Pediatric ENT in 40 Minutes

Pediatric ENT in 40 Minutes
Gil C. Grimes, MD Assistant Professor Family Medicine Texas A&M HSC COM Scott and White Family Medicine Residency April 6th 2005

Objectives Describe criteria for diagnosing Acute Otitis Media
Describe rationale for therapy for Acute Otitis Media Describe Therapy for Serous Otitis Media Describe the role of Tympanostomy Tubes Describe the strategies for diagnosing Strep Pharyngitis Describe Treatment options for Strep Pharyngitis

My Bias I am a minimalist
If the evidence for intervention is not good I do nothing

Acute Otitis Media A diagnosis of AOM requires
a history of acute onset of signs and symptoms the presence of middle ear effusion (MEE) signs and symptoms of middle-ear inflammation. Pediatrics 2004 May;113(5): Level 1a

Acute Otitis Media The presence of MEE that is indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the tympanic membrane Air-fluid level behind the tympanic membrane Otorrhea

Acute Otitis Media Signs or symptoms of middle-ear inflammation as indicated by either Distinct erythema of the tympanic membrane or Distinct otalgia discomfort clearly referable to the ear(s) and interference with or precludes normal activity or sleep

Acute Otitis Media Otitis Media? Yes No A diagnosis of AOM requires
a history of acute onset of signs and symptoms the presence of middle ear effusion (MEE) signs and symptoms of middle-ear inflammation.

Acute Otitis Media Prevalence
10% US children diagnosed by 3 months 90% by 2 years (1) Prospective cohort of children (2) 62% with AOM by 1 year 83% with AOM by 3 years 9th most common diagnosis during FM visits(3) Coded 3.2% visits (3) 1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b 2)J Infect Dis 1989 Jul;160(1):83 Level 2b 3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c

Acute Otitis Media Etiology
Viral pathogens found Tympanocentesis and Nasal Aspirate in AOM RSV and coronavirus RNA in 75% children 5% dual viral infections Bacterial pathogens detected 62% Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples Pediatrics 1998 Aug;102(2):291 Level 1c

Acute Otitis Media Etiology
Bacteria shifts Streptococcus pneumoniae S. pneumoniae is the most common bacterial organism identified non-typeable Haemophilus influenzae H. flu identified primarily in children < 5, but reduced with routine immunization Moraxella (Branhamella) catarrhalis may be changing due to heptavalent pneumococcal vaccine decrease in S. pneumoniae and increase in H. influenzae Tympanocentesis results in cohorts of 551 children in Rochester, NY persistent acute otitis media after antibiotics or treatment failure after 48 hours of antibiotics Middle ear aspirates sampled three distinct time periods (standard Amoxicillin period) (high dose Amoxicillin period) (high dose Amoxicillin and pneumococcal conjugate vaccine) Streptococcus pneumoniae (48, 44 and 31%) Haemophilus influenzae (38, 43 and 57%) There was a significant decline in S. pneumoniae (P = 0.017) An increase in H. influenzae (P = 0.012) isolations H. influenzae that were beta-lactamase-producing (P = 0.04) Percentage increased for S. pneumoniae in that were penicillin-susceptible (P = 0.17). Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b

Acute Otitis Media Risk Factors
Formula feeding incidence of otitis media is higher in formula-fed infants vs. breast-fed infants incidence of prolonged ear infections was 5x higher among formula-fed infants Duration OM episodes longer (8.8 vs. 5.9 days) J Pediatric 1995 May;126(5 Pt 1):696 Level 2b

Day Care Attendance day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life Pediatrics 1999 Sep;104(3):495 Level 2b

Acute Otitis Media Risk Factors.
Associated with 2 or more doctor-diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] ) For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included exposure to pets in day care presence of rug or carpet in area where child slept in day care nonresidential setting for day care Pediatrics 1999 Sep;104(3):495 Level 2b

Passive Smoking 625 Children Calgary first graders Middle ear disease 2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], 10 or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, ) 10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, ) during the first 3 years of life Arch Pediatric Adolescent Med Feb;152(2):127 Level 2c

Acute Otitis Media History Statistics Poor predictive value
Studies are not good Statistics LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

Acute Otitis Media Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

Acute Otitis Media Physical Findings
Based on prospective study of 8,859 ear-related visits among children years with acute symptoms myringotomy performed if middle ear effusion suspected on exam 51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy) Color not particularly helpful but cloudy membrane predictive red color was not highly predictive cloudy tympanic membrane had 80-96% positive predictive value normal color dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal color) Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

