In The Name Of God

Pharyngitis

Dr.M.Karimi

PHARYNGITISPHARYNGITIS

• What is itWhat is it??– Inflammation of the Inflammation of the

Pharynx secondary to Pharynx secondary to an infectious agentan infectious agent

– Most common infectious Most common infectious agents are Group A agents are Group A Streptococcus and Streptococcus and various viral agentsvarious viral agents

– Often co-exists with Often co-exists with tonsillitis tonsillitis

EtiologyEtiology

• Strep.AStrep.A• MycoplasmaMycoplasma• Strep.GStrep.G• Strep.CStrep.C• Corynebacterium Corynebacterium

diphteriaediphteriae• ToxoplasmosisToxoplasmosis• GonorrheaGonorrhea• TularemiaTularemia

• RhinovirusRhinovirus• CoronavirusCoronavirus• AdenovirusAdenovirus• CMVCMV• EBVEBV• HSVHSV• EnterovirusEnterovirus• HIVHIV

Acute PharyngitisAcute Pharyngitis

• EtiologyEtiology– Viral >90% Viral >90%

•Rhinovirus – common coldRhinovirus – common cold

•Coronavirus – common coldCoronavirus – common cold

•Adenovirus – pharyngoconjunctival Adenovirus – pharyngoconjunctival fever;acute respiratory illness fever;acute respiratory illness

•Parainfluenza virus – common cold; Parainfluenza virus – common cold; croupcroup

•Coxsackievirus - herpanginaCoxsackievirus - herpangina

•EBV – infectious mononucleosisEBV – infectious mononucleosis

•HIVHIV

Acute PharyngitisAcute Pharyngitis

• EtiologyEtiology– BacterialBacterial

•Group A beta-hemolytic streptococci (Group A beta-hemolytic streptococci (S. S. pyogenespyogenes)*)*

– most common bacterial cause of pharyngitismost common bacterial cause of pharyngitis– accounts for 15-30% of cases in children and accounts for 15-30% of cases in children and

5-10% in adults.5-10% in adults.

•Mycoplasma pneumoniaeMycoplasma pneumoniae

•Arcanobacterium haemolyticumArcanobacterium haemolyticum

•Neisseria gonorrheaNeisseria gonorrhea

•Chlamydia pneumoniaeChlamydia pneumoniae

PHARYNGITISPHARYNGITIS

• HISTORY HISTORY – Classic symptoms → Classic symptoms → Fever, throat pain, Fever, throat pain,

dysphagiadysphagia

VIRAL → VIRAL → Most likely concurrent URI Most likely concurrent URI symptoms of symptoms of rhinorrhearhinorrhea, cough, hoarseness, , cough, hoarseness, conjunctivitisconjunctivitis & & ulcerative lesionsulcerative lesions

STREPSTREP → Look for associated → Look for associated headacheheadache, , and/or and/or abdominal painabdominal pain

Fever and throat pain are usually Fever and throat pain are usually acute in acute in onsetonset

PHARYNGITISPHARYNGITIS

• Physical ExamPhysical Exam– VIRALVIRAL

EBVEBV – – White exudateWhite exudate covering erythematous covering erythematous pharynx and tonsils, pharynx and tonsils, cervical adenopathycervical adenopathy, ,

Subacute/chronic symptoms (fatigue/myalgias)Subacute/chronic symptoms (fatigue/myalgias) transmitted via infected salivatransmitted via infected saliva

Adenovirus/CoxsackieAdenovirus/Coxsackie – vesicles/ulcerative lesions – vesicles/ulcerative lesions present on pharynx or posterior soft palate present on pharynx or posterior soft palate

Also look for conjunctivitisAlso look for conjunctivitis

Epidemiology of Epidemiology of Streptococcal PharyngitisStreptococcal Pharyngitis

• Spread by contact with respiratory secretionsSpread by contact with respiratory secretions

• Peaks in winter and springPeaks in winter and spring

• School age child (5-15 y)School age child (5-15 y)

• Communicability highest during acute Communicability highest during acute infectioninfection

• Patient no longer contagious after 24 hours of Patient no longer contagious after 24 hours of antibioticsantibiotics

• If hospitalized, droplet precautions needed If hospitalized, droplet precautions needed until no longer contagiousuntil no longer contagious

PHARYNGITISPHARYNGITIS• Physical ExamPhysical Exam

– BacterialBacterialGASGAS – look for whitish exudate covering pharynx and – look for whitish exudate covering pharynx and

tonsilstonsils– tender anterior cervical adenopathytender anterior cervical adenopathy– palatal/uvularpalatal/uvular petechiaepetechiae– scarlatiniform rash covering torso and upper armsscarlatiniform rash covering torso and upper arms

