Red flags

  • Drooling/Secretions
  • Dysphonia
  • Dysphagia
  • Muffled "hot potato" voice
  • Neck swelling

Dangerous conditions (consider if red flags)

  • Submandibular space infections (Ludwig's angina - woody induration, crepitus)
  • Primary HIV (mucocutaneous ulcerations)
  • Peritonsillar abscess (trismus)
  • Epiglottitis (out of proportion to findings on exam)
  • Retropharyngeal space infection

If do not improve within 5-7 days or worsening symptoms, consider

  • Infectious mononucleosis (fever, pharyngitis, fatigue, lymphadenopathy, splenomegaly, palatal petechiae)
    • Consider WBC, AST, ALT, Monospot (or EBV serologies)
    • Wait minimum of 4 weeks after illness onset for contact-sports (wait 3w if non-contact)
  • HIV, Gonorrhea
  • CMV, toxoplasmosis
  • Suppurative complication (peritonsillar abscess)
  • Infectious thrombophlebitis of the internal jugular vein (Lemierre's)
    • Fusobacterium necrophorum (in 15-30yo)


  • CENTOR: Cough absent Exudate/erythema tonsils, Neck nodes, Temp, Range of age (3-14=+1, 15-45=0, >45=-1)
  • If CENTOR ≥3 (>30%): Rapid Antigen Detect Test (RADT) and/or culture
    • Negative RADT consider throat culture back-up in children or immunocompromised (sensitivity 86%)
    • Positive RADT do not need back-up culture (specificity 96%)

Not indicated to test

  • <3 years old (unless high risk factor, eg. older sibling with GAS infection)
  • CENTOR 0-1, Viral features (rhinorrhea, cough, oral ulcers, hoarseness)


  • Symptomatic
    • Acetaminophen/NSAIDs
    • Topical (Benzocaine 10mg lozenge q2h PRN, Benzydamine 0.15% 15mL gargle q3h PRN)
    • Consider Dexamethasone 0.6mg/kg (max 10mg) PO x 1 (NNT 12)
  • If strep culture positive (or rapid strep positive), consider antibiotics (NNT 4 if positive strep throat, NNT 14 if no swab taken)
    • Penicillin V (50mg/kg/day ÷ BID) 600mg PO BID x 10d
      • Can consider Pen V QID x 5d
      • Pediatrics: Amoxicillin 50 mg/kg PO daily (max 1g) x 10d
    • If allergic
      • If not anaphylactic, first generation cephalosporin
        • Cephalexin (50mg/kg/day ÷ BID) 500mg PO BID x 10 days
      • If anaphylactic
        • Clarithromycin (15mg/kg/day ÷ BID) 250mg PO BID x 10d

Return To School

  • After full dose of amoxicillin, 91% of children the next morning had negative RADT/culture
    • Consider returning to school on Day 2 of antibiotics if improved/afebrile