Tonsillopharyngitis - Acute Initial Assessment

Clinical Presentation

Clinical Features Suggestive of a Viral Etiology 

Clinical features suggestive of a viral etiology include the absence of fever, the presence of conjunctivitis, coryza, cough, diarrhea, hoarseness, malaise or fatigue, rhinorrhea, anterior stomatitis, discrete ulcerative lesions, and viral exanthem and/or enanthem.  

Clinical Features Suggestive of Group A β-hemolytic Streptococcal (GABS) Pharyngitis  

An incubation period of around 2-7 days is a clinical feature suggestive of GABS pharyngitis. Classic symptoms such as tonsillar swelling or exudates, tender anterior cervical lymphadenopathy, absence of cough, and fever of >38°C are also features suggestive of GABS pharyngitis. Other features include history of exposure, sudden onset of sore throat, pain on swallowing, petechiae on the soft palate (“doughnut” lesions), scarlet fever rash, beefy red and swollen uvula, tonsillopharyngeal inflammation and erythema with or without exudates, headache, nausea and vomiting (N/V), abdominal pain, and malodorous breath. 

Tonsillopharyngitis - Acute_Initial Assesment

History

It is important to elicit information on history of recurrent tonsillopharyngitis, peritonsillar abscess, drug allergies, and possible sources of exposure.

Physical Examination

The patient is examined for fever, tonsillar swelling, exudates, and cervical lymphadenitis.

Diagnosis or Diagnostic Criteria

Conditions Where Lab Tests for GABS are Not Available or Not Practical  

Antibiotics will not be needed for every patient that presents with sore throat. If the clinical condition is severe of GABS is suspected, antibiotic treatment should be given. The Modified Center score or FeverPAIN can be used to determine if a patient needs lab tests (throat swab or rapid antigen test [RADT]) or empiric antibiotic therapy. A score of 0-1 does not require testing or antibiotic therapy. Patients with a score of 2 or 3 require testing; positive results warrant empiric therapy. A score of ≥4 is at high risk of GABS and empiric therapy is considered. 

Clinical Scoring Systems  

Clinical scoring systems are used to aid in clinical decision-making by identifying patients with low probability of having GABS infection to avoid unnecessary testing and antibiotic use. 

Centor Criteria  

The Centor criteria is used to assess the susceptibility to GABS infection based on the patient’s age and symptoms. The results may assist in the detection to start antibiotic treatment.

The Centor criteria uses a point system where the following signs and symptoms are given 1 point each:

• Fever (>38°C or >100.4°F)
• Absence of cough
• Tender anterior cervical lymph node
• Tonsillar exudates or swelling
• Age 3-15 years
• Age ≥45 years (minus 1 point)

Modified total risk based on total acute tonsillopharyngitis score:

FeverPAIN Score  

The FeverPAIN score may be used to assess the need to start antibiotic treatment as well as the severity of throat pain.  

It uses a point system where the following signs and symptoms are given 1 point each:

• Fever during the previous 24 hours
• Exudates on the tonsils
• Presentation to a physician within 3 days after onset of symptoms
• Severely inflamed tonsils
• Absence of cough or coryza

Total risk based on total acute tonsillopharyngitis score:

High results may indicate streptococcal infection, but results should be correlated with Centor criteria score.