Paediatrics chapters
Acute pharyngitis and tonsillitis
Causes of sore throat in children, how to tell streptococcal from viral pharyngitis, which tests help, how to treat, and the complications of untreated group A strep.
- Most sore throats in children are viral; group A beta-haemolytic streptococcus (GABHS) is the commonest bacterial cause, mainly at 5 to 15 years.
- Streptococcal throat: fever, exudate, tender anterior cervical nodes, palatal petechiae, no cough or cold; confirm by throat culture (gold standard) or rapid antigen test.
- Treat with penicillin or amoxicillin for 10 days (or one IM benzathine penicillin): it prevents rheumatic fever if started within 9 days, but not glomerulonephritis.
On this page
Overview
Pharyngitis is inflammation of the pharynx (redness, swelling, exudate, ulcers or vesicles); when the tonsils are mainly involved it is tonsillitis, and the two usually occur together (pharyngotonsillitis).
The key clinical job is to pick out group A streptococcal infection, because treating it prevents acute rheumatic fever, an important preventable cause of heart disease (Nelson).
Aetiology
| Viruses (most cases) | Bacteria |
|---|---|
| Adenovirus | Group A beta-haemolytic streptococcus (Streptococcus pyogenes): commonest bacterial cause |
| Rhinovirus, RSV, influenza, parainfluenza | Mycoplasma pneumoniae |
| Epstein-Barr virus (infectious mononucleosis) | Corynebacterium diphtheriae |
| Herpes simplex virus | Haemophilus influenzae |
| Coxsackie and enteroviruses | Streptococcus pneumoniae, Chlamydia |
The tonsils and adenoids are part of the body's first defence; when chronically infected they may hold mixed organisms, including streptococci and H. influenzae.
Viral versus streptococcal features
| Feature | Viral | Group A streptococcal |
|---|---|---|
| Age | Any age | 5 to 15 years; uncommon before 2 to 3 |
| Onset | Gradual | Sudden |
| Coryza, cough, hoarseness | Common | Usually absent |
| Fever | Mild | Often high; child looks unwell |
| Throat | Red; vesicles or ulcers in some | Red, enlarged tonsils with exudate; petechiae on the palate |
| Neck nodes | Not a leading feature | Enlarged, tender anterior cervical (jugulodigastric) nodes |
| Other | Conjunctivitis (adenovirus) | Headache, abdominal pain, vomiting; scarlet fever rash in some |
Clues to specific causes
- Infectious mononucleosis (EBV): exudative pharyngitis with marked neck nodes; splenomegaly (about 50%) or hepatomegaly is the clue; atypical lymphocytes and a positive mononucleosis slide test. A diffuse red rash develops in about 80% of those given amoxicillin (Nelson).
- Herpes simplex: gingivostomatitis with ulcerating vesicles on the front of the mouth and lips, high fever and refusal to drink.
- Diphtheria: no or mild fever, grey adherent pseudomembrane that bleeds when you try to remove it (torn capillaries), bull neck; unvaccinated child. Can block the airway; the toxin affects the heart.
- Measles: intense red throat and Koplik spots.
- Mycoplasma: sore throat followed by a persistent cough.
A child with fever, sore throat, exudate, tender anterior neck nodes and no cough or runny nose is likely to have streptococcal pharyngitis; a runny nose and cough point strongly to a virus.
A membrane that bleeds when removed and a toxic, unvaccinated child suggest diphtheria, not follicular tonsillitis. Diphtheria is still seen in Pakistan.
Investigations
| Test | Use |
|---|---|
| Throat culture | Gold standard for group A streptococcus |
| Rapid antigen detection test (RADT) | Very specific (about 95% or more): a positive result can be trusted and culture is not needed; a negative result in a likely case can be checked by culture |
| PCR panel | Identifies several viral and bacterial agents within hours |
| Blood count and monospot | Atypical lymphocytes and positive slide test in infectious mononucleosis |
| ASO titre | Not helpful in acute pharyngitis (rises later); used to show recent infection in rheumatic fever or glomerulonephritis |
| Lateral neck X-ray | Size of adenoids; retropharyngeal swelling |
Management
General
- Most viral sore throats need no specific drug; symptomatic care matters.
- Paracetamol or ibuprofen for pain and fever.
- Steroids are used only for airway narrowing in infectious mononucleosis, not for ordinary pharyngitis.
Streptococcal pharyngitis
- Group A streptococcus is always sensitive to penicillin and other beta-lactams.
- Oral penicillin V or amoxicillin for 10 days, or a single intramuscular injection of benzathine penicillin, which does not rely on the child taking tablets.
- Nelson's doses: penicillin V 10 mg/kg/dose (maximum 250 mg) 2-3 times daily for 10 days; benzathine penicillin 600,000 units for children 27 kg or less, 1.2 million units for larger children (Akbar: 6-12 lac units).
