Pharyngitis - edc.mui.ac.ir · PHARYNGITIS • What is it? – Inflammation of the Pharynx...

In The Name Of God

Pharyngitis

Dr.M.Karimi

PHARYNGITISPHARYNGITIS

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

Pharynx secondary to an Pharynx secondary to an infectious agentinfectious agent

– Most common infectious Most common infectious agents are Group A agents are Group A Streptococcus and various Streptococcus and various viral agentsviral 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 i l lness fever;acute respiratory i l lness • Parainf luenza virus – common cold; Parainf luenza 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 5-10% accounts for 15-30% of cases in children and 5-10%

in adults.in adults.

• Mycoplasma pneumoniaeMycoplasma pneumoniae• Arcanobacterium haemolyticumArcanobacterium haemolyticum• Neisseria gonorrheaNeisseria gonorrhea• Chlamydia pneumoniaeChlamydia pneumoniae

PHARYNGITISPHARYNGITIS

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

VIRAL → VIRAL → Most likely concurrent URI symptoms of Most likely concurrent URI 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 onsetacute in onset

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 Streptococcal Epidemiology of Streptococcal PharyngitisPharyngitis

• 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 infectionCommunicability highest during acute infection• Patient no longer contagious after 24 hours of Patient no longer contagious after 24 hours of

antibioticsantibiotics• If hospitalized, droplet precautions needed until If hospitalized, droplet precautions needed until

no longer contagiousno longer contagious

PHARYNGITISPHARYNGITIS• Physical ExamPhysical Exam

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

and tonsilsand tonsils– tender anterior cervical adenopathytender anterior cervical adenopathy– palatal/uvularpalatal/uvular petechiaepetechiae– scarlatiniform rash covering torso and upper scarlatiniform rash covering torso and upper

armsarmsSpread via Spread via respiratory particle dropletsrespiratory particle droplets – NO – NO

school attendance until school attendance until 24 hours after24 hours after initiation of initiation of appropriate antibiotic therapyappropriate antibiotic therapy

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

Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis

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

Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis

• Skin rash:Skin rash:

– S. pyogenesS. pyogenes– HIVHIV– EBVEBV

Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis

• Conjunctivitis:Conjunctivitis:– AdenovirusAdenovirus

Suppurative Complications of Suppurative Complications of Group A Streptococcal PharyngitisGroup A Streptococcal Pharyngitis

• Otitis mediaOtitis media• SinusitisSinusitis• Peritonsillar and retropharyngeal Peritonsillar and retropharyngeal

abscessesabscesses• Suppurative cervical adenitisSuppurative cervical adenitis

Streptococcal Cervical AdenitisStreptococcal Cervical Adenitis

Nonsuppurative Complications of Nonsuppurative Complications of Group A StreptococcusGroup A Streptococcus

• Acute rheumatic feverAcute rheumatic fever– follows only streptococcal pharyngitis (not follows only streptococcal pharyngitis (not

group A strep skin infections)group A strep skin infections)• Acute glomerulonephritisAcute glomerulonephritis

– May follow pharyngitis or skin infection May follow pharyngitis or skin infection (pyoderma)(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 &Tenderadenopathy &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 gargling)Antibiotic ,Acetaminophen ,Warm salt 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 year5 times each year during two previous year

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

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

• 2-Reduce symptoms2-Reduce symptoms• 3-Prevent local suppurative complications3-Prevent local suppurative complications

BUTBUTDoes not prevent the development of the Does not prevent the development of the

post streptococcal sequel of acute post streptococcal sequel of acute glomerulonephritisglomerulonephritis

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

• 1-Clinical diagnosis of scarlet fever1-Clinical diagnosis of scarlet fever• 2-Household contact with documented 2-Household contact with documented

strep. Pharyngitisstrep. 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 splenic commonly associated with abdominal trauma and splenic rupturerupture

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 Scarlet Strawberry Tongue in Scarlet FeverFever

Scarlet FeverScarlet Fever

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

• Generalized fine, sandpapery scarlet erythema Generalized fine, sandpapery scarlet erythema with accentuation in skin folds (Pastia’s lines)with accentuation in skin folds (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, weaknessmuscular spasms, incoordination, weakness• 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 and Goal: decrease inflammation, fever and

toxicity and control heart failuretoxicity and control heart failure– Treatment may include anti-inflammatory Treatment may include anti-inflammatory

agents and steroids depending on severity agents and steroids depending on severity of illnessof 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 dysfunctionkidney that results in renal dysfunction

• Nephritogenic strain of Nephritogenic strain of S. pyogenesS. pyogenes

Poststreptococcal Poststreptococcal GlomerulonephritisGlomerulonephritis• Clinical PresentationClinical Presentation

– Edema, hypertension, and smoky or rusty Edema, hypertension, and smoky or rusty colored urinecolored 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 B)streptococcal infection (ASO or anti-DNAse 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 nontoxigenicstrains may be toxigenic or nontoxigenic

• exotoxin required for diseaseexotoxin required for disease

Corynebacterium DiphtheriaeCorynebacterium Diphtheriae

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 tonsilsAlso have pharyngeal tonsils (adenoids) and lingual tonsils

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

cervical adenopathycervical 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 membranes Inflammation of the mucous membranes covering the larynx with accompanied covering the larynx with accompanied edema of the vocal cordsedema of the vocal cords HistoryHistory → → sore throatsore throat, , dysphoniadysphonia

(hoarseness) or(hoarseness) or loss of voice loss of voice, cough, possible , cough, possible low-grade fever 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 fumes, [>3wks duration]– Inhalation of irritant fumes, vocal misuse, GERD, smokersvocal 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 pathogens90% of aspirated cultures grow bacterial pathogens 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 peritonsil lar abscesses