Pharyngitis and tonsillitis (tonsillopharyngitis) in children: A pediatrician’s approach

Acute tonsillopharyngitis is a common condition in children, accounting for 5–15% of visits to primary care pediatricians. Acute tonsillopharyngitis is characterized by the sudden onset of characteristic symptoms: sore throat (with or without difficulty swallowing), enlarged and swollen tonsils, enlarged cervical lymph nodes, fever, and general malaise. In most cases, acute tonsillopharyngitis is caused by a viral infection. Rhinovirus, coronavirus, and adenovirus account for at least 30% of all cases, while influenza or parainfluenza viruses account for approximately 4%. Other viral infections that cause ATP include Epstein- Barr virus (EBV), enteroviruses (Coxsackie B), respiratory syncytial virus, herpes viruses, cytomegalovirus, and human immunodeficiency virus. Pediatricians must differentiate between bacterial (Streptococcus pyogenes) and viral tonsillopharyngitis to determine the need for antibacterial therapy. Diagnostic scales (McIsaac, Centor) and a throat swab (strep test or bacteriological examination) are used for this purpose. In cases of GABHS tonsillitis, antibacterial therapy is administered for 10 days. For tonsillopharyngitis of any etiology, symptomatic and topical therapy are prescribed. Among topical antiseptics, the most studied and safe is ambazone (Faringazon), which is prescribed to children aged 3 years and older for 3–4 days. Ambazone has a bacteriostatic effect against Streptococcus haemoliticus, Streptococcus viridans, and Pneumococcus. This article presents a treatment algorithm for patients with ATP for practicing primary care pediatricians, based on the approved Clinical Guidelines for “Acute Respiratory Viral Infection (ARVI)” and “Acute Tonsillitis and Pharyngitis (Acute Tonsillopharyngitis)”.

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

2. Miller KM, Carapetis JR, Van Beneden CA, Cadarette D, Daw JN, Moore HC et al. The global burden of sore throat and group A Streptococcus pharyngitis: A systematic review and meta-analysis. EClinicalMedicine. 2022;48:101458. https://doi.org/10.1016/j.eclinm.2022.101458.

3. Reinholdt KB, Rusan M, Hansen PR, Klug TE. Sore throat management in Danish general practice. BMC Family Pract. 2019;20(1):75. https://doi.org/10.1186/s12875-019-0970-3.

4. Brennan-Krohn T, Ozonoff A, Sandora TJ. Compliance with guidelines for evaluation and treatment of pharyngitis in children: a retrospective study. BMC Pediatr. 2018;18(1):43. https://doi.org/10.1186/s12887-018-0988-z.

5. Caldwell JM, Ledeboer NA, Boyanton BLJr. Review: Known, Emerging, and Remerging Pharyngitis Pathogens. J Infect Dis. 2024;230(Suppl. 3):S173–S181. https://doi.org/10.1093/infdis/jiae391.

6. 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.

7. Little P, Hobbs FD, Moore M, Mant D, Williamson I, McNulty C, Cheng YE 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.k1068.

8. Chiappini E, Bortone B, Di Mauro G, Esposito S, Galli L, Landi M et al. Choosing Wisely: The Top-5 Recommendations from the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children. Clin Ther. 2017;39(3):646–649. https://doi.org/10.1016/j.clinthera.2017.06.003.

9. Fraser H, Gallagher D, Achana F, Court R, Taylor-Phillips S, Nduka C et al. Rapid antigen detection and molecular tests for group A streptococcal infections in acute sore throat: systematic reviews and economic evaluation. Health Technol Assess. 2020;24(31):1–232. https://doi.org/10.3310/hta24310.

10. Rao A, Berg B, Quezada T, Fader R, Walker K, Tang S et al. Diagnosis and antimicrobial therapy of group A streptococcal pharyngitis in children in primary care: the impact of point-of-care polymerase chain reaction. BMC Pediatr. 2019;19(1):24. https://doi.org/10.1186/s12887-019-1393.