- Penicillin allergy: cephalexin, cefadroxil, erythromycin, clarithromycin or clindamycin for 10 days, or azithromycin for 5 days.
- Strep throat often settles by itself within about 5 days, but early treatment speeds recovery and prevents rheumatic fever if started within 9 days of onset.
Antibiotics prevent acute rheumatic fever but do not prevent post-streptococcal glomerulonephritis.
Do not give amoxicillin or ampicillin to a teenager with exudative tonsillitis and big neck nodes until glandular fever is considered; it causes a widespread rash in EBV infection.
"Ten days, nine days": penicillin for 10 days, and it works against rheumatic fever if begun within 9 days.
Prophylaxis
Daily oral penicillin to prevent repeated streptococcal infections is used only to prevent recurrences of rheumatic fever, not for ordinary recurrent sore throats.
Complications of untreated streptococcal infection
Suppurative (local spread)
- Peritonsillar abscess (quinsy): infection or pus above and lateral to the tonsil capsule (Akbar). Nelson: mainly over 10 years; group A streptococci or anaerobes; unilateral tonsil swelling; a biphasic illness with sudden worsening; muffled, "hot potato" voice, drooling and trismus; fever usually over 38.5 °C; no stridor; leucocytosis. Treat with antibiotics and aspiration.
- Retropharyngeal and parapharyngeal abscess: mainly under 6 years; fever, muffled voice, drooling, arching of the neck; thickened retropharyngeal space on lateral X-ray; antibiotics and surgical drainage (Nelson).
- Acute otitis media, sinusitis.
Non-suppurative (immune)
- Acute rheumatic fever, after a latent interval of 1-5 weeks, average 3 (Akbar; Nelson gives 2-6 weeks).
- Acute post-streptococcal glomerulonephritis (after throat or skin infection).
- Post-streptococcal reactive arthritis.
- Possibly neuropsychiatric disorders (obsessive or tic disorders, PANDAS).
Chronic tonsillitis, adenoids and surgery
- Chronic tonsillitis: bad breath, repeated sore throats, a feeling of something in the throat, foul-tasting debris in the tonsil crypts.
- Big tonsils and adenoids are a major cause of upper airway obstruction: mouth breathing, nasal blockage, nasal speech, loud snoring, pauses in breathing at night (sleep apnoea), restless sleep, bedwetting, poor school performance, and in severe cases right heart failure (cor pulmonale).
- Tonsillectomy: recurrent or chronic pharyngotonsillitis; it cuts the number of infections and relieves bad breath, repeated sore throats and recurrent neck node infection, and cures resistant crypt (cryptic) tonsillitis.
- Adenoidectomy: chronic adenoiditis, chronic sinusitis failing medical treatment, recurrent otitis media, and nasal obstruction with mouth breathing and snoring.
Expect: viruses as the commonest cause and group A streptococcus as the commonest bacterial cause; strep throat age 5 to 15; exudate, tender anterior nodes and absent cough favouring streptococcus; throat culture as gold standard and the high specificity of rapid antigen tests; ASO not useful acutely; penicillin or amoxicillin for 10 days or one IM benzathine penicillin; prevention of rheumatic fever if started within 9 days but no effect on glomerulonephritis; macrolides in allergy; EBV with ampicillin rash and splenomegaly; diphtheria with a bleeding membrane; and quinsy, retropharyngeal abscess and tonsillectomy indications.
Quick revision
- Most sore throats are viral; GABHS is the main bacterial cause, age 5 to 15.
- Strep: sudden fever, exudate, palatal petechiae, tender anterior nodes, no cough or coryza.
- EBV: splenomegaly, atypical lymphocytes, rash with ampicillin.
- Diphtheria: grey membrane that bleeds on removal, bull neck.
- Throat culture gold standard; positive RADT is reliable; ASO not for acute diagnosis.
- Penicillin or amoxicillin 10 days, or benzathine penicillin IM once; allergy: macrolide (azithromycin 5 days).
- Prevents rheumatic fever (start within 9 days), not glomerulonephritis.
- Quinsy: over 10 years, one-sided tonsil swelling, trismus, drooling, hot-potato voice; antibiotics and aspiration.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).
FAQ
Which sore throat needs antibiotics?
Group A streptococcal pharyngitis, suggested by fever, exudate, tender neck nodes and no cold symptoms, and ideally confirmed by culture or a rapid antigen test.
Why give penicillin for a full 10 days?
Both Akbar and Nelson give oral penicillin or amoxicillin for 10 days; clearing the streptococcus from the throat is what prevents acute rheumatic fever.
Does treating strep throat prevent kidney problems?
No. Antibiotics prevent rheumatic fever but do not prevent post-streptococcal glomerulonephritis.
What is quinsy?
A peritonsillar abscess: infection above and lateral to the tonsil, mostly in children over 10, with one-sided tonsil swelling, trismus, drooling and a muffled hot-potato voice; it needs antibiotics and aspiration.