14 year old girl presents to the Emergency Department (ED) with a 4 day history of fever (38.7C), sore throat and odynophagia.
On examination, she appeared comfortable but was pale, had lymphadenopathy to her anterior cervical chain and was pyrexial at 38.7°C. Whilst she had no drooling, she had been unable to take oral fluids or analgesia due to the pain when swallowing. She was unable to fully open her mouth due to pain, so an initial examination of her throat was unsuccessful. Remainder of examination was normal.
Initially, she was prescribed soluble paracetamol and Difflam and a fluid challenge was given. Following this the patient was then able to open their mouth allowing a full examination which revealed a coated tongue, with bi-lateral swelling to the soft palate making it difficult to visual the palatine tonsils. The uvula appeared central, but again due to the level of inflammation examination was difficult.
Following the history and examination a diagnosis was difficult to establish as to whether the patient had severe tonsillitis or bi-lateral peritonsillar abscess.
Acute throat infections (ATI) is a term which encompasses acute pharyngitis and acute tonsillitis. It can be extremely difficult to differentiate between them clinically and severe presentations can require hospital admission. Rarely, complications such as peri-tonsillar abscess (PTA) or Quinsey can develop, which accounts for 3–5 hospital admissions per 100 000 children in England (Koshy et al 2012). These may require surgical interventions such as incision and drainage, however these procedures are infrequent in the paediatric population (Koshy et al 2012).
A paper by Choby (2009) aims to differentiate between bacterial and viral tonsillitis. They state that common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4°F (38°C), tonsillar exudates, and cervical adenopathy. In contrast, the presence of cough, coryza and diarrhoea are more common with viral pharyngitis. Although the paper supports the use of diagnostic tests which include throat culture as the diagnostic standard along with rapid antigen detection testing, these are not readily available the ED clinician. Windfuhr (2016) additionally states that there is no single parameter whichcan distinguish between either viral or bacterial tonsillitis, nor to speciﬁcally diagnose group A beta-haemolytic streptococci (GABHS) tonsillitis.
There are thankfully several guidelines that can inform the ED clinician in their decision making and when to treat tonsillitis. The Centor score is probably the most familiar and used in both primary and secondary care which offers consistency around the debate of antibiotic prescribing. The Centor score is an appropriate screening method for acute tonsillitis but limited to patients of at least 15 years of age (Windfuhr 2016). The modiﬁed Centor score, as suggested by McIsaac et al (1998) corrects for age, and therefore can be used in adults as well as in children. For patients with a score of 3 and more (Centor or McIsaac), a rapid test or culture should be considered, if relevant. This is not suggested in patients with a score of 2 and less (except if patients present with a persisting illness or unilateral ﬁnding).
Modified Centor Criteria
|History of fever||+1|
|Tender anterior cervical adenopathy||+1|
|Absence of cough||+1|
|Age <15 add 1 point||+1|
|Age >44 subtract 1 point||-1|
The National Institute of Clinical excellence (2008) also support the use of the Centor score and advise the administration of antibiotics when the Centor score is 3 or above. Interestingly the British Medical Journal (2016) offer guidance on best practice in relation to the treatment of antibiotics using the Centor criteria. They suggest that if 3 or 4 of the criteria are met then the positive predictive value is 40 – 60%, the absence of 3 or 4 of the criteria offer a negative predictive value of 80%. In contradiction to Windfuhr (2016) the BMJ have also produced a Streptococcal score card offering an indication of the likelihood of a sore throat being attributed to bacterial infection with GABHS. The criteria are -:
- Age 5 to 15 years
- Season (late autumn, winter, early spring)
- Fever (≥38.3°C [≥101°F])
- Cervical lymphadenopathy
- Pharyngeal erythema, oedema, or exudate
- No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea, or cough).
If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of children; if 6 of the criteria are met, a positive culture is predicted in 75% of children.
So how does the treatment change when considering an infection of not only the tonsils but also the peri-tonsillar region?
There are two terms used the describe infection of the peri-tonsillar region which are peri-tonsillar cellulitis(PTC) and peri-tonsillarabscess (PTA, also called Quinsy). PTC is an inflammatory reaction of the tissue between the palatine tonsil and the pharyngeal muscles but is not associated with a collection of pus (Roberts 2001). PTA is a collection of pus located between the capsule if the palatine tonsil and the pharyngeal muscle (Roberts 2001). If left untreated then they can prove fatal either due to pharyngeal obstruction or the extension of the infection to other structures of the neck and larynx (Chowdry and Bricknell 1992).
A study by Roberts (2001) surrounding the complexities of diagnosing PTC and PTA in children found that younger children (mean age of 10.8) were more likely to be diagnosed with PTC and older children (mean age of 15) were more at risk of Quinsy. While dysphagia and drooling tended to be discriminators for an abscess, and trismus was more common in those with cellulitis, patients presenting with either process had quite similar clinical scenarios. In the end, the only way to tell the two conditions apart was to re-evaluate the condition after 24 hours of treatment.
A retrospective study by Quereshi et al (2015) found that whilst there had been a decrease in tonsillectomies during the years 2000-2009, there had been an increase in the number of paediatric PTA’s that had undergone surgical drainage. The study had also discussed an increase in hospital admission rates of 33% in the UK for acute throat infections and a decrease in tonsillectomy rates, but this was not defined by age, or how these cohorts of acute throat infections had been managed.
There is still much debate on the consistency and frequency of antibiotic prescribing for acute throat infections, however in the ED in acute or severe cases, being able to clinically diagnose acute tonsillitis, PTA or PTC remains a challenge. Clinical acumen, use of the Centor score, triggers for sepsis and its management should guide the clinician in whether the child can be managed as inpatient or outpatient. It remains vital though as a clinician to be able to recognise when a patient has a potentially life threatening quinsy and to react accordingly.
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Choby, B, A,. 2009. Diagnosis and Treatment of Streptococcal Pharyngitis. American Family Physician. 79, 5, 383-390.
Chowdhury, C,R,. Bricknell, B,M,. 1992. The management of quinsy—a prospective study.The Journal of Laryngology and Otology. 106, pp. 986-988
Koshy, E,. Murray, J,. Bottle, A,. Aylin,P,. Sharland, M,. Majeed, A,. Saxena, S,. 2012. Signiﬁcantly increasing hospital admissions for acute throat infections among children in England: is this related to tonsillectomy rates? Arch Dis Child. 97:1064–1068.
McIsaac WJ, White D, Tannenbaum D, Low DE (1998) A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 158: 75–83.
National Institiute for Health and Clinical Excellence. 2008. Respiratory Tract Infections – antibiotic prescribing. Clinical Guideline 69. https://www.nice.org.uk/guideline/cg69 (accessed 09.03.2017)
Quereshi, H,. Ference, E,. Novis, S,. Pritchett, C,. Shinatani Smith, S,. Schroeder, J,.2015 Trends in the management of pediatric peritonsillar abscess in the U.S. 2000-2009. International Journal of Pediatric Otorhinolaryngology. 79. 527-531.
Roberts, J,R,. 2001 Emergency Department Approach to Peritonsillar Cellulitis . Emergency Medicine News. 23, 2, 16-20.
Windfuhr, J,. Toepfner, N,. Steffen, G,. Waldfahrer, F,. Berner, R,. 2016. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. European Archive Otorhinolaryngol 273:973–987.