Pharyngitis

1. In The Name Of God
Pharyngitis
Dr.M.Karimi

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. PHARYNGITISPHARYNGITIS
•Physical ExamPhysical Exam
–BacterialBacterial
GASGAS – 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
armsarms
Spread 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)

10. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
•Pharyngeal exudates:Pharyngeal exudates:
–S. pyogenesS. pyogenes
–C. diphtheriaeC. diphtheriae
–EBVEBV

11. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
•Skin rash:Skin rash:
–S. pyogenesS. pyogenes
–HIVHIV
–EBVEBV

12. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
•Conjunctivitis:Conjunctivitis:
–AdenovirusAdenovirus

13. 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

14. Streptococcal Cervical AdenitisStreptococcal Cervical Adenitis

15. 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

16. PharyngitisPharyngitis

17. Infectious MononucleosisInfectious Mononucleosis

18. HerpanginaHerpangina

19. PHARYNGITISPHARYNGITIS

20. PHARYNGITISPHARYNGITIS

21. pharyngitispharyngitis

22. Scarlatiniform RashScarlatiniform Rash

23. 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

24. Clinical manifestationClinical manifestation
(Viral)(Viral)
•Gradual onsetGradual onset
•RhinorrheaRhinorrhea
•CoughCough
•DiarrheaDiarrhea
•FeverFever

26. Clinical manifestationClinical manifestation
•Vesiculation & Ulceration HSVVesiculation & Ulceration HSV
Gingivostomatitis Gingivostomatitis CoxsackievirusCoxsackievirus
•Cnonjunctivitis AdenovirusCnonjunctivitis Adenovirus
•Gray-white fibrinous pseudomembraneGray-white fibrinous pseudomembrane
With 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

27. 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

28. Differential diagnosisDifferential diagnosis
•Retropharyngeal abscessesRetropharyngeal abscesses
•Peritonsilar abscessesPeritonsilar abscesses
•Ludwig anginaLudwig angina
•EpiglotitisEpiglotitis
•ThrushThrush
•Autoimmune ulcerationAutoimmune ulceration
•KawasakiKawasaki

29. 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

30. Recurrent pharyngitisRecurrent pharyngitis
•Etiology: Nonpenicillin treatment ,Different Etiology: Nonpenicillin treatment ,Different
strain ,Another cause pharyngitisstrain ,Another cause pharyngitis
•Treatment:Treatment:
TonsilectomyTonsilectomy
ifif
Culture 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

31. 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
BUTBUT
Does not prevent the development of the Does not prevent the development of the
post streptococcal sequel of acute post streptococcal sequel of acute
glomerulonephritisglomerulonephritis

32. 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

33. 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

34. PHARYNGITISPHARYNGITIS
•TreatmentTreatment
VIRAL –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 administration
EBV – 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

35. 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 1
stst
generation generation
cephalosporins for PCN allergycephalosporins for PCN allergy

36. Group A StreptococcusGroup A Streptococcus

37. Group A Beta Hemolytic Group A Beta Hemolytic
StreptococcusStreptococcus

39. Strawberry Tongue in Scarlet Strawberry Tongue in Scarlet
FeverFever

40. 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

41. Rash of Scarlet FeverRash of Scarlet Fever

42. 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

43. Erythema Marginatum

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. Corynebacterium DiphtheriaeCorynebacterium Diphtheriae

52. 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

53. TONSILLITISTONSILLITIS

54. TONSILLITISTONSILLITIS

55. 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 PE
must use fiberoptic laryngoscopy (not usually must use fiberoptic laryngoscopy (not usually
necessary )necessary )

56. 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 therapy
Prevailing data Prevailing data does NOT supportdoes NOT support the use of the use of
corticosteroids for symptomatic reliefcorticosteroids for symptomatic relief

57. 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 worsens
DysphagiaDysphagia
High 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

58. 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
11
stst
generation cephalosporin generation cephalosporin
Surgical tonsillectomy if:Surgical tonsillectomy if:
1)1)No improvement in 48 hoursNo improvement in 48 hours
2)2)H/O recurrent abscesses – 3 or more (controversial)H/O recurrent abscesses – 3 or more (controversial)

59. Bilateral peritonsillar
abscesses