Oropharyngeal Infections

Jonathan Pirie

Introduction

Most infections are viral but need to consider other causes
Strep throat uncommon in children < 2 years age
Consider infectious mononucleosis in older children, but may also present in young children

Pharyngitis

Acute pharyngitis can be caused by numerous viral and bacterial agents
Viruses predominate, while group A streptococcus is the predominant bacterial cause
Chlamydia trachomatis and Mycoplasma pneumoniae may be responsible for pharyngitis in adolescence
Candida may present in infants, immunosuppressed children, and children taking antibiotics

Clinical Presentation

Coryza, hoarseness, cough, diarrhea, conjunctivitis, anterior stomatitis, and discrete ulcerative lesions suggest a viral etiology
Epstein-Barr virus and cytomegalovirus typically have pharyngeal inflammation, diffuse lymphadenopathy, and hepatosplenomegaly
Streptococcal pharyngitis typically has an abrupt onset, fever, sore throat, ± headache, vomiting, abdominal pain, and a scarlatiniform rash
Other clinical findings: tonsillopharyngeal erythema ± tonsillar exudates, tender cervical adenopathy, a beefy red swollen uvula, petechiae of the palate, and excoriated nares in infants

Investigations

Throat culture remains the gold standard for streptococcus
Decision to obtain a throat swab should be based on age, signs and symptoms, season, and family and community epidemiology
Clinical decision rules have been used but poor positive predictive value
Rapid streptococcus by latex agglutination or immunoassay is useful if positive but does not rule out streptococcal infection
Obtain CBC, EBV titres, monospot and other bacterial isolates (Chlamydia, N. gonorrhoeae, Mycoplasma) on a case-by-case basis
Monospot commonly negative in children < 5 years; may need EBV serology

Management

Penicillin is the drug of choice for treatment of acute streptococcal pharyngitis
10-day course recommended for maximal eradication of group A streptococci
Treatment should be reserved until positive throat culture or rapid strep test
Penicillin, amoxicillin, and erythromycin are equally effective whether divided bid, tid, or qid when used for 10 days
Other antibiotics (azithromycin, cefixime, cefuroxime axetil) have been shown to be equally effective when used for shorter duration (≤ 5 days)
- Should not be routinely used as first-line therapy because of limited studies or concerns regarding broad spectrum of antimicrobial activity

Complications