If It’s Not in the Differential, It Won’t Be in the Diagnosis: Pharyngitis
Gita Pensa, MD, and Mike Weinstock, MD
- Streptococcal Pharyngitis
CENTOR Criteria: A listing of 4 criteria that can be used to estimate the probability that pharyngitis is streptococcal and to suggest a potential management course.
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- Cough (absent)
- Adenopathy
- Fever,
- Exudate (tonsillar)
- The more CENTOR criteria present, the higher the probability of Strep pharyngitis, but how accurate is this? Estimates suggest that
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- 1 out of 4 has a 10% probability of Strep pharyngitis,
- 2 out of 4 has a 20% probability,
- 3 out of 4 has a 35% probability, and
- 4 out of 4 has a 50% probability
It is suggested that for a score of 2 or less, no further treatment is recommended; for a score of 3 or 4, you can pursue a rapid Strep antigen detection test (RADT) to determine treatment based on your “clinical gestalt.”
Modified CENTOR criteria:
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- Fever
- Lymphadenopathy (LAN)
- Exudate
- No cough +
- Age:
- Age 3-14 (plus 1 point)
- Age 15-44 (0)
- Age over 45 (minus 1 point)
- Mononucleosis
- Post-cervical LAN
- Fatigue
- Splenomegaly
- Peritonsillar abscess
- Uvular deviation
- Peritonsillar enlargement
- Etc
- Retropharyngeal abscess
- Surgical emergency
- Odynophagia
- Fever
- ? Preceding pharyngitis?
- Diphtheria
-
- Pharyngitis
- Fever
- Cervical lymphadenopathy
- Gray membrane in posterior pharynx which is friable
- Suspect in patients who live in endemic areas and unvaccinated patients
- Epiglottitis
- Disease of adults (used to be children before HIB vaccine)
- Classic sitting forward drooling – now presents more gradually
- Herpes simplex virus
- Vesicles or ulcerations on exam
- May not see if not able to adequately visualize the post pharynx
- Airway obstruction from any cause
- Cancer of the head and neck
- Weight loss
- Smoker
- Patient with 3 rounds of antibiotics
- Allergic rhinitis
- Gastroesophageal reflux disease
- Irritation from recurrent acidic reflux
- Worse after intake of acid type foods
- Lemierre’s syndrome - thrombophlebitis of the internal jugular vein
- Lateral neck pain
- Treatment is ATB and anticoagulation
- Sexually transmitted infections
- Gonorrhea - can occur as high as 15% of the time in men who have sex with men (MSM) - may be asymptomatic
- Chlamydia
- Syphilis
- Warning signs
- Drooling
- Respiratory distress
- Trismus
- Muffled voice
- Neck symptoms (vascular, infectious, thrombosis)
- Respiratory distress (tachypnea, dyspnea, retractions)
- Sniffing or tripod positions
- Sepsis physiology
Other warning signs to look for:
- Severe unilateral sore throat
- Bulging of pharyngeal wall, soft palate, or floor of the oropharynx
- Neck pain or swelling
- Crepitus
- Trismus (irritation and reflex spasm of the internal pterygoid muscle)
- Stiff neck
- Toxic appearance
- Fever and rigors
- History of penetrating trauma to the oropharynx
REFERENCES:
Pharyngitis (Strep Throat). https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
Pharyngitis: approach to diagnosis and treatment
Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Can Fam Physician. 2020;66(4):251-257.
Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America
Shulman ST, Bisno AL, Clegg HW, et al. Clin Infect Dis. 2012;55(10):e86-e102. doi: 10.1093/cid/cis629. [Published correction appears in Clin Infect Dis. 2014 May;58(10):1496. Dosage error in article text]