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Despite established guidelines for group A Streptococcus pharyngitis diagnosis and treatment, pediatricians are overtreating and mistreating sore throat in children. (1) This results in unnecessary antibiotic use and contributes to antimicrobial resistance, increased health care costs, and risk for adverse drug reactions. In addition, controversy exists among pediatricians regarding the indications for tonsillectomy and adenoidectomy in children.After completing this article, readers should be able to:Sore throat is a common complaint in children and adolescents. Most cases of pharyngitis are viral and self-limited. Group A Streptococcus (GAS) pharyngitis is the only commonly occurring infectious pharyngitis in which antimicrobial treatment is indicated. Treatment of GAS decreases the risk of acute rheumatic fever (ARF), suppurative complications and transmission of disease, and provides symptomatic relief. GAS pharyngitis accounts for 20%-30% of office visits for sore throats in children. (2) Infection typically occurs in school-age children and adolescents, and is uncommon in children younger than 3 years. GAS pharyngitis occurs most commonly in the winter and early spring months and is spread through contact with oral and respiratory secretions of other humans. The relative predominance of the common viral causes varies by season with predominantly cold viruses (eg, rhinovirus, coronavirus, respiratory syncytial virus, parainfluenza) in the winter and enteroviruses in the warmer months.The signs and symptoms of pharyngitis due to GAS and other pharyngitides overlap and there is no universally agreed upon algorithm to guide clinicians’ decision to forgo GAS testing. However, the history and physical examination should directly focus on differentiating between viral etiologies and GAS to guide the need for GAS testing. Fever, throat pain, and pharyngeal and/or tonsillar exudates are nonspecific findings. Concomitant cough, rhinorrhea, hoarseness, diarrhea, and/or the presence of oropharyngeal vesicles are highly suggestive of a viral etiology. Although nonspecific in isolation, the presence of scarletiniform rash, palatal petechiae, pharyngeal exudate, vomiting, and tender cervical nodes in combination increase the likelihood of GAS to greater than 50%. (3) Stridor, neck stiffness, or head tilt, limitation of neck movement, drooling, respiratory distress, or a toxic appearance are concerning for more serious diseases such as epiglottitis, retropharyngeal abscess, or Lemierre syndrome. Click on the following link, http://pedsinreview.aappublications.org/content/38/2/81.figures-only, for a video demonstration of the oropharyngeal examination technique.Recognized viral etiologies of acute pharyngitis include adenovirus, rhinovirus, Epstein-Barr virus (EBV), parainfluenza, influenza, coxsackie, measles, and herpes simplex virus. Mycoplasma pneumonia is a common bacterial cause of pharyngitis. Pharyngitis can be a predominant symptom of acute retroviral syndrome secondary to infection with human immunodeficiency virus (HIV). Sexually active adolescents may also present with an acute pharyngitis caused by infection with Neisseria gonorrhea. Mononucleosis, commonly caused by EBV or cytomegalovirus (CMV) infection, often presents with an exudative pharyngitis, tender cervical lymphadenopathy, and constitutional symptoms. Immunocompromised patients are susceptible to opportunistic infections such as pharyngeal candidiasis (thrush) caused by Candida albicans infection. Corynebacterium diphtheria and Haemophilus influenzae b are uncommon causes of acute pharyngitis in developed countries but are possible in recent immigrants and unvaccinated children. A person infected with Francisella tularensis from ingestion of undercooked wild game meat may complain of pharyngitis. Traumatic or chemical pharyngitis can result from foreign body or caustic ingestion, respectively. Table 1 lists the full differential diagnosis and Table 2 infectious pathogens involved.Pharyngitis is a clinical diagnosis; additional testing should be focused on identifying children with the treatable causes of pharyngitis, atypical symptoms, and prolonged illness. Children and adolescents with signs and symptoms of acute pharyngitis in the absence of overt viral symptoms should be tested for GAS pharyngitis either with throat culture or rapid antigen detection test (RADT). Throat culture is the gold standard and most cost-effective test, with a sensitivity of 90% to 95%. The RADT has a specificity of 95% but variable sensitivity (ie, false-negative results occur).