PHaryngitis guide 989

Peritonsillarabscess(accumulationof pus Throatswab for cultureto excludeS. pyo

BASIC INFORMATION betweenthe tonsil and its capsule)is the genes, N. gonorrhoeae(requires specific
most common complication of acute tonsil - transport medium) in selected cases
DEFINITION litis. Clinical signs include deformed posterior
pharynx, medial displacement of the uvula,LABORATORY TESTS
Inflammation of the pharynx or tonsils 2. Extension of infection: Rapid streptococcal
tonsillar, parapharyngeal, or antigen test (culture should
SYNONYMS retropharyngeal abscess presenting be performed if rapid test negative)
Sore throat with severe pain, high fever, trismus
Group A streptococci (GAS) Streptococcal tonsillitis is
Pharyngitis manifested as TABLE 1 Seven Danger Signs in
Tonsillitis acute onset of fever, Patients with Sore Throat
GABHS headache, neck pain, odynophagia,
sore throat, otalgia, red tongue with 1. Persistence of symptoms longer than 1 wk
ICD-10CM CODES enlargement of papillae, sore throat, without improvement
J02.9 Acute pharyngitis, unspecified red swollen uvula, and tender anterior 2. Respiratory difficulty, particularly stridor
J03.0 Acute tonsillitis cervical adenitis. trismus, and muffled 3. Difficulty in handling secretions
J03.9 Acute tonsillitis, unspecified voice (hot-potato voice). 4. Difficulty in swallowing
J04.0 Acute laryngitis Table 1 describes seven danger signs 5. Severe pain in the absence of erythema
6. A palpable mass
in patients with sore throat.
7. Blood, even in small amounts, in the pharynx
EPIDEMIOLOGY & or ear
DEMOGRAPHICS ETIOLOGY
Acute pharyngitis accounts for 1.3% of Viruses:
out patient visits to health care 1. Respiratory syncytial virus
From Andreoli TE et al:
providers in the United States and is 2. Influenza A and B Andreoli and Carpenters Cecil essentials of
diagnosed in two million persons in the 3. Epstein-Barr virus medicine, ed 8, Philadelphia, 2010, Saunders.
outpatient setting each year in the 4. Adenovirus
United States. 5.

Herpes simplex
Bacteria:
P
PEAK INCIDENCE: Late winter/early
spring (GAS infections) PREDOMINANT 1. GAS: Streptococcus pyogenes. Bloodwork is only rarely
SEX: Females = males PREDOMINANT Hemolytic GAS are the most necessary
AGE: common cause of acute tonsillitis. Complete blood count with
All ages affected 2. Neisseria gonorrhoeae differential
Streptococcal pharyngitis 3. Fusobacterium necrophorum (10% of 1. May help support diagnosis of bacterial
most common among pharyngitis): highest incidence infection when diagnosis is unclear
school-age children (5-15 yr of age). in patients aged 15 to 30 2. Streptococcal infection suggested by leu
GAS are responsible for 5% to 15% of years kocytosis >15,000/mm3
cases of pharyngitis in adults and 20% Other organisms: Viral cultures, serologic studies
to 30% of cases in children (5-15 yr of 1. Mycoplasma pneumoniae rarely needed
age). 2. Chlamydophila pneumoniae Monospot if diagnosis
3. Arcanobacterium haemolyticum is unclear
PHYSICAL FINDINGS & CLINICAL
PRESENTATION IMAGING STUDIES
Pharynx:
DIAGNOSIS Seldom indicated. If necessary to
1. May appear normal to severely distinguish between tonsillitis and
DIFFERENTIAL DIAGNOSIS peritonsillar abscess, CT or MRI of the
erythema tous
2. Tonsillar hypertrophy and exudates Sore throat associated with neck can be done.
granulocytopenia, thyroiditis
com monly seen but do not indicate
etiology Tonsillar hypertrophy I TREATMENT
Viral infection: associated with
lymphoma NONPHARMACOLOGIC THERAPY
1. Rhinorrhea
Section II describes Fluids
2. Conjunctivitis
3. Cough the differential Salt water gargles
Bacterial infection, diagnosis of sore throat.
ACUTE GENERAL Rx
especially GAS: WORKUP Analgesics: aspirin (adults) or
1. High fever acetaminophen or ibuprofen
The Centor criteria to identify patients at
2. Systemic signs of infection (adults and children).
risk for GAS consists of (1) fever
Herpes simplex or If streptococcal infection
subjective or measured >38.1 C (100.5
enterovirus infection: proven or suspected:
F), (2) absence of cough, (3) tonsillar
vesicles 1. Amoxicillin 500 mg BID
exudates, (4) tender anterior cervical
Streptococcal infection: lymphadenopathy. Patients with 1 or penicillin V 500
1. Rare complications: criteria are at low risk and do not need mg PO bid for
a. Scarlet fever additional testing. The McIsaac criteria 10 days or
b. Rheumatic fever adds 1 point for ages 3 to 14 and benzathine penicillin 1.2 million
c. Acute glomerulonephritis subtracts a point for ages 45 yr. U IM once (adults). Children:
 penicillin V 250 Macrolides or clindamycin can be used There is no conclusive
mg bid or tid in penicillin-allergic patients. evidence from
2. Azithromycin 500 mg on day 1 Treatment of randomized clinical trials that
then 250 mg on days 2 through 5 peritonsillar abscess is tonsillectomy is superior to antibiotic
or erythromycin 500 mg drainage through needle or therapy for recurrent tonsillitis in
PO bid or incision. adults.
250 mg qid Avoid quinolones, Tonsillopharyngitis is
for 10 days sulfonamides, and generally managed
if penicillin allergic tetracyclines due to treatment in an outpatient setting
If gonococcal infection failures. with follow-up arranged in 1 to 2 wk.
proven or suspected: Admission to the hospital is indicated
ceftriaxone 250 mg IM once. CHRONIC Rx for local suppurative complications
Amoxicillin 500 mg tid Recurrent streptococcal (peritonsillar abscess; lateral
for 10 days is infections are pharyngeal or posterior pharyngeal
the primary antibiotic common and may represent abscess; impending airway closure; or
treatment of streptococcal tonsillitis. reinfection from other household inability to swallow food, medications,
members, including pets. or water).

990 Pharyngitis/Tonsillitis
REFERRAL SUGGESTED READINGS Strep Throat (Patient Information)
T otolaryngologist: Available at
www.expertconsult.co
m Tonsillitis(Patient Information)
1.
o If peritonsillaror other abscessis sus- AUTHOR
GLENN G. FORT, M.D., M.P.H.
pected :
RELATED CONTENT
2. If tonsillar hypertrophy persists
Sore Throat (Patient Information)