This is the protocol for Tonsillopharyngitis:
Let’s break it down!
Tonsillopharyngitis is characterized as an inflammation of the tonsils, pharynx, or both. It’s extremely common; constituting about 15% of all office visits with primary care physicians. The far majority of cases are caused by common cold viruses like adenovirus, rhinovirus, and influenza, but 30% of cases are caused by bacteria and they tend to be more severe. You may have heard the term “Strep Throat” before. Strep throat is tonsillopharyngitis that is caused by Streptococcus bacteria, particularly the Group A beta-hemolytic streptococcus (GABHS). Here’s a nice overview video of pharyngitis by Dr. Carlo Oller:
The signs and symptoms of tonsillopharyngitis are what you might expect: Sore throat, erythema (redness), swollen tonsils, etc. Palatal petechiae is a common sign as well, which refers to the strawberry-like pattern in the back of the throat. It looks like this:
You may find cervical lymphadenopathy as well, which is an engorgement of the lymph nodes as a generalized response to fight infection. It’s helpful to manually palpate the cervical lymph node sites, as shown here on the graph:
Other times, it’ll be obvious to see just by looking at them!
The key question, however, is not whether or not they have tonsillopharyngitis. That’s easy. The big question is whether or not it’s bacterial. The presence of a high fever (>102.5) is a good predictor, but a more accurate method is to utilized Centor criteria, which is a list of signs/symptoms that helps calculate the patient’s likelihood of a bacterial infection and determine a treatment plan.
You probably won’t be able to do a throat culture out in the field, but you may have access to a rapid Strep A test. Check out the video if you want to learn how to do it….it’s super easy!
1. Salt water gargles
Gargling warm, saltwater can certainly help alleviate the pain from a sore throat. It’s also said to help pull fluids from tissues and “wash the virus out”, although evidence of this is lacking. Still, it’s an easy treatment for the patient that they can do on their own, regardless of whether or not the sore throat is viral or bacterial.
2. For fever, administer Acetaminophen…
This will help break the fever, as well as provide some level of pain relief for the patient throughout their recovery. It definitely doesn’t hurt!
Although patients with strep throat typically do well even without antibiotics, a course of antibiotics will help reduce the chance of complications. This is an important thing to ensure for soldiers on the battlefield. With that being said, the protocol recommends Azithromycin. This isn’t normally our drug of choice (penicillin is), but azithromycin is easy to prescribe in a 5-day pack and it’ll help cover patients who might be allergic to penicillin.
A peritonsillar abscess is a common complication of tonsillopharyngitis, which involves a build-up of pus around the tonsil region. It often requires drainage and a separate course of stronger antibiotics to manage. To learn more about how to catch it, check out the Peritonsillar Abscess protocol
The Epstein-Barr Virus (EBV), more commonly known as “mono“, is an infection that also causes severe throat pain. It’s incredibly common; studies show that approximately 95% of the US population has been infected with EBV at some point in their lives. There’s not much we can do about it aside from symptom management, but it helps to avoid antibiotics with these patients. If the patient knows that they’ve had contact with someone else suffering from a diagnosed EBV infection, then that should help clue you in. There’s a reason it’s called the “Kissing Disease”
As long as you fix the problem, no need to bother them with transport!
The prognosis for tonsillopharyngitis is good. Strep throat will typically go away within 3-7 days, with or without treatment 👍
Good luck out there!
- MSD Manual: Tonsillopharyngitis
- EMRAP Corependium: Pharynx and Throat Emergencies
- UpToDate: Treatment and prevention of streptococcal pharyngitis
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.