(2) A negative RADT should therefore be followed by throat culture for confirmatory testing. The sensitivity of throat culture and RADT are dependent on proper specimen collection that requires vigorous swabbing of both tonsils and posterior pharynx without touching the tongue or buccal mucosa. Serologic tests are not routinely used in the diagnosis of acute GAS pharyngitis because antibody response does not occur until 2 to 3 weeks after initial infection. In general, testing for GAS in children younger than 3 years and in asymptomatic family or classroom contacts is not recommended.The judicious and targeted use of the RADT is warranted. The ease of use and availability of the RADT in children with complaints of sore throat can lead to overuse in children with viral pharyngitis. This can, in turn, lead to the identification and unnecessary treatment of GAS carriers who are exposed to unnecessary courses of antibiotics. Standing orders for ancillary personnel to perform a RADT in every child with a chief complaint of sore throat before a clinical evaluation to assess for a viral etiology should be avoided.Additional testing may be useful to diagnose non-GAS infectious tonsillopharyngitis. The need for additional testing should be individualized based on clinical signs and symptoms. With respect to EBV infection, in many cases, a clinical diagnosis can be made. However, in cases of diagnostic uncertainty and when an explanation is desired for persistent symptoms, a definitive diagnosis may be sought. There are several approaches, but no consensus exists regarding a diagnostic algorithm for EBV infection. The usefulness of the available tests varies with the duration of illness and age of the patient. In children older than 4 years who have symptoms for 2 weeks, a positive heterophile antibody test in conjunction with an absolute increase in the number of atypical lymphocytes is often considered diagnostic. The EBV viral capsid antigen immunoglobulin M test may be used in younger patients. If Neisseria gonorrhea is suspected, nucleic acid amplification testing or culture on special media (Thayer-Martin or Martin-Lewis medium) is necessary for diagnosis. Specimens should be obtained using swabs with plastic or wire shafts and rayon, polyester textile fabric, or calcium alginate tips because wood shafts and cotton tips may be toxic to the organism. (4) If acute retroviral syndrome is suspected, the combination HIV antibody/antigen test should be performed because it is the most sensitive immunoassay for HIV. Serologic testing is used to diagnose tularemia and should be ordered in patients with exposure history.Early antibiotic therapy for GAS pharyngitis (up to 9 days after illness onset) has been shown to prevent ARF, decrease symptom duration and severity, and reduce suppurative complications. (2) Whether antibiotic therapy reduces the risk of poststreptococcal glomerulonephritis (PSGN) is uncertain. Oral penicillin V is the treatment of choice for GAS pharyngitis given its proven efficacy, narrow spectrum, safety, and low cost. Oral amoxicillin may be used as a more palatable alternative that is equally effective. A single dose of intramuscular penicillin G benzathine can be used for patients who cannot tolerate a 10-day course of oral therapy, in patients with a history of poor compliance to oral therapy, and in those at increased risk for ARF. First-generation cephalosporins are an acceptable alternative for patients who report a penicillin allergy but do not have a history of anaphylaxis. Macrolides or clindamycin are acceptable alternatives in patients with a history of anaphylactic reactions to penicillin or with an unclear allergy history. Sulfonamide antibiotics, tetracyclines, and fluoroquinolones should not be used for treatment of GAS infections. Improvement is expected by 3 to 4 days after antibiotic initiation. Children are no longer considered contagious after 24 hours of treatment and may return to school. Table 3 provides specific antibiotic dosing information. (5)Treatment of viral pharyngitis is symptomatic. Systemic analgesics are the mainstay of treatment and may be used for moderate to severe throat pain (nonsteroidal anti-inflammatory drugs NSAIDs, acetaminophen). Although glucocorticoids may reduce pain from sore throat, there is limited high-quality evidence for this indication and, therefore, their use is not recommended in children at this time. Topical therapies include oral rinses, sprays, and lozenges. Oral rinses containing salt water have not been systematically studied. Rinses containing topical anesthetics (eg, lidocaine) and topical NSAIDs (eg, benzydamine hydrochloride) have been studied systematically, mainly in patients with postoperative throat pain or throat pain because of chemotherapy-induced mucositis. The current evidence base is insufficient to draw conclusions. Sprays and medicated lozenges containing local anesthetics (benzocaine, phenol) are no more effective than candy at relieving throat pain and are not recommended because of the risk for methemoglobinemia and allergic reactions.Asymptomatic patients with cultures that remain positive after a full course of treatment are likely carriers. Carrier status may be as high as 25% of asymptomatic children in high prevalence areas. (2) Carriers are not at increased risk for ARF or suppurative complications. Carriage of GAS can persist for many months but the risk of transmission from a carrier to another person is low. (2) A “test of cure” for GAS and repeated antimicrobial courses are, therefore, not indicated. Although it is possible that the child with frequent sore throats and positive cultures for GAS has recurrent GAS infections, it is more likely the child is a GAS carrier with recurrent viral illnesses. Compliance with oral therapy should be assessed, and the decision to treat should be made based on clinical findings and epidemiologic factors (patient age, season, history of contact with a person with GAS infection, family history of ARF or PSGN). Because it is not