Paeds · ent-hearing-and-oral-health
Pharyngitis, tonsillitis, peritonsillar abscess and deep neck infection
Also known as Sore throat · Group A streptococcal pharyngitis · Quinsy · Retropharyngeal abscess
Fellowship guide to paediatric sore throat progressing from viral pharyngitis through group A streptococcal tonsillitis to peritonsillar abscess and deep neck infection: the Centor and McIsaac clinical scoring systems and the principle that children need microbiological confirmation before antibiotics because clinical features alone cannot reliably separate bacterial from viral disease; first-line phenoxymethylpenicillin or amoxicillin for ten days; the drooling, trismus and toxic-child red flags that mark peritonsillar abscess, retropharyngeal abscess and parapharyngeal spread; contrast-enhanced CT of the neck; needle aspiration versus incision and drainage for quinsy; intravenous antibiotics and surgical drainage for deep neck space collections; acute rheumatic fever primary prevention; and the ANZ, UK and North American guideline approaches.
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Red flags
- Drooling, refusal to swallow, muffled (hot-potato) voice or trismus — suspect peritonsillar abscess or deep neck infection; keep the child sitting upright, do not force examination, and arrange urgent ENT assessment
- A toxic, septic child with neck stiffness, torticollis, or a palpable neck mass — suspect retropharyngeal or parapharyngeal abscess; arrange urgent contrast CT of the neck, IV antibiotics and surgical consultation
- Sore throat with rapidly progressive neck swelling, crepitus, or mediastinal or pleural involvement — suspect descending necrotising mediastinitis or Lemierre syndrome (septic jugular thrombophlebitis); this is a critical emergency
- Sore throat in an infant or immunocompromised child, or with systemic features out of proportion to the oropharyngeal findings — do not attribute it to simple pharyngitis; broaden the differential and escalate
- Persistent or worsening sore throat beyond three to five days despite appropriate therapy — reassess, reconsider the diagnosis (abscess, EBV, peritonsillar collection), and image if deep neck infection is suspected
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Board mappings
- General and Community Paediatrics
- Acute and infectious illness
- Common ear, nose and throat presentations
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment
- Renewed curriculum from 2027 — Learning goal 6: Acute and critical care
- Antimicrobial stewardship and evidence-based prescribing
- Clinical Applications
- Acute paediatrics and infection
- Short Cases
- Acute assessment scenarios
- Airway and infection scenarios
- 4. Professional skills and knowledge: Patient management
- 6. Acute and emergency care
- General Paediatrics: Recognises and manages common throat and neck presentations
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Common ENT and infection presentations
- Clinical
- History and management planning
- Acute assessment and airway safety-netting
- General Pediatrics Content Outline — Domain 2: Emergency Medicine
- General Pediatrics Content Outline — Domain 5: Infectious Diseases
- General Pediatrics EPA: Manage common acute infections and prescribe safely
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Emergency and acute care
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice: antibiotic stewardship
- Medical Expert
- Communicator
- Collaborator
- Scholar
- Pediatrics: Core EPA — Manage common paediatric infections with antimicrobial stewardship
Overview & Definition
Picture the six-year-old who comes in with a sore throat, a fever, and tonsils coated in white exudate. The parent expects an antibiotic. The fellowship task is to resist reflex treatment, because most sore throats in children are viral — and the one bacterial cause that matters, group A streptococcus, needs to be confirmed by a test, not guessed from the appearance of the throat. This single discipline — score, swab, then treat — is the hinge on which the entire topic turns. [1] [3]
Acute pharyngitis is inflammation of the pharynx, and acute tonsillitis is inflammation of the palatine tonsils; in practice the two overlap and are often described together as acute pharyngotonsillitis. The great majority of cases are viral, caused by rhinovirus, coronavirus, adenovirus, coxsackievirus, Epstein-Barr virus and many others. Group A beta-haemolytic streptococcus (Streptococcus pyogenes) is the single most important bacterial pathogen, accounting for roughly twenty to thirty per cent of sore throats in children over three years, and is the only common cause for which antibiotic treatment is recommended — both to shorten symptoms and to prevent acute rheumatic fever. [1] [6]
What makes this a fellowship topic rather than a routine prescription is that sore throat sits on a continuum with serious deep space infections. A simple tonsillitis can progress to a peritonsillar abscess (quinsy), infection can track into the retropharyngeal or parapharyngeal spaces to form a deep neck abscess, and the same organisms — GAS, mixed oral flora, Fusobacterium necrophorum — can produce Lemierre syndrome (septic jugular thrombophlebitis) or descend into the mediastinum. Recognising where on this spectrum a child sits — routine, urgent, or emergency — is the clinical skill that earns marks and saves lives. [9] [10]
References12ShowHide
- [1]Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis, 2012.PMID 22965026
- [2]Linder JA, Watson ME, Wessels MR, et al. 2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Group A Streptococcal Pharyngitis: Risk Assessment Using Clinical Scoring Systems in Children and Adults. Clin Infect Dis, 2026.PMID 41343363
- [3]McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA, 2004.PMID 15069046
- [4]McIsaac WJ, Goel V, To T, et al. The validity of a sore throat score in family practice. CMAJ, 2000.PMID 11033707
- [5]Aalbers J, O'Brien KK, Chan WS, et al. Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score. BMC Med, 2011.PMID 21631919
- [6]Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev, 2013.PMID 24190439
- [7]Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association. Circulation, 2009.PMID 19246689
- [8]Zühlke L, Beaton A, Engel M, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers, 2026.PMID 41748639
- [9]Centor RM, Atkinson TP, Xiao L Fusobacterium necrophorum oral infections - A need for guidance. Anaerobe, 2022.PMID 35122953
- [10]Darawish SM, Shahid MA, Aziz N, et al. Deep neck space infections in children: Peritonsillar, retropharyngeal, parapharyngeal, and Ludwig's angina emergencies in the pediatric emergency department. Am J Otolaryngol, 2026.PMID 42275833
- [11]Suchecki M, Wolniewicz M, Jędrychowski J, et al. Retropharyngeal and parapharyngeal abscesses in children - a 9.5-year retrospective single-center analysis followed by literature review. Otolaryngol Pol, 2026.PMID 42417448
- [12]DiBlasi M, Higgins RC, Welch N, et al. Increased pediatric head and neck abscesses following the COVID-19 pandemic. Laryngoscope, 2026.PMID 42425765