Acute Otitis Media Physical Continued
Position helpful if clearly bulging bulging tympanic membrane had 89-96% positive predictive value retracted tympanic membrane had 47-50% positive predictive value normal position had 22-32% probability of AOM Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

Acute Otitis Media Mobility helpful if distinctly impaired or clearly normal distinctly impaired mobility had 78-94% positive predictive value slightly impaired mobility had 33-60% positive predictive value normal mobility dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)

Acute Otitis Media Test Name Positive Likelihood Ratio
TM position: bulging 51.00 TM color: cloudy 34.00 TM mobility: distinctly impaired 31.00 TM color: distinctly red 8.40 TM mobility: slightly impaired 4.00 TM position: retracted 3.50 TM color: slightly red 1.40 TM position: normal 0.50 TM color: normal 0.20 TM mobility: normal

Acute Otitis Media Type A pattern is normal
Type B pattern is consistent with MEE Type C is seen with retracted TM

Acute Otitis Media Prognosis
Spontaneous resolution is the norm 81% spontaneously resolve (1) 5000 children with otitis(2) >90% resolved with supportive care 2.7% had a severe course (required antibiotics or myringotomy at 5 days) Pediatrics 5 May :1452 Level 1a Br Med J (Clin Res Ed) Apr 6; 290(6474):1033 Level 1b

Recurrent otitis media no long term consequences usually spontaneous recovery study of 222 children with recurrent otitis media who received no prophylaxis 4% developed chronic otitis media with effusion 12% continued having recurrent episodes most significant risk factor for continued recurrence was age < 16 months (1) Pediatrics 5 May :1452 Level 1a

Persistent effusion Watchful Waiting recommended in children without the following: Permanent hearing loss independent of OME Suspected or diagnosed speech and language delay or disorder Autism-spectrum disorder and other pervasive developmental disorders syndromes (e.g., Down) Craniofacial disorders that include cognitive, speech, and language delays Blindness or uncorrectable visual impairment Cleft palate with or without associated syndrome Developmental delay Pediatrics 5 May :5; Level 1a

Persistent effusion Change from B to non-B tympanogram favorable 25% of OME of unknown duration resolves in 3 months Warn parents of decreased hearing while effusion present Recheck every three months Pediatrics 5 May :5; Level 1a

Acute Otitis Media Treatment
Treat Pain Acetaminophen and ibuprofen (1) 219 children treated with cefaclor evaluated pain at 2 days Ibuprofen 7% with pain NNT 5 Acetaminophen 10% with pain NNT 6 Placebo 25% Fundam Clin Pharmacol. 1996;10(4):387 Level 1c

Initial treatment options are observation or antibiotics for children < 6 months old, antibiotics recommended for children 6 months to 2 years old observation option recommended only if all of the following are present otherwise healthy child uncertain diagnosis non-severe illness follow-up can be ensured so antibiotics can be started if symptoms persist or worsen antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured

For children > 2 years old Observation option recommended only if the following are present otherwise healthy child uncertain diagnosis OR non-severe illness follow-up can be ensured so antibiotics can be started if symptoms persist or worsen Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured DynaMed Acute Otitis Media Accessed March

No improvement in hours Confirm the diagnosis If AOM certain then begin antibiotics if not already started Change antibiotics if already started

Antibiotics CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance You must know your community Pediatrics 5 May 2004;113(5):1452 Level 1a

Amoxicillin mg/kg/day divided TID for 10 days Failure at 3 days switch to one of the following cefuroxime axetil (Ceftin) 15 mg/kg BID for 10 days amoxicillin-clavulanate (Augmentin) Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days ceftriaxone (Rocephin) IM 50mg/kg for 3 days Pediatric Infect Dis J Jan;18(1):1 Level 1a

Penicillin Sensitive patients Not Type I reaction (no urticaria or anaphylaxis) (1) Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2) Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days Ceftriaxone (Rocephin) 50mg/kg IM once Pediatrics 5 May 2004;113(5):1452 Level 1a Pediatric Infect Dis J 2000 Dec;19(12 Suppl):S181 Level 3

Penicillin Sensitive Patients Type I reaction Azithromycin (Zithromax) 10 mg/kg day one then 5 mg/kg days 2-5 Clarithromycin (Biaxin) 15 mg/day divided BID for 10 days Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg daily of erythromycin divided TID to QID for 10 days Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days Pediatrics 5 May 2004;113(5):1452 Level 1a

Acute Otitis Media Reality
Shorter therapy 5 days is likely as beneficial as longer therapy (1) Early treatment with antibiotics may lead to increased resistance (2) Side effects are as common as benefit NNT at 1 week NNH 17 at one week Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3) JAMA Jun 3;279(21):1736 Level 1a J Infect Dis Mar 15;183(6):880 Level 4 BMJ 2001 Feb 10;322:336 Level 1c

