Sore Throat and Tonsillopharyngitis

Acute infections of the upper respiratory tract. Among uncomplicated cases it is

usually important only to identify those children who have a group A streptococcal
infection.
Classification of Acute Upper Respiratory Infections, tonsillitis, pharyngitis, sore
throat, colds, flu
Among patients who have an uncomplicated acute URI, the most important step is to
identify those who do not need an antibiotic from those who have a streptococcal
infection.
Some patients who do not require an antibiotic can be recognized clinically. Such
symptoms as rhinitis, conjunctivitis, and cough or the finding of an enanthem or
exanthem indicative of an enteroviral infection are indication of respiratory virus
infection, and withholding specific antibiotic treatment.
Viruses
The adenoviruses are the most common cause of tonsillopharyngitis, especially types
1, 2, 3, and 5, which are the types that infect small children most frequently. Other
respiratory viruses are less common causes of tonsillitis; the parainfluenza viruses
probably are the most frequently isolated in this group.
Herpes simplex virus also is recognized as an occasional cause of tonsillopharyngitis,
as is Epstein-Barr virus.
The most frequent causes of the common cold, the rhinoviruses and coronaviruses,
involve the tonsils.
Viral Causes of Tonsillopharyngitis in
Children
Common
Adenoviruses, types 1, 2, 3, and 5
Less Common
Enteroviruses
Epstein-Barr virus
Herpes simplex virus
Influenza viruses
Parainfluenza viruses
Respiratory syncytial virus
Infrequent
Coronaviruses
Rhinoviruses
Bacteria. Group A Streptococcus is the most important and frequent cause of
tonsillopharyngitis. It is frequently associated with acute rheumatic fever and acute
glomerulonephritis. Appropriate treatment of streptococcal pharyngotonsillitis
prevents the occurrence of rheumatic fever.
Epidemiology
Prevalence. The average incidence of all acute URIs is five to seven per child per
year. It is estimated that children have one streptococcal infection every 4 to 5 years.
Group A streptococci is isolated in 30-36.8% of children with pharyngitis.
Age Occurrence. Pharyngitis is infrequent in the first 2 years of life, when all URIs
are most frequent. Most cases of pharyngitis occur in school-age children, when the
incidence of all infections is still high but less than in the first 2 years.
Etiology
Viruses are isolated in about 50% of children less than 2 years old but infrequently
after that.
Group A streptococcus is isolated most frequently in school-age children, while M
pneumoniae is most often in teenagers.
Season. The group A Streptococcus causes infections most frequently in late winter
and early spring and is pharyngitis, sore throat, colds, flu rare in late spring and
summer, although it causes some infections throughout the year.
Contact
All respiratory agents are spread by close contact or large droplets, with the exception
of influenza, which also is spread by small droplets and the airborne route.
A history of a household, school, or outside contact with another patient who has
tonsillopharyngitis due to a known agent, especially the group A Streptococcus,
increases the likelihood that the index infection has the same etiology.
Clinical Features
Bacterial Infections. Only one third to one half of patients infected with group A streptococci
have classic findings of streptococcal tonsillopharyngitis; the remainder have mild, atypical, or
asymptomaticdisease.
Classic Features of Streptococcal
Tonsillopharyngitis
Sudden onset
Sore throat (pain on swallowing)
Fever
Headache
Nausea, vomiting, abdominal pain
(especially in children)
Marked inflammation of throat and
tonsils
Patchy discrete exudate
Tender, enlarged anterior cervical
nodes
Scarlet fever
Features rarely associated with
streptococcal--suggestive of other
etiologies
Conjunctivitis
Cough
Laryngitis (stridor, croup)
Diarrhea
Nasal discharge (except in young
children)
Muscle aches/malaise

Viral Infections
The adenoviruses are the cause of pharyngoconjunctival fever. Hand, foot, and mouth
disease and lymphonodular pharyngitis are caused by the enteroviruses. There are no
distinctive clinical features caused by the other respiratory virus
The classic feature of herpes simplex infections in young children is gingivostomatitis,
but in older children this agent causes , which is indistinguishable.
http://www.medical-library.org/journals2a/tonsillopharyngitis.htm

Tonsillopharyngitis

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(See also Gram-Positive Cocci: Streptococcal and Enterococcal Infections.)

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms

may include sore throat, dysphagia, cervical lymphadenopathy, and fever. Diagnosis is

clinical, supplemented by culture or rapid antigen test. Treatment depends on symptoms

and, in the case of group A β-hemolytic streptococcus, involves antibiotics.

Etiology
The tonsils participate in systemic immune surveillance. In addition, local tonsillar

defenses include a lining of antigen-processing squamous epithelium that involves B-

and T-cell responses.

Tonsillopharyngitis of all varieties constitutes about 15% of all office visits to primary

care physicians.

