Acute Tonsillopharyngitis

Dr Rajesh

16/04/08

Definitions

tonsillitis: inflammation of pharyngeal tonsils tonsillopharyngitis: inflammation extending from

tonsils to the adenoids and lingual tonsils recurrent tonsillitis: 7 episodes in 1 year, 5 infections

in 2 consecutive years, or 3 infections each year for 3 years consecutively chronic tonsillitis: chronic sore throat, halitosis, tonsillitis, and persistent tender cervical nodes for greater than 4 weeks

quinsy: Greek term used for inflammation of throat and tonsils, historically used for peritonsillar abscess

Epidemiology

most cases occur in school-age children uncommon in the first 2 years of life 5-7 URIs per child per year GAS is found in 35% of children with

pharyngitis 45,000 cases of PTA per year or 30 cases

per 100,000 people per year

Causes of Tonsillopharyngitis

  •  Beta hemolytic streptococcal infection — 22 percent

  •  Mycoplasma pneumoniae — 9.4 percent

  •  Chlamydia species strain TWAR — 8.4 percent

•  Viruses — 25.5 percent

Huovinen, et al 1995

CLINICAL DIAGNOSIS

The "classic" presentation of GAS tonsillopharyngitis is a sore throat associated with fever, tonsillopharyngeal erythema and exudate, swollen and tender anterior cervical adenopathy, and an elevated white blood cell (WBC) count without rhinorrhea or cough.

However, even when this constellation of clinical symptoms is present, the likelihood of GAS infection does not exceed 60 to 70 percent in children, and 20 to 30 percent in adults.

Is it truly Group A beta hemolytic Streptoccal tonsillopharyngitis? From many studies, it would appear that the presence or

absence of a GAS pharyngitis cannot be accurately diagnosed with clinical examination alone in most patients.

It is somewhat easier to identify a subset of children (approximately 20 percent of cases) and adults (approximately 67 percent of cases) who are unlikely to have GAS.

These patients have sore throats with accompanying rhinorrhea, cough, and hoarseness. Fever is often absent. They have mild tonsillopharyngeal erythema without exudate, and slight or no cervical lymphadenitis.

Why antibiotics

Treatment of GABHS pharyngitis is important

To prevent complications of infection, particularly rheumatic fever suppurative complications

To speed recovery To prevent spread of the infection

Treatment approach based on clinical findings (Komarof, et al)

  •  Empirically treat patients with the constellation of a tonsillar exudate, tender cervical adenopathy, and a temperature >37.8º C.

 •  Obtain throat cultures in patients with only one or two of the above findings and treat based upon those results.

 •  Do not obtain cultures or treat patients with none of the above findings.

The nonsuppurative complications of GAS tonsillopharyngitis Acute rheumatic fever Scarlet fever Streptococcal toxic shock syndrome Acute glomerulonephritis PANDAS (Pediatric Autoimmune Neuropsychiatric

Disorder Associated with Group A Streptococci)

Suppurative complications

Tonsillopharyngeal cellulitis or abscess Otitis media Sinusitis Necrotizing fasciitis

Peritonsillar abscess

Mononucleosis epstein-barr virus (EBV indolent onset, gray tonsillar

exudate, tender cervical, axillary and/or inguinal lymphadenopathy, low grade fever, weight loss, myalgias, fatigue, hepatosplenomegaly atypical lymphocytes in peripheral smear

positive monospot or heterophil Ab test

rash with penicillin illness lasts more than 7-10

days

Intraoral Ultrasound

highly accurate ultrasound can exclude peritonsillar cellulitis, abscess

and retropharyngeal abscess determination of abscess volume, location

and relationship to carotid artery

CT neck with contrast

indications: spread to deep neck

structures inferior pole abscess high risk for drainage

procedures (coagulopathy) to guide drainage of PTA

after unsuccessful surgical attempt

patient unable to open mouth due to trismus

complicated PTA with rupture into carotid space

Airway Obstruction

nasal airway humidified oxygen corticosteroids monitored observation intubation cricothyroidotomy tracheostomy

Recommendations on the Management of Acute and Chronic Tonsillitis Adequate supportive care Use of analgesics, oral anesthetics, and antiseptics Antibiotics

Antibiotics

Penicillins Cephalosporins Macrolides

Bacteriological cure

in the AHA guidelines, prevention of rheumatic fever as a poststreptococcal

complication depends on eradication of GABHS bacteria from the pharynx

prevention of rheumatic fever and other nonsuppurative complications of GABHS pharyngitis still occurs when antibacterial therapy is postponed by as many as 9 days after the onset of pharyngitis symptoms

Factors influencing antibiotic choice ability to eradicate GABHS bacteria from the

pharynx Ability to resolve signs and symptoms of the

infection (bacteriologic and clinical efficacy) adherence (frequency of daily administration,

duration of therapy, and palatability), Antibacterial spectrum (narrow versus broad

activity), potential treatment-related side effects cost.

