Group B
Acute Tonsillopharyngitis
Case Scenario
Abid Ahmed Faleel
12 year old female presents with a sore throat and cough for past few days.
References:
https://www.testtargettreat.com/en/home/educational-resources/case-studies/strep-a-pharyngitis-case-study.html
Profile
● Name: Lisa
● Age: 12 years old
● Gender: Female
● Address: n/a
● Date of admission: 18/02/2021
● Informant: Mother (reliable)
Chief Complaints
Sore throat and cough for past few days
History of Presenting Illness
Along with her sore throat and cough, she has had some hoarseness in her voice over the past few days
and subjective sweats but no documented fever. She has a history of seasonal allergies in the fall, and
takes loratadine only during that season. Upon review of systems, she complains of isolated throat pain,
without any rhinorrhea, sinus pressure, or headache. Her mother has been taking her temperature at
home, and they have fluctuated from 36.5-37.2 deg C.
Systemic Review
● N/a
Past History
● Seasonal allergies in the fall but managed with loratadine.
Birth History
N/a
Developmental History
N/a
Immunization
N/a
Nutritional History
N/a
Family History
N/a
Socioeconomic History
N/a
General Physical Examination
● General Appearance: relatively comfortable, healthy child
● Temperature: 37.2oC
● Heart Rate: 115 bpm
● Respiratory Rate: 18 bpm
● Blood Pressure: 110/76 mmHg
● Oxygen Saturation: 100% on room air
General Physical Examination cont'd
● CNS: Normal for age
● HEENT: Pupils equally round and reactive to light and accommodation, no sinus
tenderness, enlarged tonsils
● Neck: Supple, mild lymphadenopathy
● RS: Normal breath sounds
● CVS: Regular rate and rhythm, no murmurs, rubs, or gallops
● GI: Non-tender, non-distended
● Legs: No edema
● Skin: No rashes
Diagnosis and management
● Acute tonsillopharyngitis
● Prescribed ibuprofen for inflammation and subjective fevers
● Pt. was asked to drink plenty of fluids and rest
● Amoxicillin to be prescribed if culture returned positive;
● Culture returned negative after 48hrs
● Pt. Symptomatically improved after 2 days
Topic discussion
Aminath
References:
Nelson essentials of pediatrics (7th ed.).Karen J. Marcdante, MD, Robert M. Kliegman, MD (page 347-349)
https://emedicine.medscape.com/article/225243-treatment#d6
Introduction
Pharyngeal inflammation causes cough, sore throat, dysphagia, and fever. If involvement of the tonsils is
prominent, the term tonsillitis or tonsillopharyngitis is often used.
One of the leading causes of pediatric OPD visits.
Epidemiology
● ⅓ rd of upper respiratory tract infections: primary symptom is sore throat
● Before 2 to 3 years of age : strep pharyngitis uncommon
● Young school going age : strep pharyngitis incidence increase
● Adolescence and adulthood : decline
● Peak in winter and early spring
Etiology
Clinical features
Streptococcal pharyngitis
● Prominent sore throat ● Pharynx: distinctly red
● Moderate to high Fever ● Tonsils: enlarged and covered with a yellow, blood tinged exudate.
● Headache ● soft palate and posterior pharynx: There may be petechiae or doughnut-shaped
● Nausea lesions
● Vomiting ● Uvula- may be red, stippled, and swollen.
● Abdominal pain ● Anterior cervical lymph nodes: enlarged and tender to touch.
● some patients exhibit the stigmata of scarlet fever: circumoral pallor, strawberry
tongue, and a fine diffuse erythematous maculopapular rash that has the feeling of
goose flesh.
Clinical features
Viral pharyngitis
● More gradual onset of symptoms
● Rhinorrhea
● Cough
● Diarrhea
● Conjunctivitis
● Coryza
● Myalgia and fever maybe mild or absent
● Gingivostomatitis: characteristic of herpes simplex virus-1
● Herpangina: enteroviral infection
Complications
1. group A streptococcal pharyngitis
● local suppurative complications
parapharyngeal abscess
other infections of the deep fascial spaces of the neck
● nonsuppurative complications
acute rheumatic fever
acute postinfectious glomerulonephritis.
2. Viral respiratory tract infections, including infections caused by influenza A, adenoviruses,
parainfluenza type 3, and rhinoviruses, may predispose to bacterial middle ear infections.
Investigations
Distinguish pharyngitis caused by group A streptococcus from pharyngitis caused by nonstreptococcal
(usually viral) organisms.
● Rapid streptococcal antigen test
● Throat culture (Gold standard)
Sometimes both done to improve diagnostic precision.
A negative rapid antigen test should be confirmed by a throat culture.
