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In Focus: OPD Management of Tonsilitis and Pharyngitis

M3 India Newsdesk Nov 03, 2022

Acute pharyngitis/tonsillopharyngitis is one of the most frequent showing symptoms in patients presenting with OPD. Hence, this article illustrates the causes, diagnosis and management of Acute pharyngitis with the help of standard treatment guidelines 2022 published by IAP.

What is acute pharyngitis/tonsillopharyngitis?

It is an inflammation of the pharynx. Acute sore throat with or without dysphagia is classed as one of these conditions. Recurrent Acute Tonsillitis is characterised as recurrent bouts of acute tonsillitis separated by asymptomatic intervals.

Carrier state - It is characterised by a positive pharyngeal culture for group A beta-hemolytic Streptococcus Pyogenes (GABHS) in the absence of acute symptoms or antistreptococcal immunologic evidence.

Recurrent streptococcal tonsillitis - When a person has seven culture-proven episodes in one year, five infections in two consecutive years, or three infections each year for three years in a row.

The IAP has published Standard Treatment Guidelines 2022 for Acute Pharyngitis/Acute Tonsillitis. The following are the most important suggestions for the guidelines

1. Agents that cause

  1. The bulk of causal agents (70–95%) are viruses.
  2. Streptococcus beta-hemolytic group A is the most prevalent pathogen among microorganisms.
  3. Group A Streptococcal Pharyngitis is prevalent in 5–11-year-old children. 11–15% of children aged 5 years are asymptomatic group A streptococcal carriers (GAS).
  4. Generally prevalent throughout winter and spring.

2. Signs and symptoms in the clinic

  1. Sudden onset of a sore throat
  2. Discomfort and pain while swallowing
  3. Fever

3. Examination

Erythema, oedema, exudates /an enanthem (ulcers and vesicles) along with lymphadenitis. A kid exhibiting clinical symptoms of acute upper airway blockage must be evaluated for:

  • Hydration status
  • Fever
  • Oral/pharyngeal ulcers (coxsackie virus)
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Hepatosplenomegaly [Epstein–Barr virus (EBV)]
  • Scarlet-fever type rash-blanching, sandpaper-like rash, usually more prominent in skin creases also flushed face/cheeks with perioral pallor (GAS)

4. Warning signs

  • Unwell/toxic appearance
  • Respiratory distress
  • Stridor
  • Trismus
  • Drooling
  • "Hot potato" voice - (muffled voice associated with pharyngeal/peritonsillar pathology) Torticollis
  • Neck stiffness/fullness. Consider other diagnoses and/or complications of GAS pharyngitis in children who seem to be in a state of acute illness


The complications of GABHS pharyngitis include:

  1. Local suppurative complications- Parapharyngeal abscess, peritonsillar and retropharyngeal abscess, and sepsis.
  2. Nonsuppurative illnesses- Acute rheumatic fever, acute post-streptococcal glomerulonephritis, post-streptococcal reactive arthritis and possible pediatric autoimmune neuropsychiatric disorders associated with S. pyogenes (PANDAS) / childhood acute neuropsychiatric symptoms (CANS).


Diagnosis is mostly clinical. The patient's history, clinical symptoms, & laboratory values all should be taken into consideration to distinguish between viral and bacterial origin.

Distinguish between viral and bacterial origin

  1. Group A streptococcal infection- Sudden onset of sore throat, presentation in winter or early spring age 5–15 years, history of exposure to streptococcal pharyngitis, fever and headache, palatal petechiae and anterior cervical adenitis, patchy tonsillopharyngeal exudates tonsillopharyngeal inflammation.
  2. Viral infection- Conjunctivitis and viral exanthema, coryza, cough, hoarseness, and discrete ulcerative stomatitis.
  3. Group A beta- Hemolytic streptococcus pyogenes pharyngitis is confirmed using a positive rapid antigen detection test (RADT).

Rapid antigen detection test:

  • Point of care test, high specificity: 98.4% 
  • Sensitivity: 89.7% 
  • Diagnostic accuracy: 96.4%

If the RADT test is positive, a throat swab culture is not required. A throat swab culture is advised if RADT is negative and there is a high clinical suspicion of GAS pharyngitis. It is not generally advised to measure antistreptococcal antibody titers.

In cases when clinical characteristics clearly point to a viral origin, diagnostic testing is not advised. Blood cultures and routine blood testing are not recommended. The modified centor McIsaac score should be considered when deciding whether to schedule a quick test or throat swab.

McIsaac score (modified Centor score).
Symptom Score


Treatment regimens for group A streptococcal infection:

Treatment regimens for group A streptococcal (GAS) infection.

1. Patients without penicillin allergy

  • Penicillin V
  1. Oral Children: 250 mg twice / thrice daily
  2. Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days
  • Amoxicillin
  1. Oral 50 mg/kg daily in two to three divided doses (maximum = 1,000 mg)
  2. Alternative : 25 mg/kg twice daily (maximum = 500 mg) 10 days
  • Penicillin G benzathine

 Intramuscular <27 kg- 600,000 U . ≥27 kg: 1,200,000 U single dose

2. Patients with penicillin allergy

  • Cephalexin, oral 20 mg/kg/dose twice daily (maximum = 500 mg/dose) 10 days
  • Cefadroxil, oral 30 mg/kg once daily (maximum = 1 g) 10 days
  • Clindamycin, oral 7 mg/kg/dose thrice daily (maximum = 300 mg/dose) 10 days
  • Azithromycin oral† 12 mg/kg once daily (maximum = 500 mg) 5 days
  • Clarithromycin oral† 7.5 mg/kg/dose twice daily (maximum = 250 mg/dose) 10 days

Adjunctive therapy:

  1. To treat moderate-to-severe symptoms or manage a high fever, an analgesic or antipyretic (such as acetaminophen and nonsteroidal anti-inflammatory medications) may be used.
  2. It is not advised to use aspirin or more corticosteroids.

Surgical management:

Tonsillectomy is advised for those who have gone through the following:

  1. More than six instances of streptococcal pharyngitis during a 12-month period, as verified by positive culture. streptococcal pharyngitis five times in two years in a row.
  2. Despite receiving excellent medical care, there have been three years in a row with three or more tonsil and/or adenoidal infections every year.
  3. When treated with beta-lactamase-resistant antibiotics, streptococcal carrier state-related chronic or recurrent tonsillitis does not improve.

Ways to decrease your dependence on antibiotics:

  1. Utilise the patient's medical history, clinical symptoms, modified Centor score, and RADT to differentiate between viral and bacterial infection.
  2. Patients with recurrent pharyngitis with test evidence of GABHS may be chronic carriers and are susceptible to recurrent viral infections; hence, antibiotics are not advised for these patients. Effective discussion of antibiotic resistance targeted symptomatic care, and a follow-up strategy in case symptoms deteriorate.
Click here to see references


Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.

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