Patient Presentation
An 8-year-old female came to clinic with acute onset of severe sore throat, fever and malaise for 1 day. Streptococcal pharyngitis is in her school and the community.
The past medical history reveals that she has had two prior streptococcal pharyngitis episodes documented by throat culture in the past year. She had two documented streptococcal pharyngitis episodes 1 year ago. She has had several viral upper respiratory infections and pharyngitis in the past two years.
The pertinent physical exam reveals a child in mild discomfort because of pain. She has a temperature of 38.5 degrees Celsius. Her tonsils are swollen just beyond the tonsillar pillars bilaterally, with enlarged crypts and white exudate on them. There are palatal petechiae.
She had mild cervical adenopathy and her ears are normal. The rest of her examination is normal.
The laboratory evaluation shows a positive rapid streptococcal antigen test.
The diagnosis of streptococcal pharyngitis is made and she is going to be treated with Penicillin V. During the discussion her father asks if she can have her tonsils out to prevent future streptococcal infections.
The general indications for tonsillectomy were discussed as well as the relative effectiveness of tonsillectomy for preventing infection. The father says he wants to discuss this more with his wife but still may want a referral to otolaryngology.
Discussion
Streptococcal pharyngitis is caused by Group A, Beta-hemolytic Streptoccus pyogenes (GAS). GAS is a common illness for people of all ages, but especially in children and adoelscents. The incubation period for strep throat is 2-5 days, and the diagnosis is made by rapid antigen testing and culture. The treatment of choice is Penicillin V, with Erythromycin or an oral Cephalosporin as alternatives for people allergic to penicillin.
Prior to effective antibiotics, and for some patients left untreated, complications of GAS can occur including abscesses of the peritonsillar and retropharyngeal areas, cervical adenitis, otitis media and sinusitis.
Nonsupprative sequelae of GAS include acute rheumatic fever and acute glomerulonephritis. GAS can cause numerous invasive infections also such as pneumonia, endocarditis, osteomyelitis, sepsis and toxic shock syndrome, to name a few.
Management of a patient with repeated frequent episodes of acute pharyngitis with positive laboratory testing for GAS can be problematic. Pharyngeal carriage of GAS is common.
To determine pharyngeal carriage the following factors must be considered:
- Were the clinical findings of the episodes more suggestive of GAS or viral infection?
- Were the community epidemiological factors during the episodes more suggestive of GAS or viral infection?
- What was the clinical response to antimicrobial therapy (usually very rapid for GAS)?
- Are laboratory tests positive for GAS between episodes of acute pharyngitis?
- Has a serological response to GAS antigens, such as Antistreptolysin O, occurred?
Antibiotics are not indicated for GAS carriers and carriage can be difficult to eradicate. The Academy of Pediatrics has recommendations for possible carriage eradication and suggested antibiotic regimens (See To Learn More below).
Treatment for tonsillitis has changed over the years. In 1896, one of the United States’ premier pediatricians, Thomas Morgan Rotch said that the treatment for acute follicular tonsillitis “should be entirely symptomatic.” “I am in the habit of having the throat kept
throughly clean with mild solutions of chlorate of potassium or borate of sodium. Holding pieces of cracked iced in the mouth often affords considerable relief.” For chronic tonsillitis, he said, “The most thorough and certain way of curing the disease is, however, by excision. This should be done with the tonsillotome, and it is best to etherize the child for the operation.”Tonsillectomy was much more common in the earlier part of the 20th century, but with the widespread use of effective antibiotics, tonsillectomies for recurrent GAS pharyngitis have decreased.
One meta-analysis found adenotonsillectomy to decrease sore throat episodes (caused by all organisms) by 1.2 episodes per year, to decrease school absence due to sore throats by 2.8 days per year and to decrease upper respiratory infections by 0.5 episodes per year.
Learning Point
After searching the National Guideline Clearinghouse, the American Academy of Pediatrics website, and several other databases and national organization websites, the following evidence-based indications for tonsillectomy were found from the Finnish Medical Society.
These indications are categorized as level C evidence, i.e. limited research-based evidence with at least one adequate scientific study.
They are:
- Recurrent, confirmed bacterial tonsillitis ( > 4 times/year), irrespective of the type of bacteria
- Complications of acute tonsillitis such as peritonsillar abscess or septicemia originating from the tonsils
- Peritonsillar abscess in a patient < 40 years of age
- Suspected malignancy including marked asymmetry or ulceration
- Airway obstruction caused by tonsils, sleep apnea, or disorder of dental occlusion
- Chronic tonsillitis is a relative indication. It is indicated if the patient continuously has bad breath, sore throat, and gagging, and if the symptoms do not decrease during follow-up.
Questions for Further Discussion
1. What is the youngest age that a child generally can get the nonsupprative complications of GAS?
2. Should a child who is too young to get the nonsupprative complications of GAS still receive antibiotic treatment?
3. What is the relative sensitivity and specificity of rapid antigen tests?
Related Cases
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Strep Throat / Strep Tonsillitis.
To view current news articles on this topic check Google News.
Rotch TM. Pediatrics. 1st Edition. J.B. Lippincott and Co. Philadelphia, PA. 1895;810-815.
American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics 2002 Apr;109(4):704-1. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/4/e69
American Academy of Pediatrics. Group A Streptococcal Infections, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;573-584.
Finnish Medical Society Duodecim. Sore throat and Tonsillitis. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004 May 13
A summary is available from the Internet at http://www.guideline.gov/ (rev. 05/13/04, cited 5/5/05).
van Staaij BK,et. al. Adenotonsillectomy for Upper Respiratory Infections: Evidence Based? Arch Dis Child. 2005 Jan;90(1):19-25.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
July 5, 2005
Pediatric Education 