The predictive values of WBC count, ESR, and CRP are not sufficient to distinguish streptococcus from
non streptococcal pharyngitis.
Treatment
● Even if untreated, most episodes of streptococcal pharyngitis resolve uneventfully over a few
days.
● Some general measures:
❖maintain adequate fluid intake, warm water gargle
❖Simple analgesics/antipyretics: Paracetamol is the drug of choice for analgesia in sore
throat (aspirin not recommended because of risk of Reye’s syndrome in children)
❖NSAIDs: Ibuprofen may be used for treatment of pain & fever in sore throat (not routinely
used - risk of GI bleeding)
❖Throat lozenges, gargles (adjunctive therapy)
● Specific antiviral therapy is unavailable for most cases of viral pharyngitis. Patients with primary
herpetic gingivostomatitis benefit from early treatment with oral acyclovir.
Treatment
● Early antimicrobial therapy accelerates clinical recovery by 12 to 24
hours.
● The major benefit of antimicrobial therapy is prevention of acute
rheumatic fever. Therefore antibiotic therapy should be started
promptly in children with a positive rapid test or throat culture (or
PCR) for group A streptococcus or a diagnosis of scarlet fever.
● A variety of antimicrobial agents can be used to treat streptococcal
pharyngitis
Treatment
Tonsillectomy:
● In severe recurrent tonsillitis.
● Criteria - The number of tonsillitis episodes in the preceding 12 months determines the indication to perform
tonsillectomy or tonsillotomy. If less than 3 episodes not recommended, which means watchful waiting for 6 months is
reasonable. However, a patient who has had 6 or more episodes of tonsillitis in the preceding 12 months is considered
a candidate for tonsil surgery.
In patients with peritonsillar abscess, the following are effective treatment methods:
● Needle aspiration
● Incision and drainage
● Abscess tonsillectomy
Prognosis
Pharyngitis caused by streptococci or respiratory viruses usually resolves completely.
Prevention
Antimicrobial prophylaxis with daily oral penicillin V prevents recurrent streptococcal infections and is
recommended only to prevent recurrences of rheumatic fever.
Otitis Media
Case Scenario THANA RAJ
A parent brings her two year old son to your office because of a chief complaint of fussiness
and tugging at his right ear for the past two days.
Reference:
https://www.hawaii.edu/medicine/pediatrics/pedtext/s06c06.html
Patient’s Profile
● Name: n/a
● Age: 2 years old
● Gender: Male
● Address: n/a
● Date of admission: n/a
● Informant: n/a
Chief Complaint
● Fussiness and tugging at his right ear for the past two days
History of Presenting Illness
Patient was brought by his parent with chief complaint of fussiness and tugging at
his right ear for the past two days. He has had coughing and a runny nose for
about 5 days that has been treated with saline nose sprays and a humidifier. He
has a low-grade fever of about 101 degrees F (38.3 degrees C) axillary for the
past two days
Systemic Review
● Was not mentioned in the case
Past History
● His past medical history is significant for ear infections in the past, with his
last otitis media episode 5 months ago, treated with amoxicillin.
Birth History
● Was not mentioned in the case
Nutritional History
● Was not mentioned in the case
Developmental History
● Was not mentioned in the case
Immunization History
● His immunizations are up to date, including 13-valent pneumococcal conjugate
vaccine
Family History
● Was not mentioned in the case
Socioeconomic History
● Both parents smoke cigarettes
● He attends daycare
Drug and Food Allergy History
● Was not mentioned in the case
General Physical Examination
● General Appearance: active, alert to his surroundings and otherwise in no distress
● Vital Signs;
- Temperature: 38.4 degree celcius
- Pulse 100 beats/min
- Respiratory Rate 28 breaths/min
- Blood Pressure: 100/65 mmHg
General Physical Examination (cont.)
