Pharyngitis/Tonsillitis/Strept
Throat
DEFINITION:
Inflammation
of the throat.
SYMPTOMS:
Fever, malaise, throat pain, swollen glands in the neck.
CAUSES:
Viruses
and Group A beta hemolytic streptococcus (strept throat).
DIAGNOSIS:
If a child presents with a sore throat or has a red, inflamed,
or white covered throat, a rapid strept test or throat culture
is performed. If the rapid strept test or throat culture is
negative (i.e., no strept throat), a diagnosis of viral pharyngitis
is made. If the throat culture or rapid strept test is positive
(i.e., strept throat), then a diagnosis of strept throat can
be made. There is no way to be sure if it is strept without
performing the lab test.
TREATMENT:
For viral pharyngitis, acetaminophen (Tylenol, Tempra), ibuprofen
(Motrin, Advil), lozenges, fluids, rest, and time: for strept
throat, antibiotics.
CONTAGION:
Strept throat is contagious until you are on antibiotics for
24 hours. Viral pharyngitis is contagious as long as symptoms
are present. Both are transmitted by respiratory secretions
i.e. coughing or sneezing. The incubation period is 2 to 3
days.
OUTCOME:
For viral pharyngitis the outcome is excellent. Sometimes
the virus causing pharyngitis can lead to an ear infection
or sinus infection, but this is rare. The outcome for strept
throat is excellent if the strept is treated. If untreated,
strept throat can lead to rheumatic
fever, scarlet fever,
and poststreptococcal glomerulonephritis, or kidney disease.
DISCUSSION:
Sore throats are very common in children. A sore throat is
usually the first symptom of a cold, but it can also be a
strept throat. If it is a viral pharyngitis, the best treatments
are acetaminophen (Tylenol, Tempra), ibuprofen (Motrin, Advil),
lozenges (if the child is old enough to take them), fluids,
rest, and time. If it is strept throat, penicillin is the
drug of choice, although most physicians use amoxicillin (the
"pink medicine") because of its better taste and once-a-day
dosing for strept. Other antibiotics can be used, but penicillin
or amoxicillin will cause the least amount of side effects
and resistance.
The only way to diagnose strept throat is by rapid strept
test or throat culture. You cannot tell if it is strept throat
by looking in the throat. Fortunately, the diagnosis will
be viral over 85% of the time. If it is strept throat, however,
it is important to get treatment within ten days of symptoms
to prevent the complications of strept, which are rheumatic
fever, scarlet fever,
and kidney disease. Once an antibiotic is started, the child
will still be contagious until he or she is on the antibiotic
for 24 hours, after which they can return to school or daycare.
Some children are strept carriers, meaning that they are always
positive on a rapid strept test or throat culture, even when
they have no symptoms. These children are not at risk for
the complications of strept, however, they can pass the strept
to others and cause illness. It is difficult to diagnosis
these children with strept because one doesn't know if a sore
throat is a new onset of strept throat or a harmless carrier
state, since the lab test will show the strept. If a child
gets multiple strept throats, or they are a strept carrier,
some physicians like to have the tonsils removed. Others will
try different antibiotics to remove the strept.
Some studies have shown that tonsillectomy helps, and others
have shown this to be of no benefit. Physicians and patients
should weigh the pros (decrease in throat infections, less
school absences, easier breathing if the tonsils are enlarged
and obstructive) and the cons (a surgical procedure with pain
and bleeding involved, possibility of no benefit), and make
an individual decision for each case. Things that have shown
to be of no benefit include Vitamin C, zinc lozenges, multivitamins,
and antihistamines.
ONE DOCTOR'S OPINION:
I have a pet peeve when it comes to a certain scenario in
my treatment of sore throats. That is when a child has presented
to my office with a painful red or white covered throat that
looks infected, I have run a rapid strept test and/or throat
culture which showed no strept, and sent the patient home
with instructions to use acetaminophen and lozenges, and I
then discover that the child's parents went to another physician
or Emergency Room, another doctor looked in the throat and
diagnosed strept, and then prescribed an antibiotic. Unless
the Emergency Room doctor has microscopic vision, it is impossible
to diagnosis strept by looking in the throat. Some of the
nastiest looking throats are the result of viral pharyngitis,
and sometimes a patient will complain of a sore throat that
looks normal, but it is, in fact, strept. One just cannot
tell by looking. I've read studies where people try to grade
symptoms: they give positive points for strept for sore throat,
fever, red spots on the tonsils (petechiae), and negative
points for congestion, cough and runny nose, which are most
likely due to viruses. None of these grading systems ever
work out well. In the back of your mind, think mononucleosis
("mono") if it's a throat covered with white material and
a negative strept. Sorry, mono is viral and there is nothing
you can do for it, but at least you know what's causing the
problem.
As an educated parent or patient, insist on a rapid strept
test or throat culture, proving strept before you're given
a prescription for antibiotics.
