Tonsillopharyngitis - Acute (1 of 10) 1 Patient presents w/ sore throat 2 EVALUATION Yes EXPERT Are there signs of REFERRAL complication? No 3 4 EVALUATION Is Group A Beta-hemolytic Yes DIAGNOSIS Streptococcus (GABHS) • Rapid antigen detection test infection suspected? (RADT) • roat culture No TREATMENT EVALUATION No A Supportive management Is GABHS confi rmed? B Pharmacological therapy (Non-GABHS) Yes 5 TREATMENT A EVALUATE RESPONSEMIMS Supportive management TO THERAPY C Pharmacological therapy • Antibiotics Poor/No Good D Surgery, if recurrent or complicated response response REASSESS PATIENT COMPLETE THERAPY & REVIEW THE DIAGNOSIS© Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B269 © MIMS Pediatrics 2020 Tonsillopharyngitis - Acute (2 of 10) 1 ACUTE TONSILLOPHARYNGITIS • Infl ammation of the tonsils & pharynx • Etiologies include bacterial (group A β-hemolytic streptococcus, Haemophilus infl uenzae, Fusobacterium sp, etc) & viral (infl uenza, adenovirus, coronavirus, rhinovirus, etc) pathogens • Sore throat is the most common presenting symptom in older children TONSILLOPHARYNGITIS 2 EVALUATION FOR COMPLICATIONS • Patients w/ sore throat may have deep neck infections including epiglottitis, peritonsillar or retropharyngeal abscess • Examine for signs of upper airway obstruction Signs & Symptoms of Sore roat w/ Complications • Trismus • Inability to swallow liquids • Increased salivation or drooling • Peritonsillar edema • Deviation of uvula • Asymmetry & forward displacement of the soft palate Signs of Upper Airway Obstruction • Stridor • Air hunger • Respiratory distress • Toxic appearance • Cyanosis Management of Complications • All abscesses should be drained • Tonsillectomy if patient has a history of recurrent tonsillitis • Acute tonsillectomy without prior incision 3 EVALUATION FOR GABHS INFECTION • Identify & treat GABHS infection as soon as possible after diagnosis to decrease risk of complications like acute rheumatic fever (ARF), glomerulonephritis, pediatric autoimmune neuropsychiatric disorders associated w/ streptococcal infection (PANDAS) syndrome, & decrease period of contagiousness • GABHS is the most common bacterial pathogen of ATP & warrants antibiotic treatment • GABHS infection should be suspected on clinical & epidemiological grounds & supported by laboratory tests • Viral pathogens are more frequent than bacteria, accounting for about 70-90% of cases in children, & almost 100% in children <3 years of age Signs & Symptoms Suggestive of GABHS Infection • Sore throat/tonsillar swelling/exudates • Swollen anterior cervical nodes • Fever >38ºC (low-grade fever <38ºC in children <3 years old) • Lack of cough, conjunctivitis, rhinorrhea,MIMS hoarseness • Symptoms in a patient aged 5-15 years Signs & Symptoms Suggestive of a Viral Etiology • Rhinorrhea • Cough • Hoarseness • Conjunctivitis • Diarrhea • Oropharyngeal ulceration • Muscle &© joint pain B270 © MIMS Pediatrics 2020 Tonsillopharyngitis - Acute (3 of 10) 4 DIAGNOSIS • Tests not needed for patients whose features do not suggest GABHS infection • For patients 3-15 years of age, perform diagnostic tests when GABHS cannot be excluded Rapid Antigen Detection Test (RADT) • Advantage of speed (within minutes versus 48 hours for culture) & specifi city (≥95%) for GABHS • Children w/ throat pain w/ ≥2 of the following are recommended to undergo RADT: - Absence of cough TONSILLOPHARYNGITIS - Presence of tonsillar exudates/swelling - History of fever - Age >15 years - Positive for swelling & tenderness of the anterior cervical lymph nodes • Confi rmation w/ culture is not necessary after a negative RADT result roat Swab Culture • Highly sensitive (90-95% sensitivity) but not done routinely because of delay in results (18-24 hours) - Recommended for those w/ history of contact w/ symptomatic persons w/ GABHS pharyngitis, recurrent GABHS infection & symptomatic patients at high risk for rheumatic fever • roat swabs from both tonsils & posterior pharyngeal wall • Optimal time for collection is at onset of symptoms & before antibiotics are started Centor Criteria • Used to assess the susceptibility of patients to GABHS infection based on the patient’s age & symptoms - Results may assist in the decision to start antibiotic treatment • Uses a points system utilizing the following signs/symptoms: - Fever (>38oC) (1) - Absence of cough (1) - Tender anterior cervical node (1) - Tonsillar exudate/swelling (1) - Age 3-14 years (1) - Age 15-44 years (0) - Age >44 years (-1) • Modifi ed total risk based on total ATP score: Total score Risk of GABHS ≥4 51-53% 3 28-35% 2 11-17% 1 5-10% ≤0 1-2.5% FeverPAIN Score • May be used