Acute Otitis Media Guideline Review Pediatrics 2004 May;113(5):1451
Summary can be found in Am Fam Physician 2004 Jun 1;69(11):2713 editorial can be found in Am Fam Physician 2004 Jun 1;69(11):2537 commentary can be found in Pediatrics 2004 Sep;114(3):898 commentary can be found in Pediatrics 2005 Feb;115(2):513

Serous Otitis Media PtEducENT/Default.htm

Serous Otitis Media Causes
Overgrowth of lymphoid tissue in the nasopharynx Chronic sinus infection Allergies of nose and nasopharynx Gastric reflux implicated Pepsin seen in MEE 45 of 54 children with SOM (1) Pepsin seen in MEE 59 of 65 children with SOM (2) Lancet 2002 Feb 9;359(9305):493 Level 4 Laryngoscope Nov;112(11):1930 Level 4

Serous Otitis Media Complications
Permanent hearing loss (?) (5) Tympanosclerosis Fibrosis of middle ear space Balance problems (1) Minor language deficits (+/-) (2) No association with attention or behavior in first 6 years of life (3) Possible behavior problems in teens (4) Balance problems studied in children who had MEE and had tympanocentesis they measure balance prior and post Language deficits were present but analysis implicates home environment more so than MEE Cohort of students with MEE vs. same population but who did not meet the MEE standard no behavior problems as rated by teachers and parents Birth Cohort looked at effect of MEE into Teenage years and saw some increased behavior problems Prospective cohort found no association with hearing loss and MEE during the first four years of life Pediatrics Mar;99(3):334 Level 4 Pediatrics May;105(5):1119 Level 2c Pediatrics May;107(5):1037 Level 1b 4) Arch Dis Child Aug;85(2):91 Level 1b 5) Pediatrics Sep;106(3):E42 Level 1c

Serous Otitis Media Physical
Physical examination Pearly gray Minimal dullness Minimal retraction Presence of effusion

Serous Otitis Media Tests
Key tests Pneumo-otoscopy with limited movement (1) Sensitivity of 94% (95% CI: 92%-96%) Specificity of 80% (95% CI: 75%-86%) Tympanogram B-curve (2) 81% sensitivity 56% specificity Audiometry Carhart Notch (2) 77% sensitivity 98% specificity Pediatrics Dec;112(6 Pt 1):1379 Level 1a Clin Otolaryngol Jun;28(3):183 Leve 1c

Serous Otitis Media Prognosis
High rate of spontaneous resolution (1) Most resolve in 3 months Meta-analysis 11 trials (2) No significant hearing loss No speech/language delay Tubes have consequences (3) 140 children followed 8 years Sequela higher at 3-5 years 47% for retraction pocket 67% for tympanic membrane atrophy 40% for myringosclerosis 23% for hearing loss Pediatrics 2004 May 5;113(5):1412 Level 1a Pediatrics 2004 March; 113(3): e238 Level 1a Arch Otolaryngol Head Neck Surg May;129(5):517 level 1b

Serous Otitis Media Treatment
Medications Antibiotics not beneficial (1) Most rigorous meta-analysis find no benefit long-term Some short-term benefit may exist Steroids Nasal steroids no evidence of benefit (2) Systemic steroids no difference long term (3) J Fam Pract Apr;52(4):321 FPIN network answer Cochrane Library 2002 Issue 4:CD Level 1a Pediatrics Dec;110(6):1071 Level 2b

Surgery no clear evidence of benefit RCT of a birth cohort that developed MEE (1) Randomized to early tube placement or delay of 6 months (unilateral MEE) to 9 months (bilateral MEE) Delayed group had better outcomes cognition, language (not significant) at age 3 Reduced time with MEE but no change in language or hearing (2) No change in quality of life N Engl J Med Apr 19;344(16):1179 Level 1b Cochrane Library 2005 Issue 1:CD Level 1a

Surgery no clear evidence of benefit Cohort 30,099 children born in the Netherlands Routine hearing screening at age 9 months 1,081 who failed 3 successive hearing screens were referred to ENT surgeon 386 found to have persistent bilateral otitis media with effusion for 4-6 months 187 children (mean age 19.5 months) were randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4), No differences in language development Pediatrics 2000 Sep;106(3):e42 Level 1c

