Acute and chronic pharyngitis

By Dr Saeed Ullah MBBS, FCPS

Classified ENT, Head and Neck Surgeon

Pharynx

• Nasopahrynx • Oropharynx • Hypopharynx

Oropharynx

• Lateral wall– Ant faucial pillar– Tonsil – Post faucial pillar

• Superior wall– Soft palate

• Inferior wall– Post 1/3 tongue

• Posterior wall

Acute pharyngitis Viral (42%)

Adenovirus (most common 31%)Epstein –Barr virus(6%)Influenza virus(5%)

Bacterial –Mixed infection common(48%) beta-hemolytic streptococci (GABHS-38%) H. influenza staphylococcus aureus Corynebacterium diphtheria gonococcus anaerobes remain uncertain.

Fungal –Candida albicans

Pathophysiology

• Invasion of mucosa• Local inflammation• Irritation of mucosa by secretion• Release of local toxins, proteases• M-protein fragment of GABHS and

sarcolemma antigens of myocardium• Antigen-antibodies complex deposition in

glomeruli

Clinical features

• Sore throat, fever, chills,• Malaise, headaches, anorexia, abdominal

pains • History of exposure to known carriers• Pain on swallowing• Redness, congestion of pharynx• Enlarged congested tonsils• Cervical lymphadenitis

Viral infections

• Herpangina-coxsakie virus• Infectious mononucleosis-EBV• Cytomegalovirus• Pharyngoconjunctival fever-Adenovirus• Acute lymphonodular pharyngitis-coxsakie

virus• Measles and chickenpox

Investigations

• Throat swab for C/S• Rapid antigen testing against GABHS• Kleb loafler’s bacillus (KLB)• Leukocytosis • Monospot test for EBV

Treatment

• NSAIDS• Antibiotics • Oral penicillin V given six-hourly for ten days

goldstandard• Cephalosporins (cefixime)• Augmented Amoxicillin• Macrolids

Recurrent sore throat

• Benzathine penicillin• Clindamycins• Cefuroxime • Tonsillectomy

Complications

• Routes of spread– Hematogenous– Lymphatics– Direct spread

Complications • Peritonsillar abscess, • Septicaemia, • Toxic shock • Otitis media/mastoiditis,• Descending necrotizing mediastinitis,• Septic thrombophlebitis, internal jugular vein • Orbital myositis • Epiglottitis, • Rhinosinusitis• Pneumonia.

Acute tonsillitis

• GABHS• Hemophilus influenzae• Viral

Types of acute tonsillitis

• Acute catarrhal or superficial • Acute follicular• Acute parenchymatous• Acute membranous

Symptoms

• Sore throat• Painfull swallowing• Fever• Earache• Constitutional – Headache– Body aches– Malaise

Signs

• Coated tongue• Hyperemia of pillars• Enlarged, red, congested tonsils• Follicles • Membranes

Treatment

• Bed rest • Analgesics• Antibiotics

Tonsillectomy

• SIGN guidelines– sore throats are due to tonsillitis;– there are five or more episodes per year– there are symptoms for at least a year;– the episodes of sore throat are disabling and

prevent normal functioning

Indications

• OSA• Unilateral enlargement• 2nd attack of quinsy• As an oncological procedure• Large symptomatic tonsilolith

Peritonsillar abscess (Quinsy)

• Streptococcus pyogenous• S. Aureus • Anaerobes

Clinical features

• High grade fever with rigors• Severe throat pain (unilateral)• Odynophagia • Muffled and thick speech (hot potato voice)• Foul breath• Trismus • Earache (ipsilateral)

On examination

• Swollen tonsil, pillars, soft palate• Uvula swollen and pushed• Bulging of soft palate above the tonsil• Cervical lymphadenitis• Torticollis

Treatment

• Needle drainage and antibiotics• Incision and drainage and antibiotics• Abscess tonsillectomy• Interval tonsillectomy

Diphtheria

• Corynebecterium diphtherae • Droplet infection• Carrier state

Clinical features

• Membrane over the tonsils, palate, uvula• Tenacious, difficult to remove• Bleeding on removal• Bull’s neck• Toxic looking• Breathing difficulty

Investigations

• Culture for KLB• ECG

Complications

• Exotoxins – Myocarditis– Cardiac arrhythmias– Circulatory failure– Paralysis of soft palate– Paralysis of diaphragm – Paralysis of ocular muscles

Treatment

• Exotoxins in blood• Organisms in tonsil• Started on suspicion• Antitoxins as IV infusion – 20,000 to 40,000– 40,000 to 80,000

Parapharyngeal abscess

• Parapharyngeal space– Medial-constrictor muscles– Post-prevertebral fascia– Lateral-medial pterygoid muscle, – mandible– Communictes with other spaces• Retropharyngeal• Submandibular• Carotid space

Causes

• Pharynx • Teeth• Ear• Other spaces• External trauma

Clinical features

• Anterior compartment– Prolapse of tonsil– Trismus– Ext swelling

• Post compartment– Bulge– Cranial nerve paralysis– 9, 10, 11, 12– Swelling of parotid region

Treatment

• Systemic antibiotics• Drainage of abscess– Tracheostomy for trismus– Horizontal incision below the angle– Blunt dissection

Retropharyngeal abscess

• Acute – In children• Suppuration of lymph nodes

– In adults• Penetrating trauma

• Chronic– Tubercolous• Lymph nodes• Cervical spine

Clinical features

• Dysphagia• Torticollis• Bulge in post wall• Stridor

Investigations

• X-Ray neck lateral view• C T scan

Treatment

• I & D• Anti TB drugs

Chronic pharyngitis

• Chronic inflammatory of the pharynx characterized by hypertrophy of mucosa,seromucinous glands and sub epithelial lymphoid tissues

Chronic pharyngitis

• Chronic non specific• Chronic specific

Non specific

• Persistent infection in neighborhood• Mouth breathing• Chronic irritants• Environmental pollution

Symptoms

• Discomfort in throat• Foreign body sensation• Cough

Signs

• Congested post wall• Odema of the wall• Nodules on the wall • Lateral pharyngeal bands

Treatment

• Predisposing factors• Saline gargles • Anti inflammatory drugs• Cautry of the nodules

Questions

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