Acute pharyngitisMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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425 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp45

Triage and immediate threats

›Airway and instability screen

›Drooling

›Stridor

›Muffled voice

›Tripod position

›Inability to handle secretions

›Toxic appearance

›Neck swelling

›Trismus

›Respiratory distress

›Hypotension

Time critical actions

›Escalation triggers

›If drooling or stridor, airway-ready setting

›Avoid agitating exam

›ENT and anesthesia activation

›Prepare for difficult airway

›Evidence level: expert consensus (ACEP Level C equivalent)

›If unilateral tonsillar swelling with uvular deviation, peritonsillar abscess pathway

›Airway risk assessment

›Drainage capability check

›If neck stiffness and bulging posterior pharynx, deep neck space infection pathway

›CT neck with IV contrast planning

›Early ENT involvement

›If systemic toxicity or dehydration, IV access and fluid resuscitation

›Crystalloid bolus 10 to 20 ml/kg

›Reassessment after bolus

02History/hx42

Symptom pattern and timing

›Core symptom inventory

›Sore throat onset and duration

›Fever pattern

›Odynophagia

›Dysphagia

›Voice change

›Drooling

›Trismus

›Neck pain or swelling

›Cough

›Coryza

›Conjunctivitis

›Hoarseness

›Oral ulcers

›Rash

Exposure and risk context

›Epidemiologic risks

›Household or school exposure to strep

›Community outbreaks

›Recent antibiotics

›Travel

›Unvaccinated status

›Sick contacts with scarlatiniform rash

›Sexual and bloodborne risks

›Oral sex exposure

›Gonorrhea risk

›Acute HIV risk

03Physical Exam/exam25

Oropharynx and airway exam

›Upper airway and pharynx findings

›Tonsillar erythema

›Tonsillar exudates

›Palatal petechiae

›Uvular deviation

›Soft palate swelling

›Trismus

›Drooling

›Voice quality

›Oral ulcers

›Posterior pharyngeal bulge

›Pseudomembrane

Lymphatic and systemic exam

›Regional nodes and systemic signs

›Anterior cervical lymphadenopathy

›Posterior cervical lymphadenopathy

›Hepatosplenomegaly

›Rash

›Strawberry tongue

›Hydration status

›Respiratory work

PITFALLS

›Diagnostic traps

›Viral URI symptoms do not fully exclude GAS

›Exudates occur in EBV and adenovirus

›Early deep neck infection may have subtle oral findings

›Attempted membrane removal in diphtheria can bleed and worsen obstruction

04Differential Diagnosis/ddx27

Infectious causes

›Acute pharyngitis differential

›Viral pharyngitis (ICD-10 J02.9, SNOMED CT 363746003)

›Rhinovirus

›Coronavirus

›Adenovirus

›Influenza

›HSV gingivostomatitis

›Streptococcal pharyngitis (ICD-10 J02.0, SNOMED CT 43878008)

›Group A Streptococcus

›Infectious mononucleosis (ICD-10 B27.90, SNOMED CT 186738001)

›EBV

›Peritonsillar abscess (ICD-10 J36, SNOMED CT 195709001)

›Retropharyngeal abscess (ICD-10 J39.0, SNOMED CT 301408002)

›Epiglottitis (ICD-10 J05.1, SNOMED CT 80384002)

›Diphtheria (ICD-10 A36.0, SNOMED CT 397430003)

›Lemierre syndrome (ICD-10 I80.8 plus A41.9 as applicable, SNOMED CT 111258000)

›Fusobacterium necrophorum

›Gonococcal pharyngitis (ICD-10 A54.5, SNOMED CT 715842005)

›Acute HIV syndrome (ICD-10 B23.0, SNOMED CT 230152000)

Noninfectious and mimics

›Mimics

›Allergic rhinitis with postnasal drip

›GERD and laryngopharyngeal reflux

›Irritant exposure

›Aphthous ulcers

›Kawasaki disease in children

›Stevens-Johnson syndrome mucositis

05Laboratory Tests/lt31

Rapid and targeted testing

›Etiology focused labs

›Rapid antigen detection test for GAS

›Most useful with intermediate to high pretest probability

›Negative RADT in children

›Backup throat culture or NAAT depending on local protocol

›Evidence level: guideline based (IDSA strong recommendation)

›Negative RADT in adults

›No backup culture in most settings

›Evidence level: guideline based (IDSA strong recommendation)

