The role of topical therapy in the complex treatment of tonsillopharyngitis in children

Acute tonsillopharyngitis is a common disease (2–5% of paediatric outpatient visits) for which systemic antimicrobials are often prescribed. However, streptococcal tonsillopharyngitis, infection caused by group A beta-hemolytic streptococci (GABHS), is one of the main indications for antibiotic therapy in acute tonsillopharyngitis in children. When developing a treatment regimen for the disease, preference is given to topical therapy (except in cases of streptococcal tonsillopharyngitis), and the topical antimicrobial therapy methodology recognises that laryngospasm may occur in young children, and the microbiome of the oral cavity and pharynx may need correction in frequently ill children after intensive antimicrobial therapy. Aerosol therapy in the form of inhalation of pharmacological agents that have higher chemical and physical activity than their liquid counterparts due to larger total surface area of the dispersed phase is the optimal method for delivering pharmacological agents into the oral cavity and pharynx. In recent years, a new generation antiseptic benzyldimethyl-myristoylamino-propylammonium chloride has become increasingly common. It showed pronounced activity against Gram-positive and Gram-negative bacteria, fungi, complex viruses, including the SARS-CoV-2 coronavirus, protozoa, aerobic, anaerobic flora in the form of monocultures and microbial associations, including strains with multiple antibiotic resistance. This antiseptic agent refers to drugs of low-toxicity, and does not have any local irritating, allergenic, mutagenic, carcinogenic or embryotoxic effect. It has been identified as having immunoadjuvant effect. The review of clinical observations showed that an aerosolized form of benzyldimethyl-myristoylaminopropylammonium chloride had a favourable clinical effect in patients with tonsillopharyngitis of both streptococcal and other, in particular viral, etiology. The aerosolized form of the drug provides a wide spray angle and finely dispersed diffusion, as opposed to a spraying device, due to which the drops of the drug cover the mucous membrane in a more accurate way. The findings of the analysis of systematic reviews on the etiology, clinical picture and diagnosis of acute tonsillopharyngitis, updates on the oropharynx microbiocenosis and methods for its correction, and clinical studies on the efficacy and safety of the aerosolized form of benzyldimethyl-myristoylamino-propylammonium chloride have led to the conclusion that its application as topical therapy is useful for the treatment of acute tonsillopharyngitis in children.

1. Дайхес НА, Баранов АА, Лобзин ЮВ, Намазова-Баранова ЛС, Козлов РС, Поляков ДП и др. Острый тонзиллит и фарингит (Острый тонзиллофарингит): клинические рекомендации. М.; 2024. 55 с. Режим доступа: https://cr.minzdrav.gov.ru/preview-cr/306_3.

2. Tarasova GD, Garashchenko TI, Molchanova EB, Garashchenko MV. Tonsillar problem: new in diagnostics and treatment. Detskaya Otorinolaringologiya. 2019;(3):18–23. (In Russ.) Available at: https://www.elibrary.ru/fttxnl.

3. Гаращенко ТИ, Страчунский ЛС. Антибактериальная терапия ЛОРзаболеваний в детском возрасте. В: Богомильский МР, Чистякова ВР (ред.). Детская оториноларингология. М.: Медицина; 2005. Т. 2, с. 275–285.

4. Kryukov AI, Ivoylov AY, Kulagina MI. Acute tonsillit in children: diagnosis, predictive value, treatment. Meditsinskiy Sovet. 2015;(3):56–59. (In Russ.) Available at: https://www.med-sovet.pro/jour/article/view/138.

5. Ilyenko LI, Garashchenko TI, Payganova NE. Current trends in the treatment of acute tonsillophayngitis in children. Clinical Practice in Pediatrics. 2022;17(4):164–173. (In Russ.) https://doi.org/10.20953/1817-7646-2022-4-164-173.

6. Garashchenko TI. Macrolides in the treatment of acute tonsillitis and its complications in children. RMJ. 2001;9(19):812–816. (In Russ.) Available at: https://www.rmj.ru/articles/pediatriya/Makrolidy_v_terapii_ostrogo_tonzillita_i_ego_osloghneniy_u_detey/.

