Pharyngitis

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This is usually caused by a Group A (strep pyogenes), but can be caused by groups C and G. It usually occurs in children ages 5-10 with peak incidence in the first few years of school. The transmission is through direct contact via respiratory or nasal secretions. There can be food or water borne outbreaks and the incubation period is 2-4 days. We have a great deal of strep throat in the Delta as well as peritonsillar abscesses.

Clinical onset in older children and adults is abrupt onset of ST, HA, malaise and feverish.

The pharynx is usually red and edematous with hyperic/hyperplastic tonsils with white exudate, tender lymphadenopathy, and T>101. Symptoms usually last 3-5 days. It may develop into a peritonsillar abscess – with an enlarged asymmetrical tonsil – exquisitely tender. This may need to be drained by needle aspiration. Exudative pharyngitis in children less than 3 is rarely streptococcal. Type specific antibodies are seen in 4-8 weeks and protect against infection with organisms of the same M-type.

Treatment

Positive strep in a patient with no allergies can be treated with LA bicillin x 1 – with age appropriate dosing. If the family requests PO treatment – it is now recommended to give penicillin – 750mg po Q day x 10 days. You can use the daily dosing to increase compliance.

Evaluate for dehydration – as some of our severely ill patients require IV fluids – as they are so dehydrated due to decreased oral intake from the pain. If a peritonsillar abscess looks likely – it will need to be drained with needle aspiration – using hurricane spray for numbing. Ask for assistance with this as it can be tricky.

Be aware that there can many complications from strep – and a review of common complications and management is important.

Recurrent Strep Infections

  • Review chart for recurrent RST. If patient meets Diagnostic Criteria and parent desires, refer to ENT for tonsillectomy.
    • Order: "Refer to ENT External - Tonsillectomy"
    • Patient must desire procedure in the Next 6 weeks
    • Diagnostic Criteria (also listed in referral order)
      • Three ST/yr x3 yrs w/ Centor criteria met
      • 7 ST in past 12 mo w/Centor criteria met
      • Recurrent tonsillitis w/ complication
      • Repeat hospitalization for tonsillitis
      • Sleep disorder breathing 2/2 hypertrophy
    • If the patient does not meet these criteria, but you or the parent still have concerns, consider placing a referral to ENT internal
      • Order: "Refer to ENT Internal"
      • This will put the patient on the queue to be seen by ENT in their Bethel Field Clinic, but may be several clinics before they can be scheduled as they are often full.

Resources/References


YKHC Clinical Guidelines
Common/Unique Medical Diagnoses