11. Chiappini E, Simeone G, Bergamini M, Pellegrino R, Guarino A, Staiano A et al. Treatment of acute pharyngitis in children: an Italian intersociety consensus (SIPPS-SIPSITIP-FIMP-SIAIP-SIMRI-FIMMG). Ital J Pediatr. 2024;50(1):235. https://doi.org/10.1186/s13052-024-01789-5.

12. Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine. 2023;98:104864. https://doi.org/10.1016/j.ebiom.2023.104864.

13. Robinson JL. Paediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance. Drugs Context. 2021;10:2020-11-6. https://doi.org/10.7573/dic.2020-11-6.

14. Hedin K, Thorning S, van Driel ML. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2023;11(11):CD004406. https://doi.org/10.1002/14651858.CD004406.pub6.

15. Guntinas-Lichius O, Geißler K, Mäkitie AA, Ronen O, Bradley PJ, Rinaldo A et al. Treatment of recurrent acute tonsillitis – a systematic review and clinical practice recommendations. Front Surg. 2023;10:1221932. https://doi.org/10.3389/fsurg.2023.1221932.

16. Coutinho G, Duerden M, Sessa A, Caretta-Barradas S. Worldwide comparison of treatment guidelines for sore throat. Int J Clin Pract. 2021;75:e13879.

17. van Driel ML, De Sutter AI, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2021;3(3):CD004406. https://doi.org/10.1002/14651858.CD004406.pub5.

18. Milani GP, Rosa C, Tuzger N, Alberti I, Ghizzi C, Zampogna S et al. Nationwide survey on the management of pediatric pharyngitis in Italian emergency units. Ital J Pediatr. 2023;49(1):114. https://doi.org/10.1186/s13052-023-01514-8.

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

20. Haddad JD, Ng P, James T. Empirical treatment of acute pharyngitis. Am Fam Physician. 2019;100(11):713–714. Available at: https://pubmed.ncbi.nlm.nih.gov/31790183.

21. Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648–655. https://doi.org/10.1056/NEJMcp1009126.

22. Горелов АВ, Калюжин ОВ, Рязанцев СВ, Савенкова МС, Мелехина ЕВ, Гуров АВ. Оптимизация лечения инфекционно-воспалительных заболеваний дыхательных путей в условиях меняющегося характера циркуляции сезонных патогенов. Вопросы практической педиатрии. 2023;18(3):137–149. https://doi.org/10.20953/1817-7646-2023-3-137-149.

23. Баранов АА, Намазова-Баранова ЛС, Лобзин ЮВ, Таточенко ВК, Усков АН, Куличенко ТВ и др. Острая респираторная вирусная инфекция (ОРВИ): клинические рекомендации. Режим доступа: https://www.pediatr-russia.ru/information/klin-rek/proekty-klinicheskikhrekomendatsiy/A0_1.06.2021.pdf.

24. Büttner R, Schwermer M, Ostermann T, Längler A, Zuzak T. Complementary and alternative medicine in the (symptomatic) treatment of acute tonsillitis in children: A systematic review. Complement Ther Med. 2023;73:102940. https://doi.org/10.1016/j.ctim.2023.102940.

25. Svistushkin VM, Mokoyan ZhT, Karpova OYu. Potential of effective topic monotherapy in patients with acute tonsillopharyngitis. Consilium Medicum. 2018;20(11):8–12. (In Russ.) https://doi.org/10.26442/20751753.2018.11.180067.

26. Kladova OV, Shamsheva OV. Clinically proven effectiveness of the antiseptic drug faringosept® (ambazone) over a long period of its use in medical practice. Paediatrician Practice. 2017;(4):29–33. (In Russ.) Available at:

27. https://medi.ru/pp/arhiv/zhurnal_praktika_pediatra_arhiv_za_2017_god/sentyabr_-_oktyabr_2017/5958.