Pharyngitis:Assessment and Management

Amy McAllister

December 2014

Case 1

22 year old Caucasian female with 2 days of sore throat, cough, headache, rhinorrheoa. No PMH/FH.

Examination:

HR 105, BP 120/80, Temp 37.9, Sats 99% RA, RR 14

Case 1

Case 1

Likely diagnosis?

Centor criteria?

Investigations?

Management?

- Steroids?

- Antibiotics?

Case 2

26 year old Indigenous male from Northern Territory with 2 days of sudden onset of sore throat and pain on swallowing without cough or coryza.

PMH: Diabetic

FH: Mother and sister have Rheumatic heart disease

Obs: HR 125, BP 90/50, Temp 38.5, sats 96% RA, RR 19

O/E: Looks septic, salivary pooling

Case 2

Case 2

Likely diagnosis?

Centor criteria?

Investigations?

Management?

- Steroids?

- Antibiotics?

Epidemiology 12 million presentations of pharyngitis annually in US

Mostly late winter or early spring

Group A strep accounts for 5-15% of adults presenting with pharyngitis

However, antibiotics are prescribed in more than 60%

Causes

Infectious

*Mostly viral*

Influenza

Infectious mononucleosis

Herpes simplex

Primary HIV

CausesInfectious

Bacterial

Group A Streptococcus (GAS)

Also Group C and G

Epiglottitis

Quinsy

Retropharyngeal abscess

HIB

N.Gonorrhoeae

Fusobacterium necrophorum

Mycoplasma pneumonia

Fungal

Candida

Causes

Other

Allergy

Trauma

Toxins

Smoking

Cancer

GORD

Thyroiditis

Group A Strep (GAS) Most important treatable agent of pharyngitis

Clinical features:

Centor criteria (1point each)

Tonsillar exudate

Fever

Tender cervical lymphadenitis

Absent cough or rhinorrheoa

Modified Centor criteria

3-14 years old = add 1 point

15-44 years old = 0 points

> 44 years old + = subtract a point

Studies – 57% of 206,870 people with 4 centor criteria tested positive for GAS

Complications of GAS

Suppurative

Sinusitis

Peritonsillar abscess

Retropharyngeal abscess

Non-suppurative

Acute Rheumatic fever

Post-strep glomerulonephritis

Scarlet fever

Toxic shock

Acute Rheumatic Fever

Modified Jones criteria:

Major criteria

Polyarthritis

Carditis

Subcutaneous nodules

Erythema marginatum

Sydenham's chorea

Acute Rheumatic Fever Minor:

Fever

Arthralgia

Raised ESR or CRP

Leukocytosis

ECG showing features of heart block

Previous episode of rheumatic fever or inactive heart disease

Excluding dangerous conditions (1)

Sore throat or odonophagia

Fever

Muffled voice

Drooling

Stridor

Respiratory distress

Hoarseness

Severity of pain out of proportion of exam

Epiglottitis

Excluding dangerous conditions (2)

Severe, usually unilateral sore throat

Fever

“Hot potato” voice

Drooling/ pooling of saliva

Trismus

Peritonsillar abscess

Excluding dangerous conditions (3)

Sore throat

Fever

Dysphagia/Odynophagia

Neck pain

Dyspnea/ stridor

Cervical lymphadenopathy

Drooling

Torticollis

Trismus

Retropharyngeal abscess

Fever, chills, malaise

Mouth pain

Stiff neck

Dysphagia

Leans forward

Absent trismus

Muffled voice or unable to speak

Tender “woody” induration or crepitus in submandibular area

Excluding dangerous conditions (4)

Ludwig's angina

Excluding dangerous conditions (5)

Fever

Malaise and severe fatigue

Pharyngitis

Lymphadenopathy

Splenomegaly

Guillain-Barre syndrome

Deranged LFTs

Infectious Mononucleosis

Investigations

RADT

Throat culture

Monospot

Gonococcal culture

Lateral neck film

Soft-tissue neck CT

Bloods?

Management

ABCs!

?Airway obstruction

Hydration

Analgesia

Antibiotics

ENT referral

Analgesia - options

OOTC lozenges/gargles

Paracetemol

Aspirin

NSAIDs

Steroids

Dose of Dex?

Cochrane review

8 trials, 743 participants (children and adults)

Patients taking steroids were x3 times more likely to have complete resolution by 24 hours vs placebo

Dose of Dex? However…

different steroids used

different doses and routes

antibiotics co-administered

sample size too small to assess for adverse effects

Useful in cases of airway obstruction

Antibiotics – why?

Reduces duration and severity of symptoms and complications

Most useful within first 2 days

Reduces by 1 day

Reduces incidence of rheumatic fever within 9 days following onset of symptoms

Reduces transmission; patient no longer contagious after 24hours

Evidence Cochrane review July 2013

27 trials, 12,835 cases of pharyngitis (adults and children)

Reduced sore throat and fever by half

Reduced symptoms by 16 hours on average

Less suppurative complications vs placebo

Reduced ARF by over 2/3 within 1 month

Antibiotics – which?

Penicillin – no clinical isolate has demonstrated resistance

Oral penicillin V for 10 days

Amoxicillin

IM Penicillin G Benzathine

First generation Cephalosporins

Macrolides

Antibiotics – who?

High incidence of acute rheumatic fever e.g. indigenous

Existing rheumatic disease or Scarlet fever

Immunosuppressed

Risks

Drug side effects

Patient expectations

Summary Most cases of adult pharyngitis are viral, and

rheumatic disease is very rare in WA

Use modified Centor criteria if GAS suspected

Antibiotics if scoring 2 or more, or high risk group

Steroids if severe odynophagia

Otherwise analgesia and supportive care

Consider different diagnosis than GAS if symptoms lasting over 7 days

References

http://www.guideline.gov/content.aspx?id=38416

http://www.rhdaustralia.org.au/sites/default/files/guideline_0.pdf

http://www.thecochranelibrary.com/details/browseReviews/578769/Pharyngitistonsillitis.html

http://www.uptodate.com/contents/evaluation-of-acute-pharyngitis-in-adults