Post-tube precautions unrandomized trial in 533 children who underwent tympanostomy tube placement parents self-selected into 1 of 3 "treatments" to prevent complications of swimming no additional precautions antibiotic drops following swimming ear molds worn during swimming control group consisted of children who never went swimming all were given precautions against deep water swimming (> 180 cm), diving and soapy water in ears during bathing no benefit was noted from antibiotic ear drops or ear plugs Arch Otolaryngol Head Neck Surg Mar;122(3):276 Level 2b

Strep Pharyngitis

Strep Pharyngitis Basics
Bacteria Streptococcus pyogenes AKA Group A beta-hemolytic streptococcus (GABHS) More than 80 sero-types based on M protein Transmission Person-person Aerosol Water NOT household pets (1) Incubation period 2-4 days Pediatric Infect Dis J 1995 May;14;372

Strep Pharyngitis Risk Factors
More common during school year Crowded living situation Exposure to GABHS Youth Immunosuppression Smoking Excessive alcohol consumption Diabetes mellitus Recent illness Griffin's 5 Minute Clinical Consult from InfoRetriever Level 5

Strep Pharyngitis Complications
Acute Rheumatic Fever (1) Develops in 1-3% children with GABHS Only throat infections not skin Common in developing nations (2) 30 million children in the developing world have heart disease due to rheumatic fever 70% of whom will die prematurely at average age of 35 Acute Glomerulonephritis Less common than rheumatic fever Most patients recover Tonsillitis Peritonsillar Abscess Pediatrician. 1986;13(4):180 Level 3 Tropical Doctor 1999 Jul;29(3):129 Level 5

Strep Pharyngitis History
Abrupt onset of symptoms Fever may last 4-5 days Constitutional symptoms Fever and chills Myalgias Headache Nausea and vomiting Unlikely to have runny nose, cough, conjunctivitis, hoarseness, diarrhea Exposure to strep throat infection in previous 2 weeks associated with increased likelihood of strep throat

Strep Pharyngitis Tests
Rapid Strep Tests Results available in 5-10 minutes 76-87% sensitivity > 95% specificity depending on specific test kit used Genzyme's OSOM Ultra Strep A test 92.6% sensitivity 92.8% specificity Biostar's Strep A OIA Max Test 75.5% sensitivity 97.1% specificity Pediatric Infect Dis J 2002 Oct;21(10):922 Level 1c

Strep Pharyngitis Tests
Rapid strep test 15% false positive rate in adults (1) Study of 522 adults with acute pharyngitis and/or tonsillitis who had positive rapid antigen detection test results 77 (15%) had negative cultures for group A streptococci Low sensitivity If sensitivity below 90% consider backup culture (3) Physicians should validate the sensitivity of their own Rapid strep tests J Infect Dis Apr 1;183(7):1135 Level 2b Br J Gen Pract 1998 Feb;48;959 Level 2b Pediatrics 2004 Apr;113(4):924

Strep Pharyngitis Rules
Canadian Approach One Point Each Temp >38 C No Cough Tender anterior lymph nodes Tonsillar swelling or exudate Age 3-14 years No Points Age years Subtract One point Age >44 years CMAJ Jan 13;158(1):75 Level 1c

Score Overall (%) Cx (-) Cx(+) LR(+) 160 (31.8) 156(97.5) 4(2.5) 0.14 1 138(27.4) 131(94.9) 7(5.1) 0.32 2 98(19.5) 87(88.8) 11(11.2) 0.84 3 54(10.7) 39(72.2) 15(27.8) 2.49 4 53(10.5) 25(47.2) 28(52.8) 6.43

Strep Pharyngitis Strategies
Canadian Scoring System Authors' recommendations withhold antibiotics and culture if score 0-1 culture if score 2-3 empiric antibiotics if score 4-5 CMAJ Oct 3;163(7):811 Level 1a

Study of 621 patients seen by 97 Canadian family physicians 600 had throat culture of which 17% were positive risk of strep throat was 1% if score 0 or -1 10% if 1 17% if 2 35% if 3 51% if 4 or 5 following clinical rule would have reduced unnecessary antibiotic prescriptions by 64% and use of throat cultures by 35% CMAJ Oct 3;163(7):811 Level 1a

Centor clinical prediction rule validated in 3 adult populations 1 point if tonsillar exudate 1 point if swollen tender anterior cervical nodes 1 point if absence of cough 1 point of history of fever 0-1 points suggests very low risk 3-4 points suggests increased risk for strep throat JAMA 2000 Dec 13;284(22);2912 Level 1a

