Pharyngitis

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Clinical-manifestations 5 Laboratory 6 Radiology 7 Complications 8 Differential-diagnosis 9 Management 10 More General Terms 11 Additional Terms 12 References

More Specific Terms

• Fusospirochetal oropharyngitis
• laryngopharyngitis
• nasopharyngitis; rhinopharyngitis
• streptococcal pharyngitis (strep throat)
• tonsillitis

Introduction

• Inflammation of the pharynx.

Etiology

• infectious

• bacteria

• Streptococcus pyogenes (17-30%)
• Neisseria gonorrhoeae
• Corynebacterium diphtheriae
• Mycoplasma pneumonia (5%)
• Arcanobacterium haemolyticus ( Corynebacterium haemolyticus)
• Fusobacterium necrophorum

• viruses

• adenovirus
• infectious mononucleosis (5%)

• Epstein-Barr virus
• cytomegalovirus

• fungal - Candida

• environmental

• tobacco smoke
• smog
• allergens - dust

• drainage

• post-nasal drip
• gastroesophageal reflux ( GERD)

• inhaled medications

• beta-adrenergic agonists
• cromolyn
• ipratropium ( Atrovent)
• glucocorticoids

• pharyngeal ulcers

• aphthous stomatitis
• herpangina
• fusospirochetal infection
• Candidiasis
• Herpes zoster
• chicken pox
• primary or secondary syphilis

• other rare causes

• thyroid disease

• hyperthyroidism
• hypothyroidism
• thyroiditis

• foreign body
• leukemia
• diptheria
• gonorrhea

Clinical-manifestations

• fever*
• pain on swallowing
• pain on extension of neck
• pharyngeal erythema
• tonsillar enlargement & exudate* suggestive, but NOT specific for streptococcal pharyngitis
• enlarged & tender anterior cervical nodes* suggests bacterial infection ( group A Streptococcus)
• enlarged & tender posterior cervical nodes suggests viral infection
• cough & coryza suggests viral infection

• group A Streptococcus without cough*

• pharyngitis with normal throat examination that becomes worse on swallowing suggests thyroiditis
• pseudomembrane suggests diphtheria
• ulcerations may be present
• drooling suggests epiglottitis
• cobblestoning in posterior pharynx suggests chronic post-nasal drip

• * predictive of group A Streptococcus

Laboratory

• rapid screen for group A streptococcus [9]
• negative rapid Strep antigen test followed up by culture for beta-hemolytic streptococcus ( gold standard) [7]
• monospot test
• complete blood count ( CBC)

Radiology

• lateral neck films if epiglottitis suspected
• CT or MRI of the neck if retropharyngial or peritonsillar abscess

Complications

• post-streptococcal glomerulonephritis
• rheumatic fever
• Lemierre syndrome due to Fusobacterium

Differential-diagnosis

• epiglottitis
• peritonsillar abscess
• laryngitis

Management

• viral

• symptomatic
• aspirin or acetaminophen
• lozenges
• saltwater gargling
• fluids
• dexamethasone (0.6 mg/kg, max 10 mg) may be of benefit [8]

• bacterial

• Centor scoring system for Streptococcal pharyngitis used for determining therapy [11]
• penicillin for group A streptococcus

• prevents non- suppurative sequelae if started within 48 hours
• 10 days of therapy recommended
• penicillin V 500 mg PO BID (as effective as TID or QID)

• erythromycin or other macrolide in penicillin- allergic patients; macrolides do not cover Fusobacterium
• prednisone 60 mg PO once (adults) may diminish pain [10]

• Candidiasis

• nystatin swish & swallow
• ketoconazole

• diphtheria

• rare in immunized populations
• diphtheria antitoxin within 48 hours

• retropharyngeal or peritonsillar abscess

• intravenous clindamycin or nafcillin
• surgery

• follow-up

• generally not necessary
• recurrences are common

More General Terms

• throat infection; pharyngeal infection; laryngeal infection
• inflammation
• pharyngeal disease

Additional Terms

• epiglottitis
• hoarseness
• laryngitis
• postnasal drip

References

1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 796
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 100-101
3. The Sanford Guide to Antimicrobial Therapy, 29th ed., Gilbert, DN et al (editors), Antimicrobial Therapy, Inc., Hyde Park VT, 1999
4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
5. Journal Watch 21(21):167, 2001 Linder JA et al Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA 286:1181, 2001 PMID: [1]
6. Prescriber's Letter 9(5):25 2002
7. Journal Watch 23(14):115, 2003 Gieseker KE et al Evaluating the American Academy of Pediatrics diagnostic standard for Streptococcus pyogenes pharyngitis: backup culture versus repeat rapid antigen testing. Pediatrics 111:e666, 2003 PMID: [2]
8. Journal Watch 25(8):65, 2005 Olympia RP, Khine H, Avner JR. Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch Pediatr Adolesc Med. 2005 Mar;159(3):278-82. PMID: [3]
9. Humair JP, Revaz SA, Bovier P, Stalder H. Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings. Arch Intern Med. 2006 Mar 27;166(6):640-4. PMID: [4]
10. Hayward G et al Corticosteroids for pain relief in sore throat: Systematic review and meta-analysis. BMJ 2009 Aug 6; 339:b2976 <PubMed> PMID: [5] <Internet> [6]
    - Little P. Sore throat in primary care. BMJ 2009 Aug 6; 339:b2476 <PubMed> PMID: [7] <Internet> [8]
11. 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 Apr 7;291(13):1587-95. PMID: [9]
    - Centor RM et al Pharyngitis management: defining the controversy. J Gen Intern Med. 2007 Jan;22(1):127-30. PMID: [10]
    - Centor RM Expand the pharyngitis paradigm to adolescents and young adults Annals of Internal Medicine 2009, 151:812 <PubMed> PMID: [11] <Internet> [12]
12. National Guideline Clearinghouse
    - Acute pharyngitis. Institute for Clinical Systems Improvement ngc-guideline: [13]
    - Acute pharyngitis in children 2-18 years old. (Michigan Quality Improvement Consortium) ngc-guideline: [14]
    - Sore throat and tonsillitis Finnish Medical Society Duodecim ngc-guideline: [15]
    - Tonsillitis and pharyngitis in children. Finnish Medical Society Duodecim ngc-guideline: [16]
    - Diagnosis and Management of Pharyngitis Institute for Clinical Systems Improvement Scottish Intercollegiate Guidelines Network (SIGN) University of Michigan Health System (UMHS) ngc-guideline-synthesis: 25660

pharyngitis