Cover image: Viral pharyngitis, the most common cause of a sore throat. | CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=960953

Acute Tonsillopharyngitis or sore throat is thoat pain due to acute inflammation of pharynx (pharyngitis) and tonsils (tonsillitis).

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Aetiology

Viral infections (M/C cause):

• Adenovirus
• Influenza
• Parainfluenza virus
• Enterovirus
• Epstein-Barr virus

Bacrerial infection:

• S. pyogenes esp. group A beta-hemolytic Streptococci
• Mycoplasma pneumoniae
• Candida albicans
• As disease prodrome:
  • Measles
  • Rubella

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Clinical features

• Sore throat
• Tonsils
  • Swollen and covered with exudates
• Fever
• Malaise
• Headache
• Nausea

Viral infection:

• Cough and rhinitis more common
• Gradual onset and less toxemia

Streptococcal infection:

• Enlarged cervical lymph nodes
• Acute illness with high fever
• Absence of nasal discharge or conjunctivitis

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Complications

• Acute glomerulonephritis
• Rheumatic fever
• Otitis media
• Sinusitis
• Peritonsillar and retropharyngeal abscesses
• Spread down the tracheobronchial tree:
  • Tracheobronchitis
  • Pneumonia

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Diagnosis

Investigations

• Group A beta-hemolytic Streptococcus:
  • Throat swab culture
  • Rapid antigen detection test (RADT)
• Enzyme immunoassays

Differential diagnosis

• Herpangina
  • Acute febrile illness due to group A Coxsackie virus
  • Dysphagia, sore throat and papulovesicular lesions surrounded by erythema over the tongue, pharynx, anterior tonsillar pillars and soft palate.
  • Pharynx appears congested.
• Diphtheria
  • Moderate fever, severe toxaemia, sore throat and membrane formation over the fauces or palate.
• Pharyngoconjunctival fever
  • Fever, conjunctivitis, pharyngitis and cervical lymphadenitis due to infection with adenovirus type 3
• Infectious mononucleosis
  • Lymphadenopathy, morbilliform rash, hepatosplenomegaly and sometimes, aseptic meningitis

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Management

Supportive management:

• Warm saline gargles (older children)
• Sip warm tea/liquids (younger children)
• Soft food
• Symptomatic relief:
  • Oral antihistaminics
    • Chlorpheniramine or promethazine
•  Fever:
  • Paracetamol

Antibiotic therapy:

• Penicillin V (250 mg q 8-12 hr)
• Amoxycillin (30-40 mg/kg/day)
• Erythromycin (40-50 mg/kg/day)
• Cephalexin (50 mg/kg/day for 10 days)
• Azithromycin (10-12 mg/kg/ day for 5 days)
• Noncompliance:
  • Benzathine penicillin (single IM dose)

Recurrent Sore Throat

• Beta-lactamase producing bacteria:
  • Amoxycillin + clavulanic acid
  • Clindamycin
• Group A beta-hemolytic streptococcal infection:
  • Penicillin prophylaxis (3-6 months)
• > 5-6 episodes of tonsillitis in a year or tonsillar or peritonsillar abscess:
  • Tonsillectomy
    • Does not prevent recurrence of pharyngeal infection
    • Other indications:
      • Diphtheria carriers
      • Presence of retention cysts in tonsils
      • Tonsils are a focus of infection for suppurative otitis media