Pharyngotonsillitis: symptoms and diagnosis
Pharyngotonsillitis is an acute infection of the pharynx, palatine tonsils or both. Symptoms may include sore throat, dysphagia, cervical lymphadenopathy and fever
Diagnosis is clinical, supported by rapid culture or antigen tests.
Treatment depends on the symptoms, and in the case of group A beta-hemolytic streptococcus, includes antibiotics.
The tonsils participate in the systemic immune defence.
In addition, local tonsillar defences include a squamous epithelial lining that processes antigens, leading to responses from B and T cells.
Pharyngotonsillitis, of any type, accounts for approximately 15% of all outpatient visits to general practitioners.
Aetiology of pharyngotonsillitis
Pharyngotonsillitis is usually viral, most often caused by common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, and 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 beta-hemolytic streptococcus is the most common, but sometimes Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae and Chlamydia pneumoniae are involved.
Rare causes include pertussis, Fusobacterium, diphtheria, syphilis and gonorrhoea.
Group A beta-hemolytic streptococcus appears most frequently between 5 and 15 years of age and is rare before 3 years of age.
Symptomatology of pharyngotonsillitis
Pain on swallowing is the hallmark and is often attributed to the ears.
Very young children, who are unable to complain of a sore throat, often refuse to eat.
High fever, malaise, headache and gastrointestinal disturbances are frequent, as are halitosis and muffled voice.
There may also be a rash.
The tonsils are swollen and red and often have purulent exudates.
Painful cervical lymphadenopathy may be present.
Fever, adenopathy, palatine petechiae and exudates are somewhat more common with group A beta-hemolytic streptococcus than with viral pharyngotonsillitis, but there is considerable overlap.
With group A beta-hemolytic streptococcus, a scarlet fever rash (scarlet fever) may be present.
Group A beta-hemolytic streptococcus generally resolves within 7 days.
Untreated group A beta-hemolytic streptococcus may lead to local suppurative complications (e.g. peritonsillar abscess or cellulitis) and sometimes rheumatic fever or glomerulonephritis.
Diagnosis of pharyngotonsillitis
- Clinical evaluation
- Group A beta-hemolytic streptococcus is excluded by rapid antigen testing, culture, or both.
Pharyngitis itself is easily recognisable clinically.
However, its cause is not.
Rhinorrhoea and coughing usually indicate a viral cause.
Infectious mononucleosis is suggested by a posterior or generalised cervical adenopathy, hepatosplenomegaly, fatigue and malaise for > 1 week; a swollen neck with petechiae of the soft palate; and dense tonsillar exudates.
A thick, tenacious, dirty-grey membrane that bleeds when detached indicates diphtheria.
Since group A beta-hemolytic streptococcus requires antibiotic therapy, it must be diagnosed early.
The criteria for examination are controversial.
Many experts recommend examination with a rapid antigen test or culture for all children.
Rapid antigenic tests are specific but not sensitive and may subsequently need culture, which is about 90% specific and 90% sensitive.
In adults, many experts recommend the use of the following 4 criteria of the modified Centor score (1):
- Positive history of fever
- Tonsillar exudates
- Absence of cough
- Anterior cervical painful lymphadenopathy
Subjects meeting only 1 criterion or no criteria are unlikely to present with group A beta-hemolytic streptococcus and should not be tested.
Patients meeting 2 criteria may be tested.
Subjects meeting 3 or 4 criteria may be tested or treated empirically for group A beta-hemolytic streptococcus.
Diagnosis reference
Fine AM, Nizet V, Mandl KD: Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med 172(11):847-852, 2012. doi: 10.1001/archinternmed.2012.950.
Treatment of pharyngotonsillitis
- Symptomatic treatment
- Antibiotics for group A beta-hemolytic streptococcus.
- Tonsillectomy is considered for recurrent group A beta-hemolytic streptococcal infections
- Supportive treatments include analgesia, hydration and rest.
Analgesics may be systemic or topical.
NSAIDs are generally effective systemic analgesics.
Some physicians may also administer a single dose of a corticosteroid (e.g., dexamethasone 10 mg IM), which may reduce the duration of symptoms without affecting relapse rates or adverse effects (1).
Topical analgesics are available as tablets and sprays; ingredients include benzocaine, phenol, lidocaine and others.
These topical analgesics can reduce pain, but they must be used several times and often affect taste. Benzocaine used for pharyngitis has rarely caused methaemoglobinaemia.
Penicillin V is generally considered the drug of choice for group A beta-haemolytic streptococcal pharyngotonsillitis; the dose is 250 mg orally twice a day for 10 days for patients < 27 kg and 500 mg for those > 27 kg.
Amoxicillin is effective and more palatable if a liquid preparation is required.
If adherence to therapy is problematic, 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.
Diluting non-prescription hydrogen peroxide with water in a 1:1 mixture and gargling with it will promote debridement and improve oropharyngeal hygiene.
Treatment may be started immediately or delayed until culture results are available. If treatment is started presumptively, it should be discontinued if cultures are negative.
Follow-up pharyngeal cultures are not routinely performed.
They are useful in patients with multiple relapses of group A beta-hemolytic streptococcus or if pharyngitis spreads to people with whom one comes into contact at home or at school.
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Tonsillectomy
Tonsillectomy has often been considered if Group A beta-hemolytic streptococcal tonsillitis recurs repeatedly (> 6 episodes/year, > 4 episodes/year for 2 years, or > 3 episodes/year for 3 years) or if the acute infection is severe and persistent despite antibiotic therapy.
Other criteria for tonsillectomy include sleep apnoea disorders, recurrent peritonsillar abscesses, and suspicion of malignant neoplasia.
Decisions must be individual, based on the patient’s age, multiple risk factors, and response to recurrence of infection (2).
Several effective surgical techniques are used to perform tonsillectomy, including electrocautery, dissection, microdebrider, radiofrequency coblation, and cold dissection.
Intraoperative or postoperative bleeding occurs in < 2% of patients, usually within 24 hours of surgery or after 7 days, when the eschar detaches.
Patients with bleeding should be referred to hospital.
If bleeding continues on arrival, patients are generally examined in the operating theatre and haemostasis is performed.
If a clot is present in the tonsillar lodge, it is removed and patients are kept under observation for 24 hours.
Postoperative EV rehydration is necessary in ≤ 3% of patients, ideally in the smallest number of patients, through the optimal use of preoperative hydration, perioperative antibiotic, analgesic and corticosteroid therapy.
Postoperative airway obstruction occurs most frequently in children < 2 years of age who have pre-existing severe obstructive sleep disorders and in patients with morbid obesity or who have neurological disorders, craniofacial abnormalities or significant preoperative obstructive sleep apnoea.
Complications are generally more frequent and more severe in adults.
Accumulating evidence suggests tonsillotomy (partial intracapsular removal of tonsillar tissue), when performed to treat various disorders is as effective as traditional tonsillectomy and is preferred because of better outcomes related to pain, postoperative complications, and patient satisfaction (3).
Treatment references
- Hayward G, Thompson MJ, Perera R, et al: Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev., 2012. doi: 10.1002/14651858.CD008268.pub2
- Ruben RJ: Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: how random are the studies and what are their limitations? Otolaryngol Head Neck Surg. 139(3):333-9, 2008. doi: 10.1016
- Wong Chung JERE, van Benthem PPG, Blom HM: Tonsillotomy versus tonsillectomy in adults suffering from tonsil-related afflictions: a systematic review. Acta Otolaryngol 138(5):492-501, 2018. doi: 10.1080/00016489.2017.1412500
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