possible to differentiate a carrier state from an active GAS infection in real time, treatment is often chosen. The best strategy to avert this is to avoid overtesting and retesting. Exceptions to this rule are a personal or family history of ARF, community outbreaks of ARF or PSGN, GAS pharyngitis outbreaks in “closed” communities such as a daycare center, and “ping-pong” episodes of GAS pharyngitis among family members. (2) Children in these exceptional circumstances should be retested and re-treated despite suspicion for carrier status. GAS carriage is difficult to eradicate with conventional antimicrobials. Oral clindamycin at a dose of 30 mg/kg per day divided into 3 doses (maximum 900 mg/day) for 10 days is the recommended treatment for GAS carriers. (2)Peritonsillar cellulitis and abscess are among the most common deep space neck infections in children and adolescents. Peritonsillar abscess (PTA) is defined as a suppurative infection of the tissue between the palatine tonsil capsule and the pharyngeal muscles. The term peritonsillar cellulitis is used when tissue inflammation is present without a discrete pus collection. According to one US study, the incidence of PTA was 9.4 per 100,000 children younger than 20 years in 2009. (6) Its incidence peaks in adolescence with an average age of 13.6 years. (6) Most PTAs are polymicrobial, with Streptococcus and Fusobacterium species being the most common etiologic agents.Patients with PTAs most commonly present with sore throat and fever. Other symptoms include dysphagia, odynophagia, voice change, drooling, and trismus (due to spasm of the internal pterygoid muscle). Physical examination signs include uvular deviation toward the contralateral side, ipsilateral tonsillar bulging, the presence of a tender neck mass, and cervical and/or submandibular lymphadenopathy. Patients may appear anxious or irritable and be unable to take anything by mouth. Younger children are less likely to complain of sore throat and are more likely to present with a neck mass. (7) Clinicians should suspect PTA in patients with symptoms of pharyngitis who have a prolonged or progressive course. Untreated PTA can lead to serious complications such as airway obstruction, aspiration pneumonia, carotid artery pseudoaneurysm or rupture with resulting sepsis and hemorrhage, and septic thrombophlebitis of the internal jugular vein (Lemierre syndrome). The differential diagnosis is similar to that for tonsillopharyngitis (Table 1).Diagnosis of a PTA is largely made on clinical suspicion, and laboratory evaluation is usually unnecessary. Similarly, imaging studies are generally not required. If the diagnosis is in question, intraoral ultrasonography was recently found to be an effective tool to determine the presence or absence of a fluid collection. Although contrast-enhanced computed tomography (CT) of the neck is also effective in determining the presence of a PTA, its use should be avoided if possible because of the close proximity of radiation-sensitive tissues such as the thyroid gland. Clinicians are encouraged to consult the American College of Radiology Appropriateness Criteria before considering CT for this indication. (8) According to the criteria, any recommended imaging studies for children who present with neck masses must take into consideration the risk of sedation and radiation dose. CT of the neck with contrast has a relative radiation level of 0.3 to 3 millisievert compared to zero radiation risk with ultrasonography. However, CT of the neck with contrast may be appropriate if there is concern for malignancy or a deep neck abscess that may require surgical drainage.Because PTA is a disease process found more commonly in adolescents, drainage while awake is considered the treatment of choice. This can often be performed under local anesthesia in the emergency department or in the office of a pediatric otolaryngologist. For younger or uncooperative patients, general anesthesia may be required. Controversy exists regarding needle aspiration versus incision and drainage. With the patient in an upright topical or anesthesia is and an needle is used to and the abscess usually in the to the tonsillar If an incision is to be it is at the of in a to A can be used to the abscess and additional usually an should perform these of any should be Patients can usually be after the with oral antibiotic therapy for to 10 or clindamycin are while culture for include the need for due to poor oral pain no and of complications after drainage such as severe or respiratory secondary to aspiration of abscess into the In the tonsillectomy in the presence of a was used as a drainage this has largely been as a retropharyngeal abscess is a suppurative deep neck infection that occurs in the space from the base of the to the posterior between the posterior pharyngeal and The retropharyngeal space a of nodes that the and posterior The of retropharyngeal abscess is to an respiratory infection with resulting of the retropharyngeal nodes and abscess The abscess may also secondary to from an foreign body or in the posterior According to one US study, the incidence of retropharyngeal abscess has increased from to per 100,000 children younger than 20 years from to is among children younger than years and in The of retropharyngeal is often and respiratory are the most common