Pharyngitis and Tonsillitis

Question 1

What are differentials for acute pharyngitis?

Answer 1

• epiglottitis → drooling, tripodding
• retropharyngeal/peritonsillar/lateral abscess → 2-4yrs
• infectious mononucleosis → >7days, adenopathy + splenomegaly
• diptheria → grey membrane
• lemierre’s syndrome → thrombophlebitis of jugular vein
• measles → maculopapular rash, koplik spots
• stevens-johnson syndrome → pharynx vesicles, anticonvulsants
• kawasaki disease → polymorphic rash, strawb tongue
• hand-foot-and-mouth disease → oral ulcers, palm/sole vesicles
• oropharyngeal cancer → hoarseness, dysphagia, dysphonia

Question 2

Acute pharyngitis often presents in children/adolescents in winter/spring seasons (bacterial) or summer/autumn (enteroviral).

What signs + symptoms does acute pharyngitis generally present with?

Answer 2

• rhinorrhoea, nasal congestion, cough
• sore throat
• pharyngeal exudate
• cervical lymphadenopathy
• fever >37^oC
• headache, n+v, abdo pain
• conjunctivitis, maculopapular rash, koplik spots

Question 3

Infectious mononucleosis (IM), also known as glandular fever, is a clinical syndrome most commonly caused by Epstein Barr virus (EBV) infection.

What are the clinical features of infectious mononucleosis?

Answer 3

• TRIAD:
  
  • fever
  • pharyngitis
  • lymphadenopathy

Along with atypical lymphocytosis, positive heterophile antibody test and serological test for antibodies against EBV are usually diagnostic.

Question 4

Tonsillitis is inflammation of the palatine tonsils as a result of either bacterial or viral infection. It will often occur in conjunction w/ inflammation of other areas of the mouth, giving rise to terms tonsillopharyngitis (pharynx also involved) and adenotonsillitis (adenoids also involved).

What are the bacterial and viral organisms responsible for tonsillitis?

Answer 4

• Bacterial →
  
  • group A beta-haemolytic streptococci (GABHS) (strep pyogenes)
  • group C beta-haemolytic streptococci
  • staphlococcus aureus
  • mycoplasma pneumoniae
  • neisseria gonorrhoea
• Viral →​
  
  • adenovirus
  • epstein-barr virus
  • rhinovirus
  • coronavirus
  • enterovirus
  • influenza + parainfluenza

It is difficult to differentiate between viral or bacterial aetiology. Blood testing should include an infectious mononucleosis screen.

Question 5

What are the clinical features of tonsillitis?

Answer 5

• generally lasts 5-7 days
  
  • if >7 days → consider glandular fever
• odynophagia + reduced oral intake
• fever
• halitosis
• new onset snoring (or even apnoeic)
• shortness of breath
• physical examination → red inflamed tonsils, white exudate (pus) spots on tonsils, cervical lymphadenopathy (most commonly lymph nodes in the region of upper 1/3rd SCM)

Question 6

Tonsillitis is a clinical diagnosis. Antibiotics will most likely benefit a patient when their sore throat is caused by streptococcal bacteria. Centor criteria will aid in the diagnosis or exclusion of GABHS-tonsillitis and determine whether antibiotics are an option.

What is the Centor criteria?

Answer 6

Was developed to try and differentiate between bacterial and viral tonsillitis based on clinical symptoms, there are four key criteria:

• tonsillar exudate
• tender anterior cervical lymphadenopathy or lymphadenitis
• fever or history of fever
• absence of cough

a score of 3 or more is highly suggestive of bacterial infection (40-60% likelihood) and a score of 2 or less suggests bacterial infection is unlikely (80% likelihood)

Question 7

The first key decision for tonsillitis is whether the patient requires inpatient admission or not.

What factors suggest severe tonsillitis + an urgent admission and assessment?

Answer 7

• resp compromise (tachypnoea, low sats, use of accessory muscles) or apnoeic episodes -> suggest tonsils are so large that they are affecting the child’s ability to ventilate, alternatively could be epiglottitis
• pts who are unable to eat or drink are at risk of dehydration - they should be admitted for treatment + monitoring until able to drink again
• pts who have been treated w/ appropriate antibiotics in community who are still not getting better should also be admitted for IV therapy + further investigation

Question 8

Paracetamol and iboprufen are effective pain relief in tonsillitis + can be alternated in order to give effective pain relief. Topical analgesia such as difflam (benzydramine) spray/mouthwash can be helpful to reduce pain and allow child to swallow oral analgesic agents.

What is the role of antibiotics in treating tonsillitis?

Answer 8

• NICE recommend antibiotics should not be routinely given for tonsillitis
• in pts fulfulling 3 or more Centor criteria, there is option of antibiotics to cover Group A strep
• also abx for those systemically unwell, with complications (eg quinsy) or at serious risk of complications due to comorbidity
• antibiotic of choice → penicillin
• data suggests cephalosporins may be more effective (?)
• co-amoxiclav often avoided due to small risk of permanent skin rash if tonsilitis is due to glandular fever

Question 9

Tonsillectomy is reserved for patients with recurrent, troublesome tonsillitis.

What are the criteria for tonsillectomy, according to SIGN guidelines?

Answer 9

• 7 episodes of tonsillitis in one year
• 5 episodes in 2 consecutive years
• 3 episodes in 3 consecutive years
• 2 episodes of quinsy
• unilateral tonsilitis
• obstructive sleep apnoea

Question 10

What are local complications of bacterial tonsillitis?

Answer 10

• acute otitis media
• abscess → pts will become more ill, w/ peaking temps, otalgia + severe dysphagia
  
  • peritonsillar (quinsy)
  • parapharyngeal
  • retropharyngeal

Question 11

What are the general complications of bacterial tonsillitis?

Answer 11

• pulmonary infection
• post-streptococcal glumerulonephritis → haematuria + oedema due to immune deposition in kidney
• rheumatic fever → autoimmune complication, manifests as carditis, arthritis, chorea + skin changes
• scarlet fever → punctate erythematous rash + “strawberry tongue”

Question 12

What is quinsy?

Answer 12

• abscess between tonsillar capsule and surrounding superior constrictor muscle
• complication of acute tonsillitis
• Hx → sore throat, unable to swallow, trismus, “hot potato” voice
• Tx → IV dexamethasone (8mg), IV benzylpenicillin + metronidazole, analgesia, IV fluids + drainage of quinsy under LA

Question 13

A tonsillectomy is a day case. What are the risks and recovery time?

Answer 13

• painful
• risks → post tonsillectomy bleed (need to return to A+E), infection, pain, damage to teeth/gum/lips, sore throat
• needs 2 weeks recovery

Question 14

What is a post-tonsillectomy bleed?

Answer 14

• likely 2^o to post-tonsillectomy infection
• occurs in 10% → 2% requiring theatre to arrest bleeding
• need admission for monitoring
• Mx → ABC, blood (FBC, cross match 2 units)
• Tx → tranexamic acid, hydrogen peroxide mouthwash, adrenaline soaked gauze, theatre