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pharyngitis

Inflammation of the pharynx. Etiology: 1) infectious a) bacteria - Streptococcus pyogenes (17-30%, 10% [18]) - Neisseria gonorrhoeae [19] - Corynebacterium diphtheriae - Mycoplasma pneumonia (5%) - Arcanobacterium haemolyticus (Corynebacterium haemolyticus) - Fusobacterium necrophorum - 21%, twice as common as S pyogenes in young adults [18] - secondary syphilis [19] b) viruses - adenovirus - infectious mononucleosis (5%) - Epstein-Barr virus - generalized lymphadenopathy, splenomegaly [26] - cytomegalovirus - Herpes simplex [19] - coxsackievirus (hand-foot-&-mouth disease) [26] c) fungal - Candida - histoplasmosis - case with associated tonsillar mass [17] 2) environmental a) tobacco smoke b) smog c) allergens - dust 3) drainage a) post-nasal drip b) gastroesophageal reflux (GERD) 4) inhaled medications a) beta-adrenergic agonists b) cromolyn c) ipratropium (Atrovent) d) glucocorticoids 5) pharyngeal ulcers a) aphthous stomatitis b) herpangina c) fusospirochetal infection d) Candidiasis e) Herpes zoster f) chicken pox g) primary or secondary syphilis 6) other rare causes a) thyroid disease - hyperthyroidism - hypothyroidism - thyroiditis b) foreign body c) leukemia d) diptheria e) gonorrhea History: - recent orogenital contact suggests gonococcal pharyngitis - a history of rheumatic fever suggests group A Streptococcus Physical examination: - cardiac auscultation for murmur to assess potential rheumatic fever if etiology is group A Streptococcus Clinical manifestations: 1) fever* 2) pain on swallowing 3) pain on extension of neck 4) pharyngeal erythema 5) tonsillar enlargement & exudate* suggestive, but NOT specific for streptococcal pharyngitis 6) enlarged & tender anterior cervical nodes* suggests bacterial infection (group A Streptococcus) 7) enlarged & tender posterior cervical nodes suggests viral infection 8) cough & coryza suggests viral infection - group A Streptococcus without cough* 9) pharyngitis with normal throat examination that becomes worse on swallowing suggests thyroiditis 10) pseudomembrane suggests diphtheria 11) ulcerations may be present 12) drooling suggests epiglottitis 13) cobblestoning in posterior pharynx suggests chronic post-nasal drip 14) generally resolves with 2-7 days when due to common cold [15] 15) persistent fever & progressive difficulty swallowing suggest suppurative pharyngitis [16] 16) headache & sudden onset consistent with group A Streptococcus [26] * Centor criteria: predictive of group A Streptococcus * image [26] Laboratory: 1) rapid screen for group A streptococcus [9] - not indicated if < 3 Centor criteria [4] 2) negative rapid Strep antigen test followed up by culture for beta-hemolytic streptococcus (gold standard) [7] 3) monospot test 4) complete blood count (CBC) Radiology: 1) lateral neck films if epiglottitis suspected 2) CT or MRI of the neck if retropharyngeal or peritonsillar abscess 3) CT of the neck with contrast if Lemierre syndrome suspected Differential diagnosis: 1) epiglottitis 2) peritonsillar abscess - dysphagia, trismus (lockjaw) - asymmetric swelling of peritonsillar area 3) laryngitis - dysphonia, hoarseness 4) mononucleosis: - stiff neck - lymphadenopathy, hepatomegaly, splenomegaly 5) tonsillitis: - enlarged tonsils 6) Ludwig's angina: - edema in the sublingual area may push the tongue up & back - drooling Complications: 1) post-streptococcal glomerulonephritis 2) rheumatic fever 3) Lemierre syndrome due to Fusobacterium 3) suppurative complications uncommon (1%) [16] a) history & physical exam findings not predictive b) culture results not predictive c) antibiotics not preventive Management: 1) viral a) symptomatic b) aspirin or acetaminophen c) lozenges (Cepacol) cetylpyridinium or benzocaine/cetylpyridinium/menthol or dyclonine (Sucrets) d) saltwater gargling e) fluids f) dexamethasone (0.6 mg/kg, max 10 mg) may be of benefit [8,23,24] - complete resolution at 48 hours (35% vs 27% for placebo, NNT=12) [23] 2) bacterial a) Centor scoring system for Streptococcal pharyngitis used for determining therapy [11] - antibiotics after laboratory confirmation of group A Streptococcus [14] - only patients with confirmed Streptococcal infection should receive antibiotics [20] - only patients with >= 3 Centor criteria need testing or treatment b) penicillin for group A streptococcus (1st line) - 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) c) amoxicillin also 1st line [22] d) erythromycin or other macrolide in penicillin-allergic patients; macrolides do not cover Fusobacterium e) ampicillin sulbactam for Fusobacterium [4] f) prednisone 60 mg PO once (adults) may diminish pain [10] 3) Candidiasis a) nystatin swish & swallow b) ketoconazole 4) diphtheria a) rare in immunized populations b) diphtheria antitoxin within 48 hours 5) retropharyngeal or peritonsillar abscess a) intravenous clindamycin or nafcillin b) surgery 6) unproven therapies a) xylitol chewing gum of no value [25] b) probiotic capsules (Lactobacillus, Bifidobacteria) of no value [25] 7) follow-up a) indicated if symptoms do not improve within 72 hours [26] b) recurrences are common

Related

Centor criteria/scoring system for Streptococcal pharyngitis epiglottitis hoarseness laryngitis upper airway cough syndrome; postnasal drip (UACS)

Specific

adenoiditis Fusospirochetal oropharyngitis laryngopharyngitis nasopharyngitis; rhinopharyngitis pharyngoconjunctional fever (PCF) streptococcal pharyngitis (strep throat) tonsillitis

General

throat infection; pharyngeal infection; laryngeal infection inflammation pharyngeal disease

References

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  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 100-101
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  10. The NNT: Corticosteroids for Acute Pharyngitis. http://www.thennt.com/nnt/steroids-for-pharyngitis/ - Hayward G et al Corticosteroids for pain relief in sore throat: Systematic review and meta-analysis. BMJ 2009 Aug 6; 339:b2976 PMID: 19661138 http://dx.doi.org/10.1136/bmj.b2976 - Little P. Sore throat in primary care. BMJ 2009 Aug 6; 339:b2476 PMID: 19661137 http://dx.doi.org/10.1136/bmj.b2476 - Hayward G, Thompson MJ, Perera R, Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008268 PMID: 23076943
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  14. Hersh AL et al Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics. Pediatrics. Nov 8, 2013 PMID: 24249823 http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260.full.pdf+html
  15. Thompson M et al Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027 PMID: 24335668 http://www.bmj.com/content/347/bmj.f7027
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  17. Durand ML et al Case 32-2014 - A 78-Year-Old Woman with Chronic Sore Throat and a Tonsillar Mass. N Engl J Med 2014; 371:1535-1543. October 16, 2014. PMID: 25317874 http://www.nejm.org/doi/full/10.1056/NEJMcpc1406191
  18. Centor RM et al The Clinical Presentation of Fusobacterium-Positive and Streptococcal-Positive Pharyngitis in a University Health Clinic: A Cross-sectional Study. Ann Intern Med. 2015;162(4):241-247 PMID: 25686164 http://annals.org/article.aspx?articleid=2118593 - Linder JA Sore Throat: Avoid Overcomplicating the Uncomplicated Ann Intern Med. 2015;162(4):311-312 PMID: 25686170 http://annals.org/article.aspx?articleid=2118605
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  22. Hersh AL et al. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016 Oct 24 PMID: 27775770
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  24. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R et al Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017;358:j3887 PMID: 28931508 http://www.bmj.com/content/358/bmj.j3887
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  26. Sinert RH Fast Five Quiz: Pharyngitis (Sore Throat). Medscape. December 14, 2022 https://reference.medscape.com/viewarticle/984986 - Acerra JR, Taylor P, III Pharyngitis (image) Medscape. April 6, 2022 https://emedicine.medscape.com/article/764304-overview
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