at pharyngitis by mikeholy

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									Acute Tonsillopharyngitis

    Dr Rajesh

   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

   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
   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

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
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

 • 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,
    atypical lymphocytes in
    peripheral smear
   positive monospot or
    heterophil Ab test
   rash with penicillin
   illness lasts more than 7-10
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
   inferior pole abscess
   high risk for drainage
    procedures (coagulopathy)
   to guide drainage of PTA
    after unsuccessful surgical
   patient unable to open
    mouth due to trismus
complicated PTA with rupture into carotid
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

   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
   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
Factors influencing antibiotic choice

   ability to eradicate GABHS bacteria from the
   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
   potential treatment-related side effects
   cost.
Changing pattern of penicillin
Clinical cure
Short course therapy of AT

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-Old
With Pharyngitis
Are Group A Streptococci Really That Uncommon
Clinical 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
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
   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
   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
   Penicillin V Potassium (Kaypen)40 mg/kg/day
    PO bid, max 3 gm/day
Tonsillectomy: Absolute
   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
   Chronic halitosis

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