RN First Call Certified Practice

Adult Decision Support Tool: EAR, NOSE AND THROAT PHARYNGOTONSILLITIS

This decision support tool is based on best practice as of February 2009. For more information or to provide feedback on this or any other decision support tools, e-mail certifiedpractice@crnbc.ca

PEDIATRIC PHARYNGOTONSILLITIS (SORE THROAT)

DEFINITION
This is a painful condition of the oropharynx associated with infection of the mucus membranes of the pharynx and the palatine tonsils. The peak prevalence is found in children less than 5 years.

POTENTIAL CAUSES
Infectious Viruses adenovirus enterovirus (more common in children less than 3 years of age) coxsackievirus Epstein Barr (mononucleosis) herpes simple influenza virus parainfluenza virus Bacterial group A beta-haemolytic strep (GAS) mycoplasma pneumoniae (10% of adolescents) pneumococci staphylococcus aureus H. Influenzae.

PREDISPOSING RISK FACTORS

Exposure to cigarette smoke Previous episodes of pharyngitis or tonsillitis Overcrowding, Poor nutrition

TYPICAL FINDINGS OF SORE THROAT (PHARYNGOTONSILLITIS)

See Appendix 1 for pathogens and clinical appearance of tonsils See Appendix 2 to aid decision making for Group A Streptococcus Bacterial History Acute onset Very sore throat Fever Headache Abdominal pain and vomiting General malaise
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Adult Decision Support Tool: EAR, NOSE AND THROAT PHARYNGOTONSILLITIS

Physical Assessment Significant fever Tachycardia Weigh until 12 years of age for medication calculations Pharyngeal and tonsillar erythema Petechiae of soft palate Tonsillar exudate (particularly with streptococcal infection, diphtheria or mononucleosis) Anterior cervical lymphadenopathy Erythematous sandpaper rash of scarlet fever (may be present with streptococcal infection) Erythematous rash (particularly if child is receiving amoxicillin) lymphadenopathy with splenic enlargement in children with mononucleosis Koplik spots Usually not associated with coryza Cough minimal or absent (this is a helpful diagnosis for sexually transmitted infections clue) Viral History Acute sore throat combined with symptoms consistent with a viral URTI (rhinorrhea, cough and often hoarseness) Physical Assessment Fever (low-grade to significant) Tachycardia Weigh until 12 years of age for medication calculations Pharyngeal and tonsillar erythema and swelling Petechiae of soft palate Tonsillar exudate similar to that occurring with bacterial infection may be present, particularly in adenovirus pharyngotonsillitis Anterior cervical lymphadenopathy Vesicles and ulcers may be present with coxsackievirus infection Hepato- and splenomegaly Diagnostic tests Throat swab for culture and sensitivity Monospot if suspect viral Do not swab a child you suspect has epiglottitis and is drooling and sitting in the tripod position

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Adult Decision Support Tool: EAR, NOSE AND THROAT PHARYNGOTONSILLITIS

MANAGEMENT AND INTERVENTIONS

If the child is greater than 2 years old, culture the throat before treatment or do rapid Strep antigen test; if negative, do throat culture. Bacterial Goals of Treatment Control pain and fever Prevent complications Rapid reduction in infectivity Prevent spread of Group A Streptococcus Decrease antibiotic resistance Non-pharmacological Interventions Rest and increase fluid intake Avoidance of irritants (smoke) Saline gargles (1tsp of salt in 2 cups of warm water ) Increase room humidity Pharmacologic Interventions All drugs must be calculated by weight until age 12 Pen V 40mg/kg/day PO divided bid for 10 days Penicillin Allergy: Erythromycin 40mg/kg/day PO divided tid for 7-10 days Viral Goals of treatment Relieve symptoms Supportive care Non-pharmacological Interventions Rest Increase oral fluids Avoid irritants Warm saline gargles qid, (1 tsp of salt in 2 cups of warm water) Pharmacological Interventions All drugs must be calculated by weight until the age of 12 Acetaminophen (Tylenol) 10-15mg/kg PO q4-6h prn (not to exceed 75mg/kg per 24 hours)

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Adult Decision Support Tool: EAR, NOSE AND THROAT PHARYNGOTONSILLITIS

POTENTIAL COMPLICATIONS
Bacterial Retropharyngeal abscess Acute glomerulonephritis Invasive GAS disease Otitis media Sinusitis Acute rheumatic fever Viral Epstein Barr Virus (splenomegaly)

CLIENT/CAREGIVER EDUCATION AND DISCHARGE INFORMATION

Advise on condition, timeline of treatment and expected course of disease process Saline gargles as described above Counsel parents/caregiver about appropriate use of medication (dosage, compliance, follow-up) If patient has any difficulty swallowing, seek help immediately

MONITORING AND FOLLOW UP

Return to clinic in 48 hours if awaiting culture results Return for care if no improvement in 48 hours

CONSULTATION AND/OR REFERRAL

Consult a physician or Nurse practitioner if child has recurrent bouts of GAS pharyngotonsillitis: greater than 5 episodes in one year.

DOCUMENTATION
As per agency requirements

REFERENCES
B.C. Health Services (2003). Diagnosis and management of sore throat. Author. Campisi, P., Tewfik, T. (2003). Tonsillitis and its complications. Canadian Journal of Diagnosis. pp. 99-105 First Nations and Inuit Health Branch (2006) Pediatric clinical practice guidelines for primary care nurses. Health Canada Public Health Agency of Canada. CCDR 2006; 32S2:1-26.Guidelines for the Prevention and Control of Invasive Group A Streptococcal Disease Shaiu, C., Toren, A. (eds) (2006). Toronto Notes: Comprehensive Medical Reference and Review. University of Toronto.

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

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RN First Call Certified Practice

Adult Decision Support Tool: EAR, NOSE AND THROAT PHARYNGOTONSILLITIS

APPENDIX 1

Source: Campisi and Tewfik. (2003). Tonsillitis and Its Complications.

APPENDIX 2

Source: BC Health Services Diagnosis and Management of Sore Throat. (2003).

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC July 09/Pub. 712