7. Karneeva, OV, Dajhes NA, Polyakov DP. Protocols for the diagnosis and treatment of acute tonsillopharyngitis. RMJ. 2015;23(6):307–310. (In Russ.) Available at: https://www.rmj.ru/articles/otorinolaringologiya/Protokoly_diagnostiki_i_lecheniya_ostryh_tonzillofaringitov/.

8. Mendes N, Miguéis C, Lindo J, Gonçalves T, Miguéis A. Retrospective study of group A Streptococcus oropharyngeal infection diagnosis using a rapid antigenic detection test in a paediatric population from the central region of Portugal. Eur J Clin Microbiol Infect Dis. 2021;40(6):1235–1243. https://doi.org/10.1007/s10096-021-04157-x.

9. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a metaanalysis. Pediatrics. 2010;126(3):e557–e564. https://doi.org/10.1542/peds.2009-2648.

10. Oliver J, Malliya Wadu E, Pierse N, Moreland NJ, Williamson DA, Baker MG. Group A Streptococcus pharyngitis and pharyngeal carriage: a metaanalysis. PLoS Negl Trop Dis. 2018;12(3):e0006335. https://doi.org/10.1371/journal.pntd.0006335.

11. Piñeiro Pérez R, Álvez González F, Baquero-Artigao F, Cruz Cañete M, de la Flor I Bru J, Fernández Landaluce A et al. Diagnosis and treatment of acute tonsillopharyngitis. Consensus document update. An Pediatr. 2020;93(3):206.e1–206.e8. (In Spanish) https://doi.org/10.1016/j.anpedi.2020.05.004.

12. Garashchenko TI, Boikova NE. Tonsillopharyngitis. Is the choice of antibiotic therapy so clear? Meditsinskiy Sovet. 2015;(1):12–17. (In Russ.) Available at: https://www.med-sovet.pro/jour/article/view/483.

13. Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Intern Med. 2006;166(13):1374–1379. https://doi.org/10.1001/archinte.166.13.1374.

14. Lobzin YuV, Briko NI, Kozlov RS, Sidorenko SV, Tatochenko VK, Bakradze MD et al. Resolution of the expert council “Principles of rational antibiotic therapy of respiratory infections in children. Let’s preserve antibiotics for future generations”. March 31, 2018, Moscow. Pediatrics. Consilium Medicum. 2018;(3):10–15. (In Russ.) Available at: https://www.elibrary.ru/ymcqqh.

15. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12(12):CD000023. https://doi.org/10.1002/14651858.cd000023.pub5.

16. Rún Sigurðardóttir N, Nielsen AB, Munck A, Bjerrum L. Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland. Scand J Prim Health Care. 2015;33(4):269–274. https://doi.org/10.3109/02813432.2015.1114349.

17. Smith DRM, Dolk FCK, Pouwels KB, Christie M, Robotham JV, Smieszek T. Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care. J Antimicrob Chemother. 2018;73(Suppl. 2):ii11–ii18. https://doi.org/10.1093/jac/dkx503.

18. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847–852. https://doi.org/10.1001/archinternmed.2012.950.

19. Muthanna A, Shamsuddin NH, Abdul Rashid A, Ghazali SS, Hamat RA, Mawardi M et al. Diagnostic Accuracy of Centor Score for Diagnosis of Group A Streptococcal Pharyngitis among Adults in Primary Care Clinics in Malaysia. Malays J Med Sci. 2022;29(4):88–97. https://doi.org/10.21315/mjms2022.29.4.9.

20. Little P, Hobbs FD, Moore M, Mant D, Williamson I, McNulty C et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013;347:f5806. https://doi.org/10.1136/bmj.f5806.

21. Ястремский АП. Диагностика острых воспалительных заболеваний глотки с применением информационных технологий. Тюмень: Тюменский дом печати; 2021. 178 с. Режим доступа: https://www.elibrary.ru/uwdhns.

22. Yastremsky AP, Izvin AI, Sannikov AG, Sokolovsky NS, Zaharov SD. Results of the expert systems comparison for diagnostics of acute pharyngeal diseases. Medical Doctor and Information Technology. 2016;(5):15–25. (In Russ.) Available at: https://elibrary.ru/wyrmxv.