Cephalosporins

Changing pattern of penicillin sensitivity

Clinical cure

Short course therapy of AT

Cephalopsorin

Azithromycin

Penicillin Resistance: Mechanism It is important to note that no strains of

GABHS resistant to penicillin or cephalosporin have ever been reported.

Copathogenicity is the most likely explanation for the increasing rate of penicillin treatment failures

GABHS susceptible to penicillin are protected by other in vivo, colocalized bacteria that lack the same susceptibility due to beta-lactamase production

beta-lactamase producing organisms is more likely to inactivate penicillin

Recurrence risk

Symptomatic bacteriologic recurrence within 30 days of initial diagnosis occurred in 37% of patients treated with penicillin V, 25% of patients treated with amoxicillin, 18% of patients treated with cephalexin or

cefadroxil, 7% of patients treated with amoxicillin-clavulanate

or a second-generation or third-generation cephalosporin

Children Less Than Three-Years-OldWith PharyngitisAre Group A Streptococci Really That UncommonClinical pediatrice , 1986

During a 15-month period, 148 infants and children less than 3-years-old who presented with

signs and/or symptoms of pharyngitis were monitored in a private pediatric practice. Clinical

signs included fever (95 or 64%), tonsillar exudate (16 or 11%), and cervical adenopathy (5 or 3%).

Beta-hemolytic streptococci (BHS) from group A were isolated from throat swabs in 37 (25%)

instances. These isolations were more common among children 25-35 months old than among

children less than 2 years old (35% vs. 19%, p < 0.05), and were significantly more likely when

overnight anaerobic culture techniques were used rather than conventional aerobic methods (23 %

vs. 11%, p < 0.01).

Recurrent tonsillitis

Recurrent tonsillitis is diagnosed when an individual has 7 episodes in 1 year, 5 infections in 2 consecutive years, or 3 infections each year for 3 years consecutively.

Microbiology of recurrent tonsillitis A polymicrobial flora consisting of both aerobic and anaerobic bacteria is observed in core

tonsillar cultures from cases of recurrent pharyngitis. Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae are the

most common bacteria isolated in recurrent tonsillitis. Bacteroides fragilis is the most common anaerobic bacterium isolated in recurrent

tonsillitis. A polymicrobial bacterial population is observed in most cases of chronic tonsillitis, with

alpha- and beta-hemolytic streptococcal species, S aureus, H influenzae, and Bacteroides species identified.

One study, based on bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy, suggests that antibiotics prescribed 6 months before surgery do not alter the tonsillar bacteriology at the time of tonsillectomy.7

A relationship between tonsillar size and chronic bacterial tonsillitis is believed to exist. This relationship is based on both the aerobic bacterial load and the absolute number of B and T lymphocytes.

H influenzae is the bacterium most often isolated in hypertrophic tonsils and adenoids. With regard to penicillin resistance or beta-lactamase production, the microbiology of

tonsils removed from patients with recurrent GABHS pharyngitis is not significantly different from the microbiology of tonsils removed from patients with tonsillar hypertrophy.

Treatment for recurent / chronic tonsillitis Clindamycin: 20-30 mg/kg PO divided tid for

10 d not to exceed 300 mg/dose + Rifampin: 10 mg/kg/dose bid for 4 days

Amoxy-clav for 4-6 weeks

Prophylaxis (5 strep infections in 6 months) Penicillin V Potassium (Kaypen)40 mg/kg/day

PO bid, max 3 gm/day

Tonsillectomy: Absolute Indications Tonsillar hypertrophy causing obstruction to

respiration or deglutition Obstructive sleep apnea

Relative Indications

Chronic tonsillitis Tonsillitis resulting in febrile convulsions Peritonsillar abscess Diphteria carrier Suspected tonsillar malignancy Hypertrophy causing malocclusion Failure to thrive Systemic disease secondary to Beta hemolytic streptococcal

infection Chronic halitosis