(See also Gram-Positive Cocci: Streptococcal Infections.)

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Symptoms may include sore throat, dysphagia, cervical lymphadenopathy, and fever. 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.

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.

Tonsillopharyngitis of all varieties constitutes about 15% of all office visits to primary care physicians.

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.

In about 30% of patients, the cause is bacterial. Group A β-hemolytic streptococcus (GABHS) is most common (see Gram-Positive Cocci: Streptococcal Infections), but Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia pneumoniae are sometimes involved. Rare causes include pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea.

GABHS occurs most commonly between ages 5 and 15 and is uncommon before age 3.

Symptoms and Signs

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. 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.

Acute Tonsillitis

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. 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 (rare in the US).

Because GABHS requires antibiotics, it must be diagnosed early. Criteria for testing are controversial. Many authorities recommend testing with a rapid antigen test or culture for all children. 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

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.

Clinical Calculator

Treatment

• Symptomatic treatment
• Antibiotics for GABHS
• Tonsillectomy considered for recurrent GABHS

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, dexamethasoneSome Trade Names
DECADRON
DEXASONE
HEXADROL
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10 mg IM), which may help shorten symptom duration. Topical analgesics are available as lozenges and sprays; ingredients include benzocaineSome Trade Names
AMERICAINE
ANBESOL
HURRICAINE
ORAJEL BABY TEETHING
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, phenolSome Trade Names
CEPASTAT
CHLORASEPTIC GARGLE
ULCEREASE
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, lidocaineSome Trade Names
XYLOCAINE
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, and other substances. These topical analgesics can reduce pain but have to be used repeatedly and often affect taste. BenzocaineSome Trade Names
AMERICAINE
ANBESOL
HURRICAINE
ORAJEL BABY TEETHING
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used for pharyngitis has rarely caused methemoglobinemia.

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 (see also Gram-Positive Cocci: Pharyngitis). AmoxicillinSome Trade Names
AMOXIL
TRIMOX
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is effective and more palatable if a liquid preparation is required. 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 clindamycinSome Trade Names
CLEOCIN
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.

Treatment may be started immediately or delayed until culture results are known. If treatment is started presumptively, it should be stopped if cultures are negative. Follow-up throat cultures are not done routinely. They are useful in patients with multiple GABHS recurrences or if pharyngitis spreads to close contacts at home or school.

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.

Numerous effective surgical techniques are used to perform tonsillectomy, including electrocautery dissection, microdebrider, radiofrequency coblation, and sharp dissection. Significant intraoperative or postoperative bleeding occurs in < 2% of patients, usually within 24 h of surgery or after 7 days, when the eschar detaches. Patients with bleeding should go to the hospital. If bleeding continues on arrival, patients generally are examined in the operating room, and hemostasis is obtained. Any clot present in the tonsillar fossa is removed, and patients are observed for 24 h. Postoperative IV rehydration is necessary in ≤ 3% of patients, possibly in fewer patients with use of optimal preoperative hydration, perioperative antibiotics, analgesics, and corticosteroids. Postoperative airway obstruction occurs most frequently in children < 2 yr who have preexisting severe obstructive sleep disorders and in patients who are morbidly obese or have neurologic disorders, craniofacial anomalies, or significant preoperative obstructive sleep apnea. Complications are generally more common and serious among adults.

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.

Last full review/revision October 2012 by Clarence T. Sasaki, MD

Content last modified November 2012