Diagnosis and Treatment of Acute Tonsillopharyngitis :

A Guideline for Clinical Practice

Tonsillopharyngitis
SUTJI PRATIWI RAHARDJO

DEPARTMENT OF OTORHINOLARYNGOLOGY － HEAD AND NECK SURGERY

2022
 DEFINITION

Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both

ANATOMY
ANATOMY
WALDEYER’S RING
• Act as sentinels to guard against foreign intruders like , viruses , bacteria &
other antigens coming in contact through inhalation & ingestion.
• Two mechanisms:
1. Providing local immunity
2. Providing a surveillance mechanism so that entire body is prepared for
defence.
Both these mechanisms are operated through humoral and cellular immunity.
 FUNCTION OF PHARYNX

Digestive Respiratory
system system

Articulation Protection
 AETIOLOGY

VIRAL BACTERIAL FUNGAL

 DIAGNOSIS

MEDICAL HISTORY PHYSICAL LABORATORY

EXAMINATION INVESTIGATION
 PATHOGEN SIGN AND SYMPTOM
Signs and symptoms
VIRAL Cough
Rhinorrhea
Diarrhea Onset : < 2 months
Fatigue
Conjunctivitis
Tonsillar hypertrophy
Sore throat Trias
Oropharyngeal erythema or edema
Fever Acute Pharyngitis
BACTERIAL Nausea and vomiting
Headache
Odynophagia
Abdominal pain Dysphagia
GROUP A STREPTOCOCCUS Scarlatiniform rash Fever
Palatal petechiae Fatigue
Tonsillar exudate Foetor ex ore
Arthralgia or myalgia Anorexia
Cervical adenopathy
Reffered otalgia
FUNGAL Loss of taste
Cephalgia
Mouth numbness
Oropharyngeal white curdlike plaques Myalgia
Oropharyngeal smooth red patches The tonsils are swollen and red
Angular cheilitis Airway obstruction sign
PHYSICAL EXAMINATION
(PHARYNGOSCOPY)

✓ Hyperemic tonsillar mucosa and

pharyngeal wall
✓ Detritus
✓ Crypts don't expand
✓ Palpation: there is tenderness
✓ No enlarged lymph nodes
PHYSICAL EXAMINATION
(PHARYNGOSCOPY)
 TONSIL
GRADING
Modified Centor scoring system
FeverPAIN scoring system
Clinical Decision Making
 LABORATORY INVESTIGATION
Throat culture remains the
criterion standard for bacterial
pharyngitis diagnosis, with 97% to
100% specificity and 90% to 95%
sensitivity. Unfortunately, culture of
throat samples is difficult and can
delay antibiotics. Cultures rarely
influence antibiotic selection, as
prescribing practices currently
cover for GAS. Rather, they can rule
out atypical infections such as non-
GAS and fungal pharyngitis that
require alternate antimicrobial
regimens.
Rapid antigen detection testing (RADT)
affords same visit diagnostics. These
point-of-care tests detect bacterial and
viral antigens from throat swabs taken
from tonsillar exudates or the posterior
oropharynx using dipsticks. Currently,
they have been designed to rule in
streptococcal infections, respiratory
syncytial virus, and influenza. The
specificity and sensitivity of RADT vary
widely from 54% to 100% and 38% to
100%, respectively. Although results are
immediate, each kit is pathogen-specific
and cannot broadly differentiate
between viral and bacterial pharyngitis.
Hence, negative results cannot rule out
non-GAS bacterial pharyngitis.
Antistreptolysin O titre tests are
used for patients with suspected
suppurative complications of GAS.
However, they are not
recommended in acute illness, as
serologic markers peak 3 to 8
weeks after symptom onset.
Individuals suspected of having EBV
infections should receive
mononucleosis spot testing.
Despite having a sensitivity of 70%
to 92% and specificity of 96% to
100%, there is a 25% false-negative
rate when used in the first 10 days
of presentation.3Neisseria
gonorrhoeae pharyngitis was
traditionally diagnosed by oral
swab culture; recently nucleic acid
amplification tests for extragenital
testing have been approved by
Public Health Ontario, the Food
and Drug Administration, and the
Centers for Disease Control and
Prevention.
 TREATMENT

Acute
Tonsillopharyngitis

General/supportive therapy:
- Bed rest
Specific/causative therapy:
- Drink enough water
according to the cause
- Gargle warm water
- Analgetic and antipyretic if necessary
- Oral hygiene

Maintaining adequate hydration is very important, regardless of the treatment option!!!

 TREATMENT
VIRAL
Treatment is conservative, as
these infections are generally self-
limiting.
Lozenges and benzocaine or
lidocaine mouth rinses also provide
mild pain relief by numbing the
oropharynx.
Analgetic and antipyretic
Acetylsalicylic acid is
contraindicated in pediatric
patients owing to the risk of
Reye Syndrome.
BACTERIAL FUNGAL
Topical fluconazole or
Amoxicillin 6- to 10- nystatin are the first-line
days drugs
Itraconazole is used when
A single resistant to fluconazole
intramuscular dose
of benzathine
penicillin G
Patients with a type 4
penicillin or amoxicillin
hypersensitivity (rash)
requiring antibiotics should
receive 10 days of cephalexin,
clindamycin, or clarithromycin
Similarly, patients with ß-
lactamase type 1 hypersensitivity
(anaphylaxis) can be prescribed a
5-day treatment of cefdinir or
cefpodoxime
PROGNOSIS

✓ In general, the prognosis is good

✓ Treatment failure is associated with antibiotic
resistance and complications.
 TAKE HOME MESSAGE

✓ Acute tonsillopharyngitis is one of the most common conditions among out-patients in

primary care
✓ Treatment can be given according to the etiology
✓ Treatment is more supportive
✓ The diagnostic accuracy can prevent irrational use of antibiotics
 Cough Medication associated with Respiratory Infections

Combination drug preparations contain antitussives, expectorants and antihistamines in one product, but
when used in the right doses, they can be used to treat cough with phlegm.
 Noscapine 10 mg,
Chlorpheniramine Maleate 2 mg,
Guaifenesin 25 mg,
Paracetamol 500 mg,
Phenylpropanolamin HCl 15 mg

Dewasa : 3 x 1 tab / hari

Anak 6 – 12 tahun : 3 x ¼ - ½ tab / hari

Noscapine 10 mg
Chlorpheniramine Maleate 2 mg,
Glyceryl Guaiacolate 50 mg,
Paracetamol 125 mg,
Succus Liqd 125 mg,
Pseudoephedrine HCl 7.5 mg

Anak 2-5 th : 3 – 4 x ½ -1 sdt / hari

Anak 6-12 th : 3-4 x 1-2 sdt / hari

Analgesic & Anti

Expectorant Antitussive Decongestant
Antipyretic Histamine
Komposisi :
Dequalinium Chloride 0,25 mg (Lozenges)
Mekanisme Kerja:
Membunuh Bakteri dan Virus dengan meningkatkan permeabilitas
Indikasi:
sel, sehingga menghambat aktivitas enzimatik mikroorganisme.
- Sakit tenggorokan
- Peradangan pada rongga mulut Dosis :
1 Tablet dihisap, tidak lebih dari 8 jam per hari
- Infeksi selaput lendir di mulut
Aman digunakan untuk usia anak diatas 8 tahun

• Packaging:
- 1 Box berisikan 100 Tablet, per strip 10 Tab
- 1 Box berisikan 20 Tablet, per strip 4 Tab

Antiseptic