Paediatric Acute care Guidelines PMH Emergency Department

Tonsillitis is inflammation of the tonsils due to infection

Background

  • The majority of tonsillitis and pharyngitis is viral and only requires symptomatic treatment
  • In bacterial tonsillitis (15-30%) an important pathogen is Group A β-Haemolytic Streptococcus
  • Viruses implicated in tonsillitis and pharyngitis include rhinovirus, coronavirus, respiratory syncytial virus, adenovirus, parainfluenza, influenza, herpes simplex virus, enteroviruses and cytomegalovirus
  • Both viruses and bacteria can cause an exudative tonsillitis
  • Epstein-Barr Virus (EBV) is a common cause of exudative tonsillitis and pharyngitis
  • Diphtheria, caused by Cornebacterium diphtheriae is rare in the developed world where immunisation against this disease is routine.
  • Mycoplasma pneumoniae can be another causative bacteria. Other bacterial causes of tonsillitis are rare.
  • Both viruses and bacteria can cause a high temperature
  • Streptococcal tonsillitis is most common in school-age children, and is uncommon in children less than 3 years old
  • Rapid onset of sore throat and high fever associated with an exudative tonsillitis is more suggestive of a Streptococcal tonsillitis, especially in the absence of typical viral features

Risk factors

  • Low socio-economic status
  • Aboriginal and Torres Strait Islander

Assessment

  • It can be difficult to distinguish clinically between viral tonsillitis (majority) and bacterial tonsillitis (15-30%)
  • Viral tonsillitis is highly likely where there are other symptoms of a viral upper respiratory tract infection

History

  • Sore throat
  • Difficulty swallowing
  • Cervical lymphadenopathy
  • Fever
  • Headaches
  • Abdominal pain
  • Worsening sleep apnoea
  • Ear aches – referred pain
  • Symptoms of a viral upper respiratory tract infection: rhinorrhoea, cough, hoarseness, watery red eyes

Examination

  • Fever
  • Normal observations
  • Erythematous tonsils and pharynx with/without exudate
  • Enlarged and tender cervical lymph nodes
  • When severe there may be upper airway obstruction – stridor, drooling, signs of respiratory distress

With Epstein-Barr Virus (EBV) there is exudative tonsillitis and there may be significant malaise, hepato-splenomegaly and submandibular (and generalised) lymphadenopathy. 

Clinical features that are more suggestive of GABHS include:

  • Scarlantiniform rash
  • Soft palate petechiae – “doughnut lesions”
  • Exudate on pharynx and/or tonsils
  • Vomiting
  • Tender cervical lymphadenopathy
  • High fever
  • Absence of viral upper respiratory tract symptoms

Investigations

  • Bacterial throat swab for culture is usually not indicated. Results take 24 to 48 hours.
    • Do not delay antibiotic treatment while awaiting results

Differential diagnoses

  • Epstein-Barr Virus (Glandular Fever)
  • Croup
  • Epiglottitis
  • Peri-tonsillar abscess (Quinsy)
  • Retro-pharyngeal abscess
  • Oral thrush (Candidiasis)
  • Herpes stomatitis
  • Hand foot and mouth disease

Management

  • The vast majority of children only need symptomatic treatment
  • Supportive care includes adequate hydration and simple analgesia

Resuscitation

  • Airway: If there is airway compromise (eg: stridor) intravenous Dexamethasone (dose: 0.15mg/kg) can be used

Initial management

  • Definitive prescription should be made empirically on clinical presentation
  • Antibiotic treatment of Streptococcal tonsillitis probably only reduces the duration of symptoms by 12-24 hours
  • The main benefits of antibiotics are the prevention of suppurative complications and the prevention of post-infectious immune-mediated acute rheumatic fever
  • Antibiotics administered within 7-9 days of the illness is almost 100% successful in preventing acute rheumatic fever. Delaying antibiotics pending the throat swab result will not reduce their efficacy in preventing acute rheumatic fever.
  • Aboriginal and Torres Strait Islander children have a higher rate of complications with rheumatic heart disease and post-streptococcal glomerulonephritis. Therefore there is a lower threshold for prescription of antibiotics for these children.
  • There is no evidence that antibiotic treatment will prevent post-streptococcal glomerulonephritis
  • Steroids can have a role in acute pain management. Studies have shown that 1-3 doses of Dexamethasone (dose: 0.15mg/kg) will improve pain faster and allow return to normal activities faster.
  • Analgesia must be used. Paracetamol is usually sufficient. Ibuprofen is an alternative.
  • Avoid aspirin in children because of the risk of Reye syndrome
  • Children older than 12 years may use aspirin gargles
  • Other symptomatic treatments such as salt water gargles, throat lozenges and sprays have varying anecdotal results and have not been proven to be of benefit in clinical trials
  • Supportive care also includes encouraging oral fluids and encouraging oral hygiene (brushing teeth and rinsing with an antiseptic mouthwash)
  • Intravenous fluids may be considered if dehydrated

Further management

Complications

Suppurative Complications:

  • Peritonsillar abscess
  • Retro-pharyngeal abscess
  • Cervical lymphadenitis
  • Sinusitis
  • Mastoiditis
  • Otitis media

Complications of GABHS:

  • Acute rheumatic fever
  • Post-Streptococcal glomerulonephritis

Other Complications:

  • Sepsis

Medications

  • Antibiotics – Penicillin V for 10 days BD
  • If penicillin allergic, use Azithromycin once daily for 3 days

Refer to the ChAMP antibiotic guidelines or Therapeutic Goods Administraion (TGA) recommendations for dose

Admission criteria

  • Upper airway obstruction
  • Severe dysphagia and inadequate oral hydration (require intravenous fluids)
  • Fever with significant signs of sepsis
  • Suppurative complications
  • Pain not controlled with oral analgesia

Referrals and follow-up

  • GP follow up regarding clinical status +/- swab results within 48 hours
  • Indications for referral to a Paediatric Ear, Nose and Throat surgeon to consider an elective tonsillectomy:
    • recurrent tonsillitis
    • episodes of severe tonsillitis requiring hospital admission
    • peritonsillar abscess
    • obstructive sleep apnoea
  • Referral to a Paediatric Respiratory Physician for further investigations should be considered where there is a history or obstructive sleep apnoea

Nursing

  • Routine nursing care

References

 

 

 

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