Etiology
Tonsillopharyngitis is usually viral, most often caused by the common cold viruses

(adenovirus, rhinovirus, influenza, coronavirus, respiratory syncytial virus), but

occasionally by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV.

In about 30% of patients, the cause is bacterial. Group A β-hemolytic streptococcus

(GABHS) is most common (see Gram-Positive Cocci: Streptococcal and Enterococcal

Infections), but Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma

pneumoniae, and Chlamydia pneumoniae are sometimes involved. Rare causes include

pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea.

GABHS occurs most commonly between ages 5 and 15 and is uncommon before age 3.

Symptoms and Signs

Pain with swallowing is the hallmark and is often referred to the ears. Very young

children who are not able to complain of sore throat often refuse to eat. High fever,

malaise, headache, and GI upset are common, as are halitosis and a muffled voice. A

scarlatiniform or nonspecific rash may also be present. The tonsils are swollen and red

and often have purulent exudates. Tender cervical lymphadenopathy may be present.

Fever, adenopathy, palatal petechiae, and exudates are somewhat more common with

GABHS than with viral tonsillopharyngitis, but there is much overlap. GABHS usually

resolves within 7 days. Untreated GABHS may lead to local suppurative complications

(eg, peritonsillar abscess or cellulitis) and sometimes to rheumatic fever or

glomerulonephritis.

Diagnosis
• Clinical evaluation
• GABHS ruled out by rapid antigen test, culture, or both

Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea

and cough usually indicate a viral cause. Infectious mononucleosis is suggested by

posterior cervical or generalized adenopathy, hepatosplenomegaly, fatigue, and malaise

for > 1 wk; a full neck with petechiae of the soft palate; and thick tonsillar exudates. A

dirty gray, thick, tough membrane that bleeds if peeled away indicates diphtheria (rare in

the US).

Because GABHS requires antibiotics, it must be diagnosed early. Criteria for testing are

controversial. Many authorities recommend testing with a rapid antigen test or culture for

all children. Rapid antigen tests are specific but not sensitive and may need to be

followed by a culture, which is about 90% specific and 90% sensitive. In adults, many

authorities recommend using the following 4 criteria:

• History of fever
• Tonsillar exudates
• Absence of cough
• Tender anterior cervical lymphadenopathy

Patients who meet 1 or no criteria are unlikely to have GABHS and should not be tested.

Patients who meet 2 criteria can be tested. Patients who meet 3 or 4 criteria can be

tested or treated empirically for GABHS.

Treatment
• Symptomatic treatment
 • Antibiotics for GABHS
• Tonsillectomy considered for recurrent GABHS

Supportive treatments include analgesia, hydration, and rest. Penicillin V is usually

considered the drug of choice for GABHS tonsillopharyngitis; dose is 250 mg po bid for

10 days for patients < 27 kg and 500 mg for those> 27 kg (see also Gram-Positive

Cocci: Pharyngitis). Amoxicillin

is effective and more palatable if a liquid preparation is required. If compliance is a

concern, a single dose of benzathine penicillin 1.2 million units IM (600,000 units for

children ≤ 27 kg) is effective. Other oral drugs include macrolides for patients allergic to

penicillin, a 1st-generation cephalosporin, and clindamycin

Treatment may be started immediately or delayed until culture results are known. If

treatment is started presumptively, it should be stopped if cultures are negative. Follow-

up throat cultures are not done routinely. They are useful in patients with multiple

GABHS recurrences or if pharyngitis spreads to close contacts at home or school.

Tonsillectomy: Tonsillectomy should be considered if GABHS tonsillitis recurs

repeatedly (> 6 episodes/yr, > 4 episodes/yr for 2 yr, > 3 episodes/yr for 3 yr) or if acute

infection is severe and persistent despite antibiotics. Other criteria for tonsillectomy

include obstructive sleep disorder, recurrent peritonsillar abscess, and suspicion of

cancer.

Numerous effective surgical techniques are used to perform tonsillectomy, including

electrocautery, microdebrider, radiofrequency coblation, and sharp dissection.

Significant intraoperative or postoperative bleeding occurs in < 2% of patients, usually

within 24 h of surgery or after 7 days, when the eschar detaches. Patients with bleeding

should go to the hospital. If bleeding continues on arrival, patients generally are

examined in the operating room, and hemostasis is obtained. Any clot present in the

tonsillar fossa is removed, and patients are observed for 24 h. Postoperative IV

rehydration is necessary in ≤ 3% of patients, possibly in fewer patients with use of

optimal preoperative hydration, perioperative antibiotics, analgesics, and corticosteroids.

Postoperative airway obstruction occurs most frequently in children < 2 yr who have

preexisting severe obstructive sleep disorders and in patients who are morbidly obese or
 have neurologic disorders, craniofacial anomalies, or significant preoperative obstructive

sleep apnea. Complications are generally more common and serious among adults.

Last full review/revision July 2008 by Clarence T. Sasaki, MD

Content last modified July 2008

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