (acetaminophen, nonsteroidal anti-inflammatory drugs).
- Warm saline gargles, soft foods, bed rest.
- Aspirin and adjunctive corticosteroids contraindicated.
Pharmacotherapy For Group A Streptococcus
| Patient Status | Drug Choice | Dose | Duration |
|---|---|---|---|
| No Penicillin Allergy | Oral Penicillin V | Children: 250 mg twice/thrice daily. | 10 days. |
| No Penicillin Allergy | Oral Amoxicillin | 50 mg/kg daily in 2-3 divided doses. | 10 days. |
| No Penicillin Allergy | Benzathine Penicillin G | Intramuscular single dose. | Single dose. |
| Penicillin Allergy | Oral Cephalexin/Cefadroxil | 20-30 mg/kg/dose. | 10 days. |
| Penicillin Allergy | Oral Clindamycin | 7 mg/kg/dose thrice daily. | 10 days. |
| Penicillin Allergy | Oral Azithromycin | 12 mg/kg once daily. | 5 days. |
Surgical Management (Tonsillectomy)
-
7 culture-proven episodes in one year.
-
5 episodes in two consecutive years.
-
3 or more infections per year for three consecutive years despite medical therapy.
-
Chronic tonsillitis with streptococcal carrier state unresponsive to beta-lactamase-resistant antibiotics.
-
Diphtheria carriers, retention cysts, suppurative otitis media focus.