Paediatric Pathways

Tonsillitis and peritonsillar abscess (quinsy) pathway for children presenting to hospital

DIFFERENTIALS

Acute presentation of inflamed tonsils.
Presence of fever, progressive worsening of symptoms, deviated uvula and trismus suggest possible peritonsillar abscess (quinsy).
Presence of fever, stridor, difficulty swallowing, drooling or torticollis suggest possible deep neck space infection.
Organisms causing tonsillitis include Gp A streptococcus, Fusobacterium, EBV and CMV. EBV generally presents non-specifically in younger children and with tonsillitis in children aged 10 years and over.
Non-infectious differentials include acute leukaemia.

RED FLAGS:

  • Stertor or stridor suggesting airway obstruction
  • Difficulty swallowing/drooling
  • Muffled speech
  • Torticollis (can occur in minor infections but potential sign of deep neck space infection)
  • Severe respiratory distress
  • Haemodynamic instability / sepsis (may require urgent source control) or signs of toxic shock syndrome (shock, mucosal erythema, rash, GI symptoms)

If any red flags present, URGENT senior review and ENT input

INVESTIGATIONS

Evaluating severity of infection:
MILD = systemically well or fever but haemodynamically stable
MODERATE = systemically unwell including fever AND persisting tachycardia / tachypnoea
SEVERE = presence of any red flags

If MILD infection, no investigations required.
If MODERATE / SEVERE infection#, for FBC, CRP and blood culture, EBV testing (Monospot acceptable in child > 5 years, EBV serology in younger child if EBV considered)2 +- throat swab. If abdominal pain, check for hepatosplenomegaly and consider LFTs.
If peritonsillar abscess (quinsy), ENT team may decide on early aspiration in older children.

If red flags present, urgent senior review and ENT input. Ensure airway secure before imaging performed.

MANAGEMENT

MILD infection – optimise analgesia (paracetamol or ibuprofen).
Only treat with antibiotics if FeverPAIN * score 4 or 5 or Centor * score 3 or 41

If antibiotics indicated, oral antibiotics as per local/national guidelines.1 Total duration of treatment 5 days (10 days if recurrent infection within 2 weeks of previously treated infection).1
If organomegaly secondary to EBV, advise against contact sports for 4 weeks.
Provide verbal and written safety netting information
If no improvement despite >72 hours of adequate oral Abx (check dose and adherence), consider 2nd line oral Abx therapy as per local guidelines.


In MILD infection requiring antimicrobial therapy, only consider IVAbx if oral Abx not tolerated / absorbed

MANAGEMENT

MODERATE infection – consider initial management with IVAbx as per local / national empirical antibiotic guidelines.

If clinical deterioration despite 24 hours Abx or persisting fever/no clinical improvement despite 48 hours Abx, consider quinsy or retropharyngeal abscess. Arrange ENT review for consideration of imaging +- surgical management (source control).4-7

If development of red flags, for urgent ENT review. Ensure airway secure before imaging performed.

MANAGEMENT

SEVERE infection – start IVAbx as per local / national empirical antibiotic guidelines. Consider stat dose steroids (IV dexamethasone 0.15mg/kg) if signs of airway obstruction.

Urgent ENT review and consideration of source control (operative management)8
If airway is compromised by swelling, consider emergency measures to secure it including extending supraglottis, nebulised adrenaline and non-invasive ventilation/nasopharyngeal airway.

If evidence of toxin mediated disease, consider adding an antitoxin antibiotic (i.e. clindamycin) and lower threshold for urgent drainage (source control).

Consider ambulation9 on IVAbx from ED / assessment unit (admission avoidance) unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information

IV to oral switch when:

  • Clinically improving +- improving inflammatory markers
  • Apyrexial
  • If source control (I+D) of peritonsillar abscess, then early IV to oral switch recommended.3
  • Choice of oral antibiotics as per local / national empirical antibiotic guidelines. Total duration of treatment (IV+oral) = 5 days (10 days if recurrent infection with 2 weeks, peritonsillar abscess or retropharyngeal abscess)

If clinically deteriorating or remains pyrexial despite antibiotics, consider:

  • Deep seated infection requiring source control; ENT review +- imaging
  • Resistant organism – check risk factors and microbiology results
  • Non-infective pathology or unusual infection (consider differentials)
  • Seek ID/micro advice if complex infection

SEVERE infection – start IVAbx as per local empirical antibiotic guidelines. Consider stat dose steroids (IV dexamethasone 0.15mg/kg) if signs of airway obstruction.

Urgent ENT review and consideration of source control (operative management)8
If airway is compromised by swelling, consider emergency measures to secure it including extending supraglottis, nebulised adrenaline and non-invasive ventilation/nasopharyngeal airway.

If evidence of toxin mediated disease, consider adding an antitoxin antibiotic (i.e. clindamycin) and lower threshold for urgent drainage (source control).

*FeverPAIN score
• Fever, purulence, attend within 3 days or less, severely Inflamed tonsils, no cough or coryza
1 point for each

Centor score
• Tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever (>38°C), no cough
1 point for each

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. NICE (National Institute for Health and Care Excellence). Sore throat (acute): antimicrobial prescribing. NICE Guideline [NG84]. Available at https://www.nice.org.uk/guidance/ng84. 2018.
  2. Marshall-Andon T, Heinz P. How to use ... the Monospot and other heterophile antibody tests. Arch Dis Child Educ Pract Ed 2017; 102: 188-93.
  3. Sexton DG, Babin RW. Peritonsillar abscess: a comparison of a conservative and a more aggressive management protocol. Int J Pediatr Otorhinolaryngol 1987; 14: 129-32.
  4. Lamkin RH, Portt J. An outpatient medical treatment protocol for peritonsillar abscess. Ear Nose Throat J 2006; 85: 658, 60.
  5. Al-Sabah B, Bin Salleen H, Hagr A et al. Retropharyngeal abscess in children: 10-year study. J Otolaryngol 2004; 33: 352-5.
  6. McClay JE, Murray AD, Booth T. Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg 2003; 129: 1207-12.
  7. Page C, Biet A, Zaatar R et al. Parapharyngeal abscess: diagnosis and treatment. Eur Arch Otorhinolaryngol 2008; 265: 681-6.
  8. Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope 2001; 111: 1413-22.
  9. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.