23. Ivaska L, Niemelä J, Gröndahl-Yli-Hannuksela K, Putkuri N, Vuopio J, Vuorinen T et al. Detection of group A streptococcus in children with confirmed viral pharyngitis and antiviral host response. Eur J Pediatr. 2022;181(12):4059–4065. https://doi.org/10.1007/s00431-022-04633-2.

24. Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev. 2016;7(7):CD010502. https://doi.org/10.1002/14651858.CD010502.pub2.

25. Boykova NE, Garashchenko TI. Topical therapy in acute tonsillopharyngitis. Lechaschi Vrach. 2014;(9):32. (In Russ.) Available at: https://www.lvrach.ru/2014/09/15436049.

26. Ryazantsev SV, Pavlova SV. Modern possibilities of topical therapy of upper respiratory tract and throat infectious inflammatory diseases. Meditsinskiy Sovet. 2020;(6):14–20. (In Russ.) https://doi.org/10.21518/2079-701X2020-6-14-20.

27. Rosatkevich AG, Pavlycheva DK, Denisyuk DA, Antipyat NA, Smetanina SV, Lazareva NB, Payganova NE. Use of topical antiseptics in case of acute tonsillopharyngitis: Estimation of current treatment tendencies and prevention of complications of the disease. Therapy. 2019;(6):183–189. (In Russ.) https://doi.org/10.18565/therapy.2019.6.183-189.

28. Savlevich EL, Simbirtsev AS, Chistyakova GN, Terekhina KG, Batskalevich NA. The state of systemic and local immunity in acute nasopharyngitis with ARVI. Therapy. 2021;(4):57–63. (In Russ.) https://doi.org/10.18565/therapy.2021.4.57-63.

29. Kirichenko IM. Survey of efficiency of application of Miramistin® preparation in exacerbation of chronic tonsillitis and acute pharyngitis. Lechaschi Vrach. 2013;(6):92. (In Russ.) Available at: https://www.lvrach.ru/2013/06/15435741.

30. Leneva IA, Gracheva AV, Korchevaya EP, Smirnova DI, Faizuloev EB. Experimental study of the effect of the active substance of miramistin® on the infectious activity of the SARS-CoV-2 in vitro. Epidemiology and Infectious Diseases. Current Items. 2022;12(3):91–96. (In Russ.) https://doi.org/10.18565/epidem.2022.12.3.91-6.

31. Nikolaeva IV, Gerasimova ES, Pavlova TYu. Efficacy of miramistin in the correction of the oropharynx microbiocenosis in sickly children. Russian Pediatric Journal. 2016;19(1):9–14. (In Russ.) Available at: https://miramistin.ru/upload/iblock/6c6/0tn3bwsjtbgm00w5yo51qn6j9 49nj290.pdf.

32. Khan MA, Lyan NA, Vakhova YEL, Mikitchenko NA. Using of Miramistin® preparation in treatment of children with acute nasopharyngitis. Lechaschi Vrach. 2014;(1):93. Available at: https://www.lvrach.ru/2014/06/15435999.

33. Khan MA, Lyan NA, Vakhova EL, Mikitchenko LI, Radetskaya LI. Inhalation of myramistin in the children presenting with acute respiratory diseases. Voprosy Kurortologii, Fizioterapii, i Lechebnoi Fizicheskoi Kultury. 2015;92(3):35–39. (In Russ.) https://doi.org/10.17116/kurort2015335-39.

34. Svistushkin VM, Nikiforova GN, Toporkova LA, Karpova OYu. Possibilities of topical etiotropic drugs in the treatment of patients with acute tonsillopharyngitis. RMJ. 2018;26(10):97–102. (In Russ.) Available at: https://www.rmj.ru/articles/otorinolaringologiya/Vozmoghnosti_topicheskih_etiotropnyh_preparatov_v_lechenii_bolynyh_ostrym_tonzillofaringitom/.

35. Karpischenko SA, Kolesnikova OM. Modern solution in the treatment of acute tonsillopharyngitis. RMJ. 2023;(1):46–50. (In Russ.) Available at: https://www.rmj.ru/articles/otorinolaringologiya/Sovremennoe_reshenie_v_lechenii_ostrogo_tonzillofaringita/.