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Viral pharyngitis/tonsillitis may present with fever, odynophagia, and petechial or vesicular lesions on the soft palate and tonsils. These symptoms are often associated with cough, rhinorrhea, and congestion. Viral infections typically lack tonsilar exudates and cervical adenopathy except those associated with mononucleosis, influenza, and acute retroviral syndrome. Bacterial pharyngitis, particularly Group A β-Hemolytic Streptococcus Pharyngitis (GABHS), presents with acute onset of fever, sore throat, and odynophagia. Patients often display tonsilar erythema, exudates, and tender anterior cervical adenopathy. Cough, conjunctivitis, and rhinorrhea are typically lacking.
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Diagnosis and Differential
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The Centor criteria for GABHS are (1) tonsilar exudates, (2) tender anterior cervical adenopathy, (3) absence of cough, and (4) fever. Multiple authorities recommend no antibiotic therapy for patients with 0 or 1 criteria. For patients with 2 or more criteria, a rapid antigen test is recommended, and treatment is based on the results on the rapid test. For patients with 3 or more criteria, some authorities recommend empiric treatment while others recommend rapid antigen testing. The need for throat culture to follow negative rapid tests should be individualized as the false negative rate is 5% to 10%; increased Centor scores are associated with increased likelihood of a positive throat culture after a negative rapid antigen test.
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Emergency Department Care and Disposition
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Nonbacterial causes are treated with supportive care: antipyretics, analgesics, and IV fluids if dehydrated.
GABHS: single dose of benzathine penicillin G 1.2 million units IM or penicillin VK 500 milligrams orally PO 3 to 4 times daily for 10 days. Penicillin-allergic: macrolide or clindamycin.
Dexamethasone 10 milligrams PO or IM may be considered in moderate to severe cases.
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The patients may appear ill and often complain of fever, sore throat, odynophagia, trismus, dysphagia, and potentially a muffled voice (hot potato voice). The infected tonsil is typically displaced medially, causing deflection of the uvula to the opposite side.
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Diagnosis and Differential
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Additional conditions to consider include peritonsillar cellulitis, infectious mononucleosis, retropharyngeal abscess, neoplasm, and internal carotid artery aneurysm. Diagnosis is typically made through the history and physical, but needle aspiration, CT, or US may be required for confirmation. Needle aspiration has the advantage of simultaneously confirming the diagnosis and treating the condition.
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Emergency Department Care and Disposition
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Needle aspiration (18- or 20-gauge needle) or I&D after local anesthesia.
After adequate aspiration patients able to tolerate PO, may be discharged home on antibiotics. Penicillin VK (500 milligrams PO 4 time daily) or clindamycin (300 to 450 milligrams PO 3 to 4 times daily) for 10 days.
Otolaryngology should be consulted in cases that the emergency physician feels uncomfortable in managing themselves.
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Patients often present with a 1 to 2 day history ...