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Sore Throat & Tonsillitis

/ENT

A very common presentation. Trick is to figure out who needs antibiotics, and who has developed complications / red flags (quinsy / retropharyngeal abscess / epiglottitis).
This topic covers:
1) Stepwise approach to patient with sore throat – red flags and consideration of antibiotics.
2) Management of Simple Tonsillitis and Tonsilitis with suspicion of Group A Strep.
3) Consultoids: Management of suppurative complications. Mental framework for interns/teaching. Spiel for ad hoc teaching.

Part 1: Stepwise Approach To Sore Throat

Step 1) Rule Out Red Flags
Appears unwell/toxic, or in resp distress
Obstructive features (epiglottitis / quinsy / retropharyngeal abscess)
         Stridor
         Trismus (restricted jaw movement due to pain)
         Drooling
         ‘hot potato’ voice
         uvula deviation.
         Neck stiffness / pain on movement / Torticollis

Are there risk factors for glandular fever (EBV)?
         Screen for Hepatosplenomegaly.
         Consider Epstein Barr Virus and Monospot test
         Rx: nil. simple analgesia. Baseline LFTs. Handout and conservative management.

Step 2) Consider Antibiotics ONLY FOR HIGH RISK POPULATIONS*

Apply CENTOR criteria (0 = 5%, 2-3 20%, >4 50%) for Strep Throat
         Cough not present (+1)
         Exudates/swelling of tonsils (+1)
         Nodes on neck (+1)
         Temperature > 38C (+1)
         Often young <15yo (+1)
         Rarely Old > 45 (minus 1)

0-1          No swab. Low likelihood GAS
2-3          Mod risk. Swab (with results instructed to be sent to GP). GP to start antibiotics if positive.
4+           High risk. Empiric antibiotics. Swab.

*Advice technically applies to ATSI / Hx Rheumatic heart disease / Immunosuppressed cohorts. However, anecdotally, many patients from urban/metropolitan areas from non-high risk cohorts are treated similarly with antibiotics

Part 2: Management of Tonsilitis

Simple Tonsillitis (uncomplicated, likely viral, but significant pain)
**NO ANTIBIOTICS**
Simple Analgesia spiel (see discharge advice section)
Steroids to reduce inflammation – single 1mg/kg (max 50mg) prednisolone.
2ml oromucosal lignocaine (from pink lady mix!) given neat, in an oral syringe.
^provide syringe of 10ml to pt, for use before meals. Max 10ml/day.
Health Advocacy: Antibiotic Resistance spiel. Side effect of antibiotics.

Management of Tonsillitis + Risk Factors for GAS (Pending Swab Result)
 In addition to the above, add:
Phenoxymethylpenicillin 15mg/kg BD (500mg),  *OR* Amoxicillin 50mg/kg (1g) daily,     for 10 days

Part 3: Consultoids and Management of Complications

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