A Clinical Approach to Tonsillitis, Tonsillar Hypertrophy, and Peritonsillar and Retropharyngeal Abscesses

1. Risa E. Bochner, MD* 2. Mona Gangar, MD*,† 3. Peter F. Belamarich, MD* 1. *Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, NY 2. †Department of Otorhinolaryngology/Head and Neck Surgery, Division of Pediatric Otorhinolaryngology, Albert Einstein College of Medicine, Bronx, NY * Abbreviations: ALPS: : Autoimmune lymphoproliferative syndrome ARF: : Acute rheumatic fever CMV: : Cytomegalovirus CT: : Computed tomography EBV: : Epstein-Barr virus GAS: : Group A Streptococcus HIV: : Human immunodeficiency virus NSAIDs: : Nonsteroidal anti-inflammatory drugs OSA: : Obstructive sleep apnea PFAPA: : Periodic fever, apthous stomatitis, pharyngitis, and adenitis PSGN: : Poststreptococcal glomerulonephritis PTA: : Peritonsillar abscess RADT: : Rapid antigen detection test SDB: : Sleep-disordered breathing T&A: : Tonsillectomy and adenoidectomy Despite established guidelines for group A Streptococcus pharyngitis diagnosis and treatment, pediatricians are overtreating and mistreating sore throat in children. (1) This results in unnecessary antibiotic use and contributes to antimicrobial resistance, increased health care costs, and risk for adverse drug reactions. In addition, controversy exists among pediatricians regarding the indications for tonsillectomy and adenoidectomy in children. After completing this article, readers should be able to: 1. Describe the clinical presentation, differential diagnosis, diagnostic evaluation, and management of tonsillitis/pharyngitis in pediatric patients. 2. Describe the clinical presentation, diagnostic evaluation, and management of peritonsillar abscess in pediatric patients. 3. Describe the clinical presentation, diagnostic evaluation, and management of retropharyngeal abscess in pediatric patients. 4. Describe the indications for tonsillectomy and adenoidectomy in pediatric patients and associated complications. ### Epidemiology Sore throat is a common complaint in children and adolescents. Most cases of pharyngitis are viral and self-limited. Group A Streptococcus (GAS) pharyngitis is the only commonly occurring infectious pharyngitis in which antimicrobial treatment is indicated. Treatment of GAS decreases the risk of acute rheumatic fever (ARF), suppurative complications and transmission of disease, and provides symptomatic relief. GAS pharyngitis accounts for 20%-30% of office visits for sore throats in children. (2) Infection typically occurs in school-age children and adolescents, and is uncommon in children younger than 3 years. GAS pharyngitis occurs most commonly in the winter and early spring months …