CDC evidence-based guidelines Adults (1) 4 empiric treatment 3 empiric treatment or rapid antigen testing with treatment only if positive 2 rapid antigen testing (treatment only if positive) or no testing or antibiotic treatment 1 or 0 no testing or antibiotic treatment 1) JAMA 2000 Dec 13;284(22);2912 Level 1a

Strep Pharyngitis Therapy
Comfort Medications systemic analgesics and antipyretics - such as acetaminophen (Tylenol) or NSAIDs (e.g., ibuprofen [Motrin]) topical analgesics (e.g., nonprescription throat sprays) and anesthetics (e.g., viscous lidocaine 2%) warm salt water gargles throat lozenges, hard candy or frozen desserts soft foods or cold thick liquids (e.g., ice cream, nectars, pudding) humidifier

Antibiotics Penicillin is the gold standard for prevention of Rheumatic Fever (Historically) Benzathine penicillin G 1.2 million U ( ,000 U if age < 12) IM once Penicillin V 500 mg PO tid for 10 days In children, penicillin VK mg/kg/day divided bid to qid CDC Recommendations

Amoxicillin in children, mg/kg/day divided bid to tid short-course amoxicillin (1 g PO bid for 6 days) as effective as penicillin 500 mg tid for 10 days in trial of 338 patients > 15 years old (1) clinical cure rate was 96.4% vs. 96.5% at 72 hours after treatment and 93.5% vs. 96.3% at 1 month 10 vs. 6 recurrences throat pain resolved more quickly on amoxicillin 3% vs. 5.2% adverse effects 1) Scand J Infect Dis. 1996;28(5):497 Level 1c

Amoxicillin once-daily amoxicillin 750 mg PO qd for 10 days No significant difference in clinical or bacteriologic responses at hour follow-up visit 5% vs. 11% bacteriologic treatment failures at subsequent follow-up visits over 4 days through 3 weeks, 16% vs. 21% had positive throat cultures many were considered a "new acquisition" since the organism was a different strain of group A beta-hemolytic streptococci; among 79 patients in amoxicillin group 2 had macular rash 3 had diarrhea 3 had abdominal pain Pediatrics Jan;103(1):47 Level 1c

Oral Cephalosporins Systematic review and meta-analysis of 35 randomized trials with 7,125 children Most trials were low quality 59% with Jahad Score 0-2 Jahad score rates quality of study 0 (low) to 5 (high) Bacteriologic cure rates (92.6% vs. 80.6%, NNT 8) Clinical cure rates (93.6% vs. 85.8%, NNT 13) Differences in clinical cure occurred among studies of cefuroxime and loracarbef Pediatrics 2004 Apr;113(4):866 Level 1a

Clarithromycin for 5 days as effective as penicillin for 10 days 349 patients aged with acute strep Randomized to clarithromycin modified-release 500 mg once daily for 5 days vs. penicillin 590 mg tid for 10 days No significant differences in clinical cure rates (88% vs. 92%) or eradication rates (83% vs. 84%) Open Label Phase III Study J Antimicrob Chemother 2002 Feb;49(2):337 Level 2c

Azithromycin Associated with similar clinical cure rates but lower bacterial eradication rates 94% Azithromycin vs. 98%Ceftibuten Higher bacterial recurrence rates compared to beta-lactam antibiotics in randomized trials Regimen evaluated was azithromycin 10 m/kg/day (maximum 500 mg) for 3 days Pediatric Infect Dis J Oct;19(10):963 Level 2c

Dexamethasone 10 mg PO or IM in single dose associated with faster pain relief (median 4 hours) and may reduce return visits; 118 patients > 15 years old presenting to emergency department Randomized to dexamethasone 10 mg PO vs. dexamethasone 10 mg IM vs. double placebo All patients given penicillin VK 500 mg (erythromycin 333 mg if penicillin-allergic) PO tid for 10 days and 6 doses of acetaminophen for 24 hours Pain measured on 0-10 scale Laryngoscope 2002 Jan;112;87

Median reduction in pain scores IM dexamethasone 12 hours -4 24 hours -5 19% resolution at 24 hours PO dexamethasone 12 hours -3 24 hours -4 20% resolution pain at 24 hours Placebo 12 hours -2 3% resolution of pain at 24 hours

Time to onset of pain relief was 5.8 hours with IM dexamethasone 6 hours with PO dexamethasone 10.1 hours with placebo (p = 0.029) Return Visits within 5 days No patients receiving IM dexamethasone 7% receiving PO dexamethasone 16% receiving placebo returned to emergency department for sore throat within 5 days (p = 0.23)

Strep Pharyngitis Guidelines
Sore Throat Encounter Form American Family Physician 2003 Sep1;68(5):938

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