From the Guidelines
I strongly recommend referring a patient with recurrent strep throat to an ENT specialist after they've had 7 or more episodes in one year, 5 or more episodes per year for two consecutive years, or 3 or more episodes per year for three consecutive years, as stated in the clinical practice guideline for tonsillectomy in children 1. This recommendation is based on the frequency of throat infections with documentation of sore throat and at least one of the following: temperature > 38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. The ENT specialist will evaluate the patient for potential tonsillectomy, which may be beneficial in reducing future strep infections, as the tonsils can harbor streptococcal bacteria in their crypts, making them difficult to eradicate with antibiotics alone 1. Before referral, ensure proper documentation of each strep episode with positive rapid strep tests or throat cultures, antibiotic treatments given, and the patient's response. The ENT will also assess for complications of recurrent strep such as peritonsillar abscess or rheumatic fever risk, and may consider additional factors like the impact on quality of life, missed school or work days, and antibiotic allergies when determining the appropriate treatment approach. It's worth noting that the Infectious Diseases Society of America recommends against tonsillectomy solely to reduce the frequency of GAS pharyngitis 1, but the American Academy of Otolaryngology-Head and Neck Surgery suggests that tonsillectomy may be considered for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years 1. Given the potential benefits and harms, referral to an ENT specialist is recommended for patients who meet the specified criteria, as it may improve their quality of life and reduce the risk of future complications.
From the Research
Referral for ENT for Recurrent Strep
- Recurrent strep throat, also known as recurrent streptococcal pharyngitis, is a common condition that can lead to complications such as rheumatic fever and post-streptococcal glomerulonephritis 2, 3, 4.
- The diagnosis of streptococcal pharyngitis is typically made using clinical decision rules, rapid antigen testing, and throat culture 2, 3.
- Antibiotic treatment is usually recommended for patients with streptococcal pharyngitis, with penicillin and amoxicillin being the first-line antibiotics 2, 3, 5, 6.
- However, there is limited evidence to support the use of other antibiotics, such as cephalosporins and macrolides, over penicillin 5, 6.
- Tonsillectomy may be considered in patients with recurrent streptococcal pharyngitis, but the benefits and risks of this procedure should be carefully weighed 2, 3, 4.
Indications for Referral to ENT
- Patients with recurrent streptococcal pharyngitis may be referred to an ENT specialist for further evaluation and management 2, 3, 4.
- Indications for referral to ENT may include:
- Recurrent streptococcal pharyngitis despite adequate antibiotic treatment
- Complications of streptococcal pharyngitis, such as rheumatic fever or post-streptococcal glomerulonephritis
- Tonsillar hypertrophy or other anatomical abnormalities that may contribute to recurrent infection
- Patient or family history of recurrent streptococcal pharyngitis or other conditions that may increase the risk of complications
Management of Recurrent Strep
- The management of recurrent streptococcal pharyngitis typically involves a combination of antibiotic treatment and supportive care 2, 3, 5, 6, 4.
- Patients with recurrent streptococcal pharyngitis should be educated on the importance of completing the full course of antibiotic treatment and following proper hygiene practices to reduce the risk of transmission to others 2, 3, 4.
- In some cases, tonsillectomy may be recommended as a preventive measure to reduce the risk of recurrent streptococcal pharyngitis 2, 3, 4.