PANCE Blueprint EENT (7%)

8 y/o with sore throat, fever, and loss of appetite

Patient will present as → a 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.

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I. Bacterial pharyngitis:

• Group A Streptococcal pharyngitis: 5-15% of pharyngitis cases, S. pyogenes.
• Centor Criteria (MDCalc): Estimates probability that pharyngitis is streptococcal, and suggests management course
  • GABHS-suggestive manifestations include fever (> 38°C or 100.4°F), tender anterior cervical adenopathy, lack of cough, and pharyngotonsillar exudate
  • Rapid streptococci screening for GABHS has 90% to 99% sensitivity. If negative and group A streptococci is still suspected, a throat culture is the gold standard
  • Rheumatic fever and post-strep glomerulonephritis
• Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis.

Presentation (bacterial)	Evaluation	Treatment	Image
High fever A severe sore throat No cough Edematous tonsils with white or yellow exudate Cervical adenopathy	Rapid antigen agglutination kit for screening Throat swab culture is the gold standard	Penicillin to prevent acute rheumatic fever If allergic, erythromycin or a first-generation cephalosporin

II. Viral Pharyngitis

• Less likely exudative: CMV, EBV (mononucleosis), adenovirus (most common), influenza, herpes simplex
• Infectious mononucleosis: Caused by Epstein Barr virus, characterized by malaise, fever, severe sore throat, splenomegaly
  • Rash with penicillins
  • Diagnosed by atypical lymphocytes, heterophile agglutination test (monospot)
  • Splenic rupture possible with trauma/contact sports

Presentation (viral)	Evaluation	Treatment	Image
Sore throat Fever Red eye	Clinical	Supportive

III. Fungal Pharyngitis

• Common in patients using inhaled steroids – counsel patients to rinse mouth after use of inhaled steroids.

Presentation (fungal)	Evaluation	Treatment	Image
Sore throat Dysphagia Cheesy white patches in the oropharynx Seen in AIDS patients and small children	Clinical or endoscopy	Clotrimazole troches (one 10-mg troche dissolved slowly five times daily) Miconazole mucoadhesive buccal tablets (50 mg once daily applied to the mucosal surface over the canine fossa) Nystatin swish and swallow (400,000 to 600,000 units four times daily) Fluconazole in HIV + patients

Centor Score for Strep Pharyngitis (MDCalc): 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy

• Not suggestive of strep - coryza, hoarseness, and cough
• If  3 out of 4 Centor criteria are met, get a rapid streptococcal test (sensitivity > 90%)
• If negative → throat culture is the gold standard

Group A Streptococcal pharyngitis: Intramuscular (IM) penicillin can be used if patient compliance is in doubt. Otherwise, oral penicillin or cefuroxime can be used

• Erythromycin or another macrolide can be substituted in cases of penicillin allergy
• Inadequate treatment can lead to complications such as scarlet fever, glomerulonephritis, and abscess formation

Infectious mononucleosis (Epstein Barr virus): Symptomatic and avoid contact sports (splenic rupture), steroids if respiratory distress. Ampicillin and amoxicillin cause rash

• For athletes planning to resume non-contact sports, training can be gradually restarted starting three weeks from symptom onset
• For strenuous contact sports (including football, gymnastics, rugby, hockey, lacrosse, wrestling, diving, and basketball) or activities associated with increased intraabdominal pressure (such as weightlifting) ⇒ four weeks after illness onset

Fungal: clotrimazole, miconazole, or nystatin

Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections

• Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
  • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered