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New Treatments for Sore Throat and Tonsillopharyngitis

In about a quarter of patients with a sore throat, the disorder is caused by group A streptococcal tonsillopharyngitis. Appropriate treatment of streptococcal tonsillopharyngitis reduces the occurrence of subsequent rheumatic fever, a systemic disease that affects the joints and heart and sometimes the skin, central nervous system.

Prevalence of Pharyngitis

Sore Throat Pharyngitis

Group A beta-hemolytic streptococcus (GABHS) is responsible for 10-30% of sore throat cases. It typically occurs in patients 5-11 years of age, and it is uncommon in children under 3 years old. Most cases of pharyngitis occur during the colder months. Streptococcal infections usually cold appear in late winter.

In patients who present with pharyngitis, the major goal is to detect GABHS infection because the potentially serious sequelae of rheumatic fever may result. Severe GABHS infections may cause a toxic-shock-like illness (toxic strep syndrome), bacteremia, streptococcal deep tissue infections (necrotizing fascitis), and streptococcal cellulitis.

Etiologic Causes of Sore Throat

Viral. Common cold, influenza, Epstein-Barr virus

Bacterial. Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, anaerobes, Mycoplasma pneumoniae, Candida albicans

Clinical Evaluation of Sore Throat

Presentation. GABHS infection is characterized by sudden onset of sore throat, fever, and tender swollen anterior cervical lymph nodes, typically in a child 5-11 years of age.

Cough, rhinorrhea and hoarseness.

Viral infections usually last 5 to 7 days,4 whereas streptococcal infections last slightly longer. Infectious mononucleosis (usually caused by Epstein-Barr virus) may linger.

Physical Examination

Vital signs, especially temperature should be assessed.

Streptococcal infection is suggested by erythema and swelling of the pharynx, enlarged and erythematous tonsils, tonsillar exudate.

Unilateral inflammation and swelling of the pharynx suggests peritonsillar abscess. Distortion of the posterior pharyngeal wall suggests a retropharyngeal abscess. Corynebacterium diphtheriae is indicated by a dull membrane.

The tympanic membrane should be examined for erythema.

The neck should be palpated for lymph node enlargement; tender nodes usually occur in an acute infection, whereas nontender enlargement is indicative of chronic infection.

Diagnostic Testing

Rapid streptococcal testing has a specificity of 90% and a sensitivity of 80%; the overall accuracy is 86% . A dry swab should be used to sample both the posterior wall and the tonsillar fossae, especially erythematous.

Diagnostic Approach

Patients presenting with an acute, severe episode of pharyngitis should receive a rapid streptococcal antigen test.

Antibiotic Therapy

Penicillin G benzathine (Bicillin LA).

Another treatment option is use of macrolides. Clarithromycin (Biaxin).

Penicillinase-resistant penicillins, such as dicloxacillin sodium (Dycill, Pathocil).