Acute inflammation of the tonsils and pharynx. Sore throats are viral in most cases and do not require antibiotic treatment.
The bacterial tonsillitis are mainly due to streptococcus and mainly affects children between 3 and 14 years.Rheumatic fever is a severe and late complication of strep throat, common in developing countries, and can be prevented by antibiotic therapy.
One of the main objectives during the review is to identify patients who require antibiotic therapy.
– Common Signs all tonsillitis:
Sore throat and dysphagia (difficulty swallowing), with or without fever
– Specific signs depending on the cause:
Common forms:
• Angina erythematous (red throat) or pulpy erythematous (red throat and whitish coating):
This presentation is common viral and bacterial tonsillitis, other criteria must be taken into account to distinguish:
In children under 3 years, strep throat is uncommon, throat infections are almost exclusively viral.
In children between 3 and 14 years, the presence of at least 3 of the following 4 signs [absence of cough, fever above 38 ° C, at least a painful anterior cervical lymphadenopathy, presence of exudate] is in favor ‘strep throat. Conversely, the presence of cough, rhinorrhea, conjunctivitis or cervical ganglia post, in favor of viral pharyngitis.
With a more than 14 year-old patient, the probability is low strep throat.
Infectious mononucleosis (IM) due to Epstein-Barr virus should be suspected in an adolescent or young adult with severe fatigue with diffuse lymphadenopathy, splenomegaly often associated.
Erythematous angina or erythematous pultaceous can also be caused by gonorrhea or occur as part of primary HIV infection.
In these cases, it is mainly the story of the patient that can suggest the diagnosis.
• pseudomembranous angina (red throat covered with a very false adherent membrane): see diphtheria, page 55
Less common forms:
• Angina vesicular (small vesicles bouquets on the tonsils): always viral (coxsackie virus or primary herpetic infection).
• necrotizing ulcerative Angina: syphilitic chancre of the tonsil, in indurated edge, painless; tonsillar ulcer soft to the touch in a patient with poor dental hygiene, halitosis (Vincent angina).
– Local complications:
tonsillar abscess: fever, severe pain, muffled voice, trismus (involuntary contractions of the jaw), unilateral deviation of the uvula.
Treatment:
– In all cases: treatment of fever and pain (paracetamol PO, page 26)
– Viral tonsillitis usually heal spontaneously within a few days (or weeks for MNI): no antibiotic therapy.
– Choice of antibiotic for strep throat:
• If available injecting equipment disposable, benzathine benzylpenicillin is the treatment of choice: the resistance of Streptococcus penicillin are rare, this is the only antibiotic that has demonstrated efficacy in reducing the incidence of rheumatic fever and treatment is administered in a single dose.
benzathine benzylpenicillin IM
Children under 6 years: 600 000 IU single dose
Children over 6 years and adults: 1.2 MIU single dose
• Penicillin V is the oral standard treatment, but this treatment may be an issue of compliance because of its duration.
phenoxymethylpenicillin (penicillin V) PO for 10 days
Children under one year: 250 mg / day in 2 divided doses
Children from 1 to 5 years: 500 mg / day in 2 divided doses
Children 6 to 12 years: 1 g / day in 2 divided doses
Adult: 2 g / day in 2 divided doses
• The PO amoxicillin is a possible alternative treatment has the advantage of being relatively short. However, amoxicillin can cause acute skin reactions in patients with undiagnosed MNI and should be avoided when MNI has not been ruled out.
amoxicillin PO for 6 days
Children: 50 mg / kg / day in 2 divided doses
Adult: 2 g / day in 2 divided doses
• The resistance to macrolides is frequent, erythromycin and azithromycin
should be reserved for patients allergic to penicillin. The duration of erythromycin treatment with a higher risk of non-compliance. Treatment with azithromycin to the advantage of being short.
erythromycin PO for 10 days
Child: 30 to 50 mg / kg / day divided in 2 or 3 doses
Adults: 2 to 3 g / day in 2 or 3 doses
or
azithromycin PO for 3 days
Children: 20 mg / kg / once daily
Adult: 500 mg / once daily
– Angina gonococcal and syphilitic: same treatment as gonorrhea and syphilis
– Diphtheria Angina: see diphtheria, page 55
– Vincent’s angina: penicillin V or erythromycin as above
– Tonsillar abscess: refer for surgical drainage