● Hands: Not mentioned
● Eyes: Not mentioned
● Ears: Right tympanic membrane is erythematous and bulging, with poor mobility
on pneumatic otoscopy. Left TM is clear with good mobility
● Nose: Not mentioned
● Mouth: Throat is non-erythematous
● Neck: There are small cervical lymph nodes
● Legs: Not mentioned
● Skin: Not mentioned
Systemic Examination
● Respiratory System;
- Inspection: Not mentioned
- Palpation: Not mentioned
- Percussion: Not mentioned
- Auscultation: Lungs are clear to auscultation
● The rest of the examination is normal
Diagnosis and Management
● He is diagnosed with acute right otitis media
● He is prescribed amoxicillin and acetaminophen
● His parent is told to follow up in 2 to 3 days if he is not better, and warned against
the dangers of their child to second-hand cigarette smoke
Topic discussion
Udari Pasquel
Otitis media
Acute Otitis Media Otitis Media with
(Suppurative) effusion
Due to acute infection (Secretory or
nonsuppurative otitis
media)
The two types are interrelated and middle ear effusion is a feature of both categories
Nelson’s textbook of Pediatrics 20th edition-3085
Pathogenesis
Upper airway infection causing inflammatory edema /Hypertrophied adenoids
Blockage of the nasopharyngeal end of the eustachian tube
Leads to absorption of air and negative intratympanic pressure
Negative pressure in the cavity- Reflux of nasopharyngeal bacteria(facilitated by
short,horizontal and poorly functioning ET)
Meanwhile,interruption of ventilation initiates an inflammatory response(secretory
metaplasia,mucociliary transport system compromise,effusion of fluid into tympanic
cavity)
Facilitate establishment and persistence of infections
Nelson’s textbook of Pediatrics 20th edition-3087;Nelson’s Essentials of Pediatrics 7th edition-351
Etiology Risk factors
➔ Bacteria ● Young age
● Streptococcus pneumoniae ● Lack of breastfeeding
● Haemophilus influenzae ● Breast or bottle feeding in a young
● Moraxella catarrhalis infant in horizontal position
● Group A Streptococcus ● Passive exposure to tobacco
● Smoke
● Increased exposure to infectious
➔ Viruses agents (day care).
● Rhinovirus ● Craniofacial abnormalities-cleft
● Respiratory Syncytial Virus palate
● Influenza
Recurrent Otitis Media:
● Immunodeficiency-IgA and Selective IgG
Nelson’s textbook of Pediatrics 20th subclass
edition-3086,3087 ● HIV infection
Symptoms
● In infants- fever, irritability, poor feeding,changed sleeping habits,holding or
tugging at the ear
● In older children and adolescents -fever and otalgia
● May present with otorrhea after spontaneous rupture of the tympanic membrane.
● Symptoms of a common cold occasionally.
● Sometimes hearing loss
● Balance difficulties or disquilibrium if effusion is present
Nelson’s textbook of Pediatrics 20th
edition-3088
Signs(otoscopy findings)
AOM
● Tympanic membrane- Hyperemic,buldging
● Visualization of purulent material
● Presence of effusion in the middle ear
cavity-white,yellow,amber
● Middle ear structures are obscured
● A hole in the tympanic membrane or purulent
drainage confirms perforation.
OME
● Tympanic membrane-no buldging or retracted
● Erythema slight or absent
● Air fluid levels maybe visible
Diagnosis
Nelson’s textbook of
Pediatrics 20th
edition-3088,3093
Investigations
● Tympanometry
● Tympanocentesis
● Middle ear exudate culture -may be useful in
neonates, immunocompromised patients,
and patients not responding to therapy
Nelson’s textbook of Pediatrics 20th edition-3087;Nelson’s Essentials of
Pediatrics 7th edition-352
Management(Acute Otitis Media)
➔ Antibiotics
● Less than 6 months-Even presumed episodes of AOM should be treated
● Less than 2 years-Treat all confirmed cases
● Between 6 months - 2 years-if questionable diagnosis but severe disease(fever>39C,significant
otalgia,toxic appearance)
● Children with an uncertain diagnosis who are older than 2 years of age may be observed if
appropriate follow-up can be arranged.
●
● First line treatment- Amoxicillin (80 to 90 mg/kg/day in two divided doses).
● Penicillin Allergy-cefdinir,cefuroxime,cefpodoxime,ceftriaxone
● Second line treatment(infection with β-lactamase-producing H. influenza, M. catarrhalis or
resistant S. pneumoniae-Amoxillin-clavulanate,Cefdinir,Cefurixime axetil,IM ceftriaxone
➔ Paracetamol/ibuprofen as an analgesic and antipyretic
Nelson’s textbook of Pediatrics 20th edition-3093,3094
Management(continued)
➔ Myringotomy
➔ Insertion of tympanostomy tubes
Otitis Media with effusion
➔ Watchful waiting- 3 months
➔ Myringotomy and tympanostomy tubes-if persistent after 3-6
months
➔ Adenoidectomy
Nelson’s textbook of Pediatrics 20th edition-3094,3095,3096
Complications
➔ Affecting the middle ear-
● CSOM
● Tympanosclerosis
● Cholesteatoma (cyst-like keratinized
● Atelectasis
epithelial growth),
● Adhesive OM
● Labryinthitis
● Conductive hearing loss-loss is
● Facial nerve paralysis
mild to moderate and often is
● Acute mastoiditis
transient or fluctuating
● Intracranial complications (meningitis,brain
● Affect speech and language
abscess, subdural abscess,epidural
development
abscess,focal encephalitis , venous
thrombosis,otitic hydrocephalus), .
Nelson’s textbook of Pediatrics 20th edition-3096-3100