Spread via Spread via respiratory particle dropletsrespiratory particle droplets – NO school – NO school attendance until attendance until 24 hours after24 hours after initiation of appropriate initiation of appropriate antibiotic therapyantibiotic therapy

– Absence of viral symptoms (rhinorrhea, cough, Absence of viral symptoms (rhinorrhea, cough, hoarseness)hoarseness)

Differential diagnosis of Differential diagnosis of pharyngitispharyngitis

• Pharyngeal exudates:Pharyngeal exudates:– S. pyogenesS. pyogenes– C. diphtheriaeC. diphtheriae– EBVEBV

Differential diagnosis of Differential diagnosis of pharyngitispharyngitis

• Skin rash:Skin rash:

– S. pyogenesS. pyogenes– HIVHIV– EBVEBV

Differential diagnosis of Differential diagnosis of pharyngitispharyngitis

• Conjunctivitis:Conjunctivitis:– AdenovirusAdenovirus

Suppurative Complications of Suppurative Complications of Group A Streptococcal Group A Streptococcal PharyngitisPharyngitis• Otitis mediaOtitis media

• SinusitisSinusitis

• Peritonsillar and retropharyngeal Peritonsillar and retropharyngeal abscessesabscesses

• Suppurative cervical adenitisSuppurative cervical adenitis

Streptococcal Cervical Streptococcal Cervical AdenitisAdenitis

Nonsuppurative Complications Nonsuppurative Complications of Group A Streptococcusof Group A Streptococcus

• Acute rheumatic feverAcute rheumatic fever– follows only streptococcal pharyngitis follows only streptococcal pharyngitis

(not group A strep skin infections)(not group A strep skin infections)

• Acute glomerulonephritisAcute glomerulonephritis– May follow pharyngitis or skin May follow pharyngitis or skin

infection (pyoderma)infection (pyoderma)– Nephritogenic strainsNephritogenic strains

PharyngitisPharyngitis

Infectious MononucleosisInfectious Mononucleosis

HerpanginaHerpangina

PHARYNGITISPHARYNGITIS

PHARYNGITISPHARYNGITIS

pharyngitispharyngitis

Scarlatiniform RashScarlatiniform Rash

Clinical manifestationClinical manifestation(Strep.)(Strep.)

• Rapid onsetRapid onset

• HeadacheHeadache

• GI SymptomsGI Symptoms

• Sore throatSore throat

• ErythmaErythma

• ExudatesExudates

• Palatine petechiaePalatine petechiae

• Enlarged tonsilsEnlarged tonsils

• Anterior cervical Anterior cervical adenopathy adenopathy &Tender&Tender

• Red& swollen uvulaRed& swollen uvula

Clinical manifestationClinical manifestation(Viral)(Viral)

• Gradual onsetGradual onset

• RhinorrheaRhinorrhea

• CoughCough

• DiarrheaDiarrhea

• FeverFever

Clinical manifestationClinical manifestation• Vesiculation & Ulceration HSVVesiculation & Ulceration HSV Gingivostomatitis Gingivostomatitis CoxsackievirusCoxsackievirus

• Cnonjunctivitis AdenovirusCnonjunctivitis Adenovirus

• Gray-white fibrinous pseudomembraneGray-white fibrinous pseudomembraneWith marked cervical lymphadenopathy Diphteria With marked cervical lymphadenopathy Diphteria • Macular rash Scarlet feverMacular rash Scarlet fever

• Hepatosplenomegally &RashHepatosplenomegally &Rash &Fatigue &Cervical lymphadenitis EBV&Fatigue &Cervical lymphadenitis EBV

DiagnosisDiagnosis

• Strep:Strep:

Throat culture(Gold Throat culture(Gold stndard)stndard)

Rapid Strep. Antigen kitsRapid Strep. Antigen kits

• Infectious Mono.: Infectious Mono.:

CBC(Atypical lymphocytes)CBC(Atypical lymphocytes)

Spot test (Positive slide Spot test (Positive slide agglutination)agglutination)

• Mycoplasma:Mycoplasma:

Cold agglutination testCold agglutination test

Differential diagnosisDifferential diagnosis

• Retropharyngeal abscessesRetropharyngeal abscesses

• Peritonsilar abscessesPeritonsilar abscesses

• Ludwig anginaLudwig angina

• EpiglotitisEpiglotitis

• ThrushThrush

• Autoimmune ulcerationAutoimmune ulceration

• KawasakiKawasaki

TreatmentTreatment((Antibiotic ,Acetaminophen ,Warm salt Antibiotic ,Acetaminophen ,Warm salt gargling)gargling)

• Strep:Strep: Penicillin Penicillin ,Erythromycin , Azithromycin,Erythromycin , Azithromycin

• Carrier of strep:Carrier of strep: ClindamycinClindamycin ,Amoxicillin clavulanic ,Amoxicillin clavulanic

• Retropharyngeal abscesses:Retropharyngeal abscesses: Drainage + AntibioticsDrainage + Antibiotics

• Peritonsilar abscesses:Peritonsilar abscesses: penicillin + Aspirationpenicillin + Aspiration

Recurrent pharyngitisRecurrent pharyngitis

• Etiology: Nonpenicillin treatment ,Different Etiology: Nonpenicillin treatment ,Different strain ,Another cause pharyngitisstrain ,Another cause pharyngitis

• Treatment:Treatment: TonsilectomyTonsilectomy

ififCulture positive, severe GABHS more thanCulture positive, severe GABHS more than

7 times during previous year7 times during previous year oror

5 times each year during two previous 5 times each year during two previous yearyear

Benefit of treatment of Strep. Benefit of treatment of Strep. PharyngitisPharyngitis

• 1-Prevention of ARF if treatment 1-Prevention of ARF if treatment started within 9 days of illnessstarted within 9 days of illness

• 2-Reduce symptoms2-Reduce symptoms

• 3-Prevent local suppurative 3-Prevent local suppurative complicationscomplications

BUTBUT

Does not prevent the development of Does not prevent the development of the post streptococcal sequel of acute the post streptococcal sequel of acute

glomerulonephritisglomerulonephritis

Antibiotic started immediately with Antibiotic started immediately with symptomatic pharyngitis and positive Rapid symptomatic pharyngitis and positive Rapid testtest(Without culture)(Without culture)

• 1-Clinical diagnosis of scarlet fever1-Clinical diagnosis of scarlet fever

• 2-Household contact with 2-Household contact with documented strep. Pharyngitisdocumented strep. Pharyngitis

• 3-Past history of ARF3-Past history of ARF

• 4-Recent history of ARF in a family 4-Recent history of ARF in a family membermember

PHARYNGITISPHARYNGITIS

• LAB AIDSLAB AIDS Rapid strep antigen → detects GAS antigenRapid strep antigen → detects GAS antigen

Tonsillar swab → 3-5 minutes to performTonsillar swab → 3-5 minutes to perform• 95% specificity, 90-93% sensitivity95% specificity, 90-93% sensitivity

GAS Throat culture → “gold standard” GAS Throat culture → “gold standard” • >95% sensitivity>95% sensitivity

Mono Spot → serologic test for EBV heterophile AbMono Spot → serologic test for EBV heterophile Ab

EBV Ab titers → detect serum levels of EBV IgM/IgGEBV Ab titers → detect serum levels of EBV IgM/IgG

PHARYNGITISPHARYNGITIS

• TreatmentTreatmentVIRAL –VIRAL – Supportive care only – Analgesics, Supportive care only – Analgesics,

Antipyretics, FluidsAntipyretics, Fluids No strong evidenceNo strong evidence supporting use of oral or supporting use of oral or

intramuscular corticosteroids for pain relief → few intramuscular corticosteroids for pain relief → few studies show transient relief within first 12–24 hrs studies show transient relief within first 12–24 hrs after administrationafter administrationEBV – infectious mononucleosisEBV – infectious mononucleosis

activity restrictions – mortality in these pts most activity restrictions – mortality in these pts most commonly associated with abdominal trauma and commonly associated with abdominal trauma and splenic rupturesplenic rupture

PHARYNGITISPHARYNGITIS

• Treatment Treatment → → Do so to prevent Do so to prevent ARF ARF (Acute Rheumatic Fever)(Acute Rheumatic Fever)

GASGAS → →Oral PCN – treatment of choiceOral PCN – treatment of choice

10 day course of therapy10 day course of therapy

IM Benzathine PCN G – 1.2 million units x 1IM Benzathine PCN G – 1.2 million units x 1

Azithromycin, Clindamycin, or 1Azithromycin, Clindamycin, or 1stst generation generation cephalosporins for PCN allergycephalosporins for PCN allergy

Group A StreptococcusGroup A Streptococcus

Group A Beta Hemolytic Group A Beta Hemolytic StreptococcusStreptococcus

Strawberry Tongue in Strawberry Tongue in Scarlet FeverScarlet Fever

Scarlet FeverScarlet Fever

• Occurs most commonly in Occurs most commonly in association with pharyngitisassociation with pharyngitis– Strawberry tongueStrawberry tongue– RashRash

•Generalized fine, sandpapery scarlet Generalized fine, sandpapery scarlet erythema with accentuation in skin folds erythema with accentuation in skin folds (Pastia’s lines)(Pastia’s lines)

•Circumoral pallorCircumoral pallor

•Palms and soles sparedPalms and soles spared

– Treatment same as strep pharyngitisTreatment same as strep pharyngitis

Rash of Scarlet FeverRash of Scarlet Fever

Acute Rheumatic FeverAcute Rheumatic Fever

• Immune mediated - ?humoralImmune mediated - ?humoral

• Diagnosis by Jones criteriaDiagnosis by Jones criteria– 5 major criteria5 major criteria

•CarditisCarditis

•Polyarthritis (migratory)Polyarthritis (migratory)

•Sydenham’s choreaSydenham’s chorea– muscular spasms, incoordination, muscular spasms, incoordination,

weaknessweakness

•Subcutaneous nodulesSubcutaneous nodules– painless, firm, near bony prominencespainless, firm, near bony prominences

•Erythema marginatumErythema marginatum

Erythema Marginatum

Acute Rheumatic FeverAcute Rheumatic Fever

• Minor manifestationsMinor manifestations– Clinical FindingsClinical Findings

•arthralgiaarthralgia

•feverfever– Laboratory FindingsLaboratory Findings

•Elevated acute phase reactantsElevated acute phase reactants– erythrocyte sedimentation rateerythrocyte sedimentation rate– C-reactive proteinC-reactive protein

•Prolonged P-R interval on EKG Prolonged P-R interval on EKG

Acute Rheumatic FeverAcute Rheumatic Fever

• Supporting evidence of antecedent group A Supporting evidence of antecedent group A streptococcal infectionstreptococcal infection– Positive throat culture or rapid Positive throat culture or rapid

streptococcal antigen teststreptococcal antigen test– Elevated or rising streptococcal antibody Elevated or rising streptococcal antibody

titer titer •antistreptolysin O (ASO), antiDNAse Bantistreptolysin O (ASO), antiDNAse B

• If evidence of prior group A streptococcal If evidence of prior group A streptococcal infection, 2 major or one major and 2 minor infection, 2 major or one major and 2 minor manifestations indicates high probability of manifestations indicates high probability of ARFARF

Acute Rheumatic FeverAcute Rheumatic Fever

• TherapyTherapy– Goal: decrease inflammation, fever Goal: decrease inflammation, fever

and toxicity and control heart failureand toxicity and control heart failure– Treatment may include anti-Treatment may include anti-

inflammatory agents and steroids inflammatory agents and steroids depending on severity of illnessdepending on severity of illness

Poststreptococcal Poststreptococcal Glomerulonephritis Glomerulonephritis

• Develops about 10 days after Develops about 10 days after pharyngitispharyngitis

• Immune mediated damage to the Immune mediated damage to the kidney that results in renal kidney that results in renal dysfunctiondysfunction

• Nephritogenic strain of Nephritogenic strain of S. S. pyogenespyogenes

Poststreptococcal Poststreptococcal GlomerulonephritisGlomerulonephritis• Clinical PresentationClinical Presentation

– Edema, hypertension, and smoky or Edema, hypertension, and smoky or rusty colored urinerusty colored urine

– Pallor, lethargy, malaise, weakness, Pallor, lethargy, malaise, weakness, anorexia, headache and dull back painanorexia, headache and dull back pain

– Fever not prominentFever not prominent

• Laboratory FindingsLaboratory Findings– Anemia, hematuria, proteinuriaAnemia, hematuria, proteinuria– Urinalysis with RBCs, WBCs and castsUrinalysis with RBCs, WBCs and casts

Poststreptococcal Poststreptococcal GlomerulonephritisGlomerulonephritis

• DiagnosisDiagnosis– Clinical history, physical findings, and Clinical history, physical findings, and

confirmatory evidence of antecedent confirmatory evidence of antecedent streptococcal infection (ASO or anti-DNAse streptococcal infection (ASO or anti-DNAse B)B)

• TherapyTherapy– Penicillin to eradicate the nephritogenic Penicillin to eradicate the nephritogenic

streptococci (erythromycin if allergic)streptococci (erythromycin if allergic)– Supportive care of complicationsSupportive care of complications

DiphtheriaDiphtheria

• Etiologic agent: Corynebacterium Etiologic agent: Corynebacterium diphtheriadiphtheria– Extremely rare, occurs primarily in Extremely rare, occurs primarily in

unimmunized patientsunimmunized patients– Gram positive rodGram positive rod– nonspore formingnonspore forming– strains may be toxigenic or strains may be toxigenic or

nontoxigenicnontoxigenic•exotoxin required for diseaseexotoxin required for disease

Corynebacterium Corynebacterium DiphtheriaeDiphtheriae

TONSILLITISTONSILLITIS

Inflammation/Infection of the tonsilsInflammation/Infection of the tonsils Palatine tonsilsPalatine tonsils → visible during oral exam → visible during oral exam

Also have pharyngeal tonsils (adenoids) and lingual Also have pharyngeal tonsils (adenoids) and lingual tonsilstonsils

• HistoryHistory → sore throat, fever, otalgia, dysphagia → sore throat, fever, otalgia, dysphagia• Physical ExamPhysical Exam → whitish plaques, → whitish plaques,

enlarged/tender cervical adenopathyenlarged/tender cervical adenopathy• EtiologyEtiology → GAS, EBV – less commonly HSV → GAS, EBV – less commonly HSV• TreatmentTreatment → same as for pharyngitis → same as for pharyngitis

TONSILLITISTONSILLITIS

TONSILLITISTONSILLITIS

LARYNGITISLARYNGITIS

• Inflammation of the mucous Inflammation of the mucous membranes covering the larynx with membranes covering the larynx with accompanied edema of the vocal cordsaccompanied edema of the vocal cords HistoryHistory → → sore throatsore throat, , dysphoniadysphonia

(hoarseness) or(hoarseness) or loss of voice loss of voice, cough, , cough, possible low-grade fever possible low-grade fever

Physical ExamPhysical Exam → →cannot directly visualize larynx on standard PEcannot directly visualize larynx on standard PEmust use fiberoptic laryngoscopy (not usually must use fiberoptic laryngoscopy (not usually

necessary )necessary )

LARYNGITISLARYNGITIS

• ETIOLOGYETIOLOGY → → AcuteAcute [<3wks duration]– Think infectious → most [<3wks duration]– Think infectious → most

commonly viral – symptoms most commonly resolve commonly viral – symptoms most commonly resolve in 7-10 daysin 7-10 days

ChronicChronic [>3wks duration]– Inhalation of irritant [>3wks duration]– Inhalation of irritant fumes, vocal misuse, GERD, smokersfumes, vocal misuse, GERD, smokers

TreatmentTreatment → symptomatic care → complete → symptomatic care → complete voice rest, avoid exposure to insulting agent, voice rest, avoid exposure to insulting agent, anti-reflux therapyanti-reflux therapyPrevailing data Prevailing data does NOT supportdoes NOT support the use of the use of

corticosteroids for symptomatic reliefcorticosteroids for symptomatic relief

PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS

Accumulation of pus in the tonsillar fossa → thought to be an Accumulation of pus in the tonsillar fossa → thought to be an infectious complication of inappropriately treated infectious complication of inappropriately treated pharyngitis/tonsillitispharyngitis/tonsillitis

HistoryHistory → →Antecedent sore throat 1-2 wks prior - progressively worsensAntecedent sore throat 1-2 wks prior - progressively worsensDysphagiaDysphagiaHigh feverHigh fever Ipsilateral throat, ear & possibly neck painIpsilateral throat, ear & possibly neck pain

Physical ExamPhysical Exam → → Trismus – 67% of casesTrismus – 67% of cases muffled voice (“Hot Potato”)muffled voice (“Hot Potato”) Drooling &/or fetid breathDrooling &/or fetid breath look for unilateral mass in the supratonsilar area with possible uvula look for unilateral mass in the supratonsilar area with possible uvula

deviationdeviation fluctuant upon palpationfluctuant upon palpation

PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS

EtiologyEtiology → → 90% of aspirated cultures grow bacterial 90% of aspirated cultures grow bacterial pathogenspathogens

GAS – most common (approximately 30% of cases)GAS – most common (approximately 30% of cases) Staphylococcus aureusStaphylococcus aureus Anaerobes – most commonly Peptostreptococcal microbes Anaerobes – most commonly Peptostreptococcal microbes

TreatmentTreatment → → Prompt ENT consultation for Prompt ENT consultation for needle aspirationneedle aspiration (*always (*always

send cultures) or possible surgical drainage send cultures) or possible surgical drainage Systemic abx – Systemic abx – usually Clindamycin usually Clindamycin andand a a ββ-Lactam or -Lactam or

11stst generation cephalosporin generation cephalosporin Surgical tonsillectomy if:Surgical tonsillectomy if:

1)1) No improvement in 48 hoursNo improvement in 48 hours2)2) H/O recurrent abscesses – 3 or more (controversial)H/O recurrent abscesses – 3 or more (controversial)

Bilateral peritonsillar abscesses