Acute tonsillopharyngitis

ATP

1. Acute tonsillopharyngitis Presented by Sah , Kalpana SWU- School of medicine

2. anatomy

3. TONSIL FUNCTION The tonsils participate in systemic immune surveillance. In addition, local tonsillar defenses include a lining of antigen-processing squamous epithelium that involves B- and T-cell responses.

4. DEFINITION Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both.

5. Etiology Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus , and respiratory syncytial virus), but occasionally by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV.

6. ETIOLOGY In about 30% of patients, the cause is bacterial. Group A  β- hemolytic streptococcus (GABHS) is most common (Streptococcal Infections) but Staphylococcus aureus ,   Streptococcus pneumoniae ,   Mycoplasma pneumoniae, and   Chlamydia pneumoniae  are sometimes involved.

7. etiology Rare causes include pertussis ,  Fusobacterium ,  diphtheria, syphilis, and gonorrhea. GABHS occurs most commonly between ages 5 and 15 and is uncommon before age 3.

8. Sign and symptoms Pain with swallowing is the hallmark and is often referred to the ears. Very young children who are not able to complain of sore throat often refuse to eat . High fever, malaise, headache, and GI upset are common, as are halitosis and a muffled voice. A scarlatiniform or nonspecific rash may also be present. The tonsils are swollen and red and often have purulent exudates. Tender cervical lymphadenopathy may be present.

9. Sign and symptoms Fever, adenopathy , palatal petechiae , and exudates are somewhat more common with GABHS than with viral tonsillopharyngitis , but there is much overlap. GABHS usually resolves within 7 days. Untreated GABHS may lead to local suppurative complications ( eg , peritonsillar abscess or cellulitis ) and sometimes to rheumatic fever or glomerulonephritis .

10. acute tonsillitis with exudate and erythema .

11. Symptoms Diagnosis is clinical, supplemented by culture or rapid antigen test. Treatment depends on symptoms and, in the case of group A  β- hemolytic streptococcus, involves antibiotics.

12. Grading Scale Tonsil 0: Normal tonsil Tonsil 1+: Tonsils <25% of space between pillars Tonsil 2+: Tonsils <50% of space between pillars Tonsil 3+: Tonsils <75% of space between pillars Tonsil 4+: Tonsils >75% of space between pillars

13. Complete dx ?

14. diagnosis Clinical evaluation GABHS ruled out by rapid antigen test, culture, or both Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea and cough usually indicate a viral cause.

15. diagnosis Infectious mononucleosis is suggested by posterior cervical or generalized adenopathy , hepatosplenomegaly , fatigue, and malaise for > 1 wk; a full neck with petechiae of the soft palate; and thick tonsillar exudates. A dirty gray, thick, tough membrane that bleeds if peeled away indicates diphtheria.

16. diagnosis Rapid antigen tests are specific but not sensitive and may need to be followed by a culture, which is about 90% specific and 90% sensitive. In adults, many authorities recommend using the following 4 criteria: History of fever Tonsillar exudates Absence of cough Tender anterior cervical lymphadenopathy

17. Patients who meet 1 or no criteria are unlikely to have GABHS and should not be tested. Patients who meet 2 criteria can be tested. Patients who meet 3 or 4 criteria can be tested or treated empirically for GABHS.

18. Treatment Symptomatic treatment Antibiotics for GABHS Tonsillectomy considered for recurrent GABHS

19. treatment Supportive treatments include analgesia, hydration, and rest. Analgesics may be systemic or topical. NSAIDs are usually effective systemic analgesics. Some clinicians also give a single dose of a corticosteroid ( eg,dexamethasone  10 mg IM), which may help shorten symptom duration.

20. treatment Topical analgesics are available as lozenges and sprays; ingredients include  benzocaine , phenol,  lidocaine , and other substances. These topical analgesics can reduce pain but have to be used repeatedly and often affect taste.  Benzocaine  used for pharyngitis has rarely caused methemoglobinemia .

21. treatment Penicillin V is usually considered the drug of choice for GABHS tonsillopharyngitis ; dose is 250 mg po bid for 10 days for patients < 27 kg and 500 mg for those > 27 kg.  Amoxicillin is effective and more palatable if a liquid preparation is required.

22. treatment If adherence is a concern, a single dose of benzathine penicillin 1.2 million units IM (600,000 units for children ≤ 27 kg) is effective. Other oral drugs include macrolides for patients allergic to penicillin, a 1st-generation cephalosporin, and  clindamycin .

23. Tonsillectomy Tonsillectomy should be considered if GABHS tonsillitis recurs repeatedly (> 6 episodes/yr, > 4 episodes/yr for 2 yr, or > 3 episodes/yr for 3 yr) or if acute infection is severe and persistent despite antibiotics. Other criteria for tonsillectomy include obstructive sleep disorder, recurrent peritonsillar abscess, and suspicion of cancer.

24. Key Points Pharyngitis itself is easily recognized clinically, but diagnosing the 25 to 30% of cases caused by streptococci is not. Clinical criteria (modified Centor score) can help to select patients for further testing or empiric antibiotic treatment, although some authorities recommend testing all children using a rapid antigen test and sometimes culture. Penicillin remains the drug of choice for streptococcal pharyngitis ; cephalosporins or macrolides are alternatives for patients allergic to penicillin.

25. Thank you 