›Throat culture for GAS

›Reference standard for confirmation

›Turnaround time limitation

›NAAT for GAS if available

›High sensitivity option

›Stewardship considerations

Complication and alternative diagnosis labs

›Expanded testing triggers

›Heterophile antibody test for EBV

›False negative early illness

›EBV serologies when heterophile negative with high suspicion

›VCA IgM

›VCA IgG

›EBNA

›CBC for severe illness or atypical features

›Lymphocytosis with atypical lymphocytes supporting EBV

›Pregnancy test when imaging or teratogenic meds considered

›HIV Ag/Ab testing when acute HIV risk present

06Diagnostic Tests/dt64

Scoring Systems

›Pretest probability tools

›Centor criteria

›Tonsillar exudates

›Tender anterior cervical lymphadenopathy

›Fever

›Absence of cough

›McIsaac modification

›Age 3 to 14 years add 1

›Age 15 to 44 years add 0

›Age 45 years or older subtract 1

›Clinical use

›Low score

›No GAS testing

›Supportive care only

›Intermediate score

›RADT preferred

›Culture or NAAT based on age and local practice

›High score

›RADT or NAAT

›Empiric antibiotics only when testing not feasible and follow up limited

›Evidence level: guideline based with stewardship emphasis

›FeverPAIN alternative

›Fever

›Purulence

›Attend rapidly within 3 days

›Severely inflamed tonsils

›No cough or coryza

07Disposition/dispo19

Level of care decisions

›Discharge eligibility

›Stable airway

›Able to tolerate oral intake

›Pain controlled with oral agents

›No concern for abscess or epiglottitis

›Reliable follow up and return precautions

›Admission indications

›Airway compromise risk

›Dehydration requiring ongoing IV fluids

›Deep neck infection suspicion

›Peritonsillar abscess with failed outpatient management

›Immunocompromised with severe infection

›Transfer criteria

›Need for ENT drainage not available

›Airway team not available for suspected epiglottitis

Follow up planning

›Timing

›Reassessment within 24 to 48 hours for worsening symptoms

›Primary care follow up for uncomplicated cases

›ENT follow up after abscess drainage

08Treatment/t83

Supportive care

›Symptom control

›Acetaminophen PO 15 mg/kg per dose every 6 hours

›Maximum 1 g per dose

›Maximum 4 g per day

›Ibuprofen PO 10 mg/kg per dose every 6 to 8 hours

›Adult typical 400 mg every 6 to 8 hours

›Maximum 2400 mg per day for self care context

›Oral hydration

›Warm fluids

›Cold fluids as tolerated

›Salt water gargles

›Throat lozenges if age appropriate

›Corticosteroid for severe pain

›Dexamethasone PO or IM 0.6 mg/kg once

›Maximum 10 mg once

›Evidence level: moderate evidence for pain reduction, not routine for all

Antibiotics for confirmed or strongly suspected GAS

›First line regimens

›Penicillin V PO

›Adults 500 mg twice daily for 10 days

›Children 250 mg twice daily for 10 days

›Evidence level: guideline based (Class I equivalent)

