Acute Tonsillitis And Pharyngitis

Acute pharyngitis and tonsillitis are usually viral. Group A Streptococcus is the major bacterial pathogen because treatment can reduce symptom duration modestly, limit transmission and prevent suppurative and post streptococcal complications in susceptible populations.

Viral features such as cough, coryza, conjunctivitis, oral ulceration and hoarseness reduce the likelihood of streptococcal infection.

Typical bacterial pharyngitis may cause:

• Sudden sore throat
• Fever
• Painful swallowing
• Tonsillar erythema or exudate
• Tender anterior cervical lymphadenopathy
• Palatal petechiae
• Absence of cough

Scarlet fever may produce a fine sandpaper like rash and strawberry tongue.

Features suggesting deep neck infection include:

• Trismus
• Drooling
• Muffled or hot potato voice
• Unilateral tonsillar swelling
• Uvula deviation
• Neck swelling
• Torticollis
• Respiratory difficulty

Diagnosis is primarily clinical.

Clinical scoring systems such as FeverPAIN or Centor can support antibiotic decisions in older children but should not replace clinical judgment.

Routine throat swabs are not necessary for every child.

Rapid antigen testing or throat culture may be useful where confirmation would alter management.

Consider:

• Infectious mononucleosis
• Diphtheria
• Peritonsillar abscess
• Retropharyngeal abscess
• Epiglottitis
• Kawasaki disease

Most uncomplicated sore throats require:

• Oral fluids
• Analgesia
• Antipyretics

When bacterial pharyngitis is sufficiently likely or confirmed:

Phenoxymethylpenicillin PO for 10 days is a narrow spectrum first line option.

Typical dosing:

• 1 to 5 years: 125 mg four times daily or 250 mg twice daily
• 6 to 11 years: 250 mg four times daily or 500 mg twice daily
• 12 years and older: 500 mg four times daily or 1 g twice daily

A full 10 day course gives greater microbiological eradication than shorter treatment.

For penicillin allergy:

Clarithromycin 7.5 mg/kg PO twice daily for 5 days, maximum according to age and weight.

Peritonsillar abscess requires ENT review, IV antibiotics and drainage where indicated.

Retropharyngeal or parapharyngeal abscess requires urgent imaging and ENT management.

Acute Asthma Exacerbation In Children

An acute asthma exacerbation is a sudden or progressive worsening of wheeze, cough, breathlessness and expiratory airflow limitation requiring escalation of treatment. Viral respiratory infection is the commonest trigger in children, but allergens, smoke, exercise, poor controller adherence and incorrect inhaler technique are frequent contributors.

Severity is determined by the child's overall respiratory state, not wheeze intensity alone. A quiet or silent chest in a distressed child suggests critically reduced airflow and impending respiratory failure.

Mild to moderate exacerbations cause:

• Wheeze
• Cough
• Tachypnoea
• Prolonged expiration
• Increased work of breathing
• Reduced exercise or feeding tolerance

Severe or life threatening features include:

• SpO₂ below 90%
• Central cyanosis
• Inability to speak, drink or breastfeed normally
• Severe accessory muscle use
• Agitation followed by drowsiness
• Exhaustion
• Markedly reduced air entry
• Silent chest
• Bradycardia or hypotension
• Altered consciousness

A rising PaCO₂ in a child with severe asthma is ominous. Early attacks usually produce hypocapnia. Normalizing or rising carbon dioxide with persistent respiratory distress suggests fatigue and impending ventilatory failure.

Diagnosis is clinical.

Immediately assess:

• Respiratory rate
• Heart rate
• Work of breathing
• Ability to speak or feed
• Air entry
• Wheeze
• Conscious level
• Oxygen saturation

Peak expiratory flow can help quantify severity in cooperative older children, but inability to perform it should never delay treatment.

Chest radiography is not routine. Obtain it when pneumothorax, focal pneumonia, foreign body aspiration or another diagnosis is suspected.

Blood gas is reserved for severe disease, exhaustion, deteriorating consciousness or suspected ventilatory failure.

Give inhaled salbutamol immediately.

For younger children:

• Salbutamol 4 to 6 puffs of 100 micrograms via pMDI and spacer, one puff at a time with several tidal breaths after each puff

• Salbutamol 2.5 mg nebulised

Repeat every 20 minutes for the first hour in moderate or severe exacerbations, then reassess.

Give oxygen for significant hypoxaemia.

Add ipratropium bromide 250 micrograms nebulised every 20 minutes for 3 doses in severe exacerbations.

Give systemic corticosteroid early:

• Prednisolone 1 to 2 mg/kg PO once daily for 3 to 5 days

Maximum:

• 20 mg/day if younger than 2 years
• 30 mg/day at 2 to 5 years

For older children, usual maximum dosing may extend to 40 to 50 mg/day depending on protocol.

In severe disease with poor response:

• Magnesium sulfate 40 to 50 mg/kg IV over 20 minutes, maximum 2 g

Escalate urgently for silent chest, exhaustion, worsening hypoxaemia, altered consciousness or rising PaCO₂.

Do not routinely give antibiotics unless bacterial infection is independently suspected.

Acute Tonsillitis And Pharyngitis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management