of retropharyngeal abscess is variable and no of symptoms and signs is diagnostic. Patients commonly present with complaints of neck pain, and Other symptoms include sore throat, odynophagia, oral drooling, and pain if there is physical examination signs include cervical lymphadenopathy, limited neck or and the presence of a neck mass. and may also be Patients may appear and and must be when these children because the of the examination can result in or airway There is also a risk of abscess For patients with signs of airway such as or the examination in the an surgical airway can be if is Untreated retropharyngeal abscess can lead to serious infectious and complications similar to those for complications include and because of the proximity of the retropharyngeal space to these The differential diagnosis causes of sore throat and airway as in Table In patients with neck pain or stiffness, the differential diagnosis should also include cervical abscess of the and diseases the diagnosis is from history and physical examination laboratory studies may not be In cases of diagnostic a may be to signs of inflammation A throat culture for GAS and a if can guide antibiotic Other tests to in patients with include and and should be for cases in which the diagnosis is in question, if is or no is after to hours of antibiotic neck is often the imaging and may of the tissues the level of the cervical greater than is considered or greater than at the level of the cervical neck has a high secondary to in and In addition, cannot differentiate between and abscess A should be obtained if is neck CT is the imaging of choice to differentiate abscess from and for 2 and However, judicious use of CT is recommended given the of radiation exposure in children. For one should CT to children who have treatment and require is generally not an neck is considering of retropharyngeal the consideration is the or positive may be for moderate airway obstruction, but or is Although this to be deep neck space infections are commonly with 24 to hours of (eg, because of infections may with For patients who to or despite antimicrobial therapy, surgical treatment should be a is used to the abscess an incision in the posterior pharyngeal For with cervical to the to the or into other neck a is generally fluid is for culture and a may be if another process is drainage by can also be considered for in difficult to should be considered for patients who to or symptoms return after a of and adenoidectomy is the most common performed in the The 2 indications for tonsillectomy are and severe recurrent throat throat infection, as defined by the is a sore throat 1 of the greater than cervical nodes or in tonsillar exudate, positive GAS RADT or infection is defined as more than episodes of severe throat infections in 1 more than episodes per for 2 or more than 3 episodes per for 3 years. 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The current generally as an acceptable treatment for have and in and of after However, is less likely in children with those of American and those who have severe at decision to with therefore, be made between the and patient family after and consideration of such as are to patients with the necessary for to take an active in the with close for and of episodes of of and/or of with are recommended for patients who do not the 4 recommended clinical decision indication for adenoidectomy is severe of severe include and must present for more than 1 and must persist despite treatment such as a of antimicrobial therapy and to infectious and allergic causes of indications for adenoidectomy include recurrent acute and media with in children who of postoperative complications after is occurs in of is as if it occurs the 24 hours after and secondary if it is more than 24 hours after is to be due to of from the tonsillar and occurs most on postoperative day to The usually but requires surgical of personal or family history of and postoperative regarding this are therefore complications occur in of may be such as increased postoperative or but may also be more or respiratory positive airway oral or airway or and have been Children with are more likely to have respiratory complications than those for other by and may also occur after Patients with and syndrome are at risk for this it occurs is most often may also occur after This presents with and through the complications of include and from the used the pain, vomiting, and are also with or without is recommended for postoperative pain with use of due to increased risk for respiratory complications with this of with any surgical there is also a risk of infection. However, the American of and antimicrobial have as a after due to the of is therefore to patients to and physical Other complications of include a of the that presents as severe neck pain and Children with are more to this The risk of with is 1 in to general, one should postoperative in children who are younger than 3 children with severe at and those with that at increased risk for postoperative respiratory complications (eg, disease, and to acute or infection, other can lead to tonsillar and In the of tonsillar it is to for such as or human of the Although syndrome is also In addition, diseases such as the are with tonsillar and (Table
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