›Amoxicillin PO

›50 mg/kg once daily for 10 days

›Maximum 1000 mg once daily

›Alternative 25 mg/kg twice daily for 10 days

›Maximum 500 mg per dose

›Benzathine penicillin G IM once

›Weight under 27 kg 600000 units once

›Weight 27 kg or higher 1200000 units once

›Use when adherence concern

›Nonanaphylactic penicillin allergy

›Cephalexin PO

›20 mg/kg per dose twice daily for 10 days

›Maximum 500 mg per dose

›Cefadroxil PO

›30 mg/kg once daily for 10 days

›Maximum 1000 mg once daily

›Anaphylactic penicillin allergy

›Clindamycin PO

›7 mg/kg per dose three times daily for 10 days

›Maximum 300 mg per dose

›Azithromycin PO

›Day 1 12 mg/kg once

›Maximum 500 mg

›Days 2 to 5 6 mg/kg once daily

›Maximum 250 mg

›Local macrolide resistance consideration

›Clarithromycin PO

›7.5 mg/kg per dose twice daily for 10 days

›Maximum 250 mg per dose

Peritonsillar abscess management

›Drainage and adjuncts

›Needle aspiration or incision and drainage

›Airway readiness check before procedure

›Ultrasound guidance when available

›Antibiotics covering GAS and anaerobes

›Amoxicillin-clavulanate PO 875 mg twice daily for 10 to 14 days

›Clindamycin PO 300 to 450 mg three times daily for 10 to 14 days

›Dexamethasone PO or IV 10 mg once for significant edema

Deep neck infection and epiglottitis pathways

›Deep neck infection initial therapy

›Ampicillin-sulbactam IV 3 g every 6 hours

›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours

›MRSA risk

›Add vancomycin IV 15 to 20 mg/kg per dose every 8 to 12 hours

›Trough guided per local protocol

›ENT consultation early

›Suspected epiglottitis

›Avoid provoking airway collapse

›No tongue depressor exam if drooling or stridor

›Ceftriaxone IV 2 g daily

›Add vancomycin if MRSA risk or severe sepsis

›Airway management in controlled setting

›Evidence level: expert consensus (Class I equivalent)

Diphtheria suspected

›Immediate actions

›Erythromycin PO or IV 500 mg four times daily for 14 days

›Penicillin G IV 2 to 3 million units every 4 hours for 14 days

›Diphtheria antitoxin via public health coordination

›Cardiac monitoring for myocarditis risk

›Close contacts prophylaxis per public health

Lemierre syndrome suspected

›Sepsis and thrombophlebitis coverage

›Piperacillin-tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours

›Imaging for internal jugular thrombosis

›Early infectious diseases consultation

09Special Populations/sp27

Pregnancy

›Pregnancy considerations

›GAS testing and treatment same indications

›Penicillin and amoxicillin preferred safety profile

›Imaging choices for complications

›Ultrasound first line when feasible

›CT neck with IV contrast when airway or deep infection concern outweighs fetal risk

›Avoidance priorities

›Tetracyclines avoidance

›Fluoroquinolones avoidance unless specialist guided

Geriatric

›Older adult considerations

›Lower fever frequency despite serious infection

›Higher dehydration risk

›Broader differential

›Malignancy

›Medication induced xerostomia with throat discomfort

›Lower threshold for imaging with neck swelling or systemic toxicity

Pediatrics

›Pediatric specifics

›GAS testing strategy

›No routine testing under age 3 years unless risk factors and classic presentation

›RADT negative backup culture recommended

›Retropharyngeal abscess risk higher in young children

›Neck stiffness

›Refusal to extend neck

›Drooling

›Weight based dosing verification

10Background/b27

Epidemiology

›Frequency and patterns

›Viral causes predominate in all ages

›GAS proportion higher in school age children

›Winter and early spring seasonality for GAS

›Transmission via respiratory droplets

Pathophysiology

›Mechanisms

›Viral mucosal inflammation and ulceration patterns by pathogen

›GAS adherence and toxin mediated inflammation

›Scarlatiniform rash from erythrogenic toxins

›Suppurative spread

›Peritonsillar space

›Retropharyngeal space

›Parapharyngeal space

›Nonsuppurative sequelae of GAS

›Acute rheumatic fever

›Poststreptococcal glomerulonephritis

Therapeutic Considerations

›Stewardship and outcomes

›Antibiotics indicated for confirmed GAS

›Reduced symptom duration modest

›Reduced transmission

›Prevention of acute rheumatic fever

›No antibiotics for viral pharyngitis

›Reduced adverse drug events

›Reduced resistance selection

›Timing

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Home care and expectations

›Fluids

›Rest

›Acetaminophen or ibuprofen as directed

›Warm salt water gargles

›Avoid sharing drinks and utensils

›Antibiotic guidance when prescribed

›Complete full course

›Contagiousness reduction after 24 hours of antibiotics

›Replace toothbrush after 24 to 48 hours on antibiotics if recurrent infections concern

›Return to ED now

›Trouble breathing

›Drooling

›Stridor

›Cannot swallow liquids

›Severe dehydration

›Worsening unilateral throat pain

›Neck swelling or stiffness

›Persistent fever beyond 3 days or new fever after improvement

›Rash with ill appearance

›Follow up

›If not improving within 48 to 72 hours

›If recurrent episodes or complications concern

12References/r12

Clinical guidelines and evidence

›Guideline sources

›IDSA guideline for group A streptococcal pharyngitis diagnosis and management

›CDC clinical guidance for strep throat and GAS testing

›AAP Red Book guidance for pediatric pharyngitis and diphtheria management

›National and local public health guidance for diphtheria antitoxin and contact management

›Decision tools

›Centor criteria validation studies

›McIsaac score derivation and validation studies

›FeverPAIN score studies

›Complications and imaging

›Evidence summaries for peritonsillar abscess ultrasound guidance

›Deep neck space infection imaging and management reviews

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.