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Is Pharyngitis in the Eye of the Beholder?

March 14, 2019

Written by Clay Smith

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Interrater agreement on whether a child’s throat was red or not was “fair” (aka…pretty bad), although agreement was significantly better when grading tonsillar hypertrophy.

Why does this matter?
To determine if a patient has pharyngitis, it is important to be able to tell if it’s red and the tonsils are swollen. But can we even agree on whether or not a patient’s throat is red? Is a red throat in the eye of the beholder?

Is that throat red? Who knows…
The authors showed 20 throat pictures to 33 physicians with varying levels of experience to determine the interrater agreement on whether the throat had pharyngeal injection (PI) or palatine tonsillar hypertrophy (PTH). For PI, agreement (Fleiss’ kappa) was 0.296, which is pretty bad. Officially, 0.21-0.40 means “fair agreement.” Clinicians were better at PTH; agreement (Kendall’s W) was 0.674, which is pretty good. Values between 0.61 to 0.80 mean “substantial agreement.” Agreement was no better among more experienced clinicians nor did providing history with the images help much.

There are two applications. 1. Examination of the throat is subjective. If a child complains of sore throat, we may want to do a rapid strep. It may just not look red to you. 2. If your attending tells you that you missed an obvious red throat, they may be full of crap. I’ll leave it to you to diplomatically share that with them.

Interexaminer reliability of pharyngeal injection and palatine tonsillar hypertrophy in a pediatric emergency department. Am J Emerg Med. 2019 Jan 21. pii: S0735-6757(19)30016-6. doi: 10.1016/j.ajem.2019.01.016. [Epub ahead of print]

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What are your thoughts?