to assess the need to start antibiotic treatment as well as the severity of throat pain • High results may indicate streptococcal infection; results should be correlated w/ Centor criteria score 5 RESPONSE TO THERAPY • Clinical response is usually evident withinMIMS 24-48 hours • Persistence beyond 48 hours may indicate alternative causes or development of suppurative complications which warrants reassessment A SUPPORTIVE MANAGEMENT General Measures • Adequate fl uid intake • Warm saline gargle (¼ teaspoon of salt per 8 oz glass of water) • Elimination of close contact w/ family members or visitors if patient has been confi rmed to have GABHS • Remain at© home until 24 hours of antibiotic therapy has been received Alternative erapy • ere are not enough studies to support use of acupunture & herbal treatments for tonsillopharyngitis Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B271 © MIMS Pediatrics 2020 Tonsillopharyngitis - Acute (4 of 10) B PHARMACOLOGICAL THERAPY - NON-GABHS INFECTION Symptomatic Treatment • Symptomatic treatment is important in the management of children w/ sore throat Simple Analgesics/Antipyretics • Paracetamol is the drug of choice for analgesia in sore throat • Aspirin is not recommended due to the risk of Reye’s syndrome Nonsteroidal Anti-infl ammatory Drugs (NSAIDs) TONSILLOPHARYNGITIS • Ibuprofen is a safe & eff ective alternative for analgesia & antipyrexia • Diclofenac may also be used for against pain caused by ATP • As NSAIDs are associated w/ signifi cant risk of GI bleeding, their routine use is not recommended roat Lozenges/Gargle/Spray • May be helpful especially in those w/ signifi cant throat pain or discomfort C PHARMACOLOGICAL THERAPY - GABHS INFECTION Symptomatic Treatment • Important in the management of children w/ sore throat • Same as for non-GABHS infection Antimicrobial erapy • Treatment started only for documented GABHS infection • Due to practical constraints, antibiotics may be started empirically if: - GABHS is clinically suspected - Patient is toxic-looking - Follow-up is not possible • Empiric treatment of GABHS is discouraged due to poor diagnostic accuracy even w/ elaborate clinical scoring systems • A RADT or throat swab should be taken before starting empiric antibiotics • If antibiotics are started empirically, & culture results are negative, the antibiotic should be discontinued • Appropriate antibiotics prevent ARF, prevent suppurative complications, decrease infectivity & shorten clinical course Penicillin • Drug of choice • Proven effi cacy, narrow spectrum, safety & low cost • Full 10-day course of treatment for oral medications • IM penicillin may be advisable if poor compliance is a concern Amoxicillin • Better tolerated than Penicillin • 2nd line to Penicillin in pediatric patients due to taste preference Macrolides • Eg Azithromycin, Clarithromycin, Erythromycin, Roxithromycin • May be used for patients w/ Penicillin allergy • Local resistance patterns vary geographically & should be included in the consideration for an alternative antibiotic in Penicillin-allergic patients MIMS • Azithromycin or Cephalexin may be used for Erythromycin-intolerant patients Cephalosporins • Eg Cefaclor, Cefadroxil, Cefdinir, Cefi xime, Cefpodoxime, Cephalexin • Alternative to Amoxicillin for the eradication of streptococcal infection especially in recurrent cases • Studies show that a 5-day treatment w/ a cephalosporin is superior to a 10-day course w/ Penicillin Clindamycin • May be used for those who are both Penicillin-allergic & Erythromycin-intolerant • Reported resistance of GABHS isolates to Clindamycin are generally low & thus may still be considered a reasonable© alternative to macrolides & Penicillin Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B272 © MIMS Pediatrics 2020 Tonsillopharyngitis - Acute (5 of 10) D SURGERY Treatment Goal • For recurrent tonsillopharyngitis, surgery aims for reduction in occurrence of sore throat & improved general health w/ tonsillectomy Indications for Tonsillectomy Recurrent Tonsillitis • Sore throat due to infl ammation of tonsils TONSILLOPHARYNGITIS • ≥7 episodes of tonsillitis over a 12-month period or ≥5 episodes/year in the past 2 years or ≥3 episodes/year in the past 3 years w/ documentation for each episode of sore throat & ≥1 of the following: - Temperature >38.3°C (101°F) - Cervical adenopathy - Tonsillar exudate - Positive test for GABHS infection • Symptoms interfere w/ patient’s normal daily function Peritonsillar Abscess or Quinsy • All abscesses should be drained • Tonsillectomy if without response to appropriate antibiotics &/or incision & drainage Contraindications to