Pharyngitis


Article Author:
Robert Wolford


Article Editor:
Timothy Schaefer


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 9:55:54 PM

Introduction

Pharyngitis is the inflammation of the mucous membranes of the oropharynx. In most cases, the cause is an infection, either bacterial or viral. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins.[1][2]

Etiology

About 50% to 80% of pharyngitis, or sore throat, symptoms are viral in origin and include a variety of viral pathogens. These pathogens are predominantly rhinovirus, influenza, adenovirus, coronavirus, and parainfluenza. Less common viral pathogens include herpes, Epstein-Barr virus, human immunodeficiency virus (HIV), and coxsackievirus. More severe cases tend to be bacterial and may develop after an initial viral infection.

The most common bacterial infection is Group A beta-hemolytic streptococci, which causes 5% to 36% of cases of acute pharyngitis. Other bacterial etiologies include Group B & C streptococci, Chlamydia pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Candida, Neisseria meningitidis, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Fusobacterium necrophorum, and Corynebacterium diphtheriae. Environmental allergies and chemical exposures may also cause acute pharyngitis.

Pharyngitis symptoms may also be part of the symptom complexes of other serious illnesses, including peritonsillar abscess, retropharyngeal abscess, epiglottitis, and Kawasaki disease.[3][4]

Epidemiology

In 2010, there were 1.814 million emergency department visits for pharyngitis, of which 692,000 were for patients under the age of 15. Most cases of pharyngitis occur in children under the age of 5. Adults can also develop the disorder but at a lower rate. Globally, pharyngitis rates are very high chiefly in countries where antibiotics are overprescribed.[5][6]

Pathophysiology

Bacteria and viruses can cause direct invasion of the pharyngeal mucosa. Certain viruses like rhinovirus can cause irritation secondary to nasal secretions. In almost all cases, there is a local invasion of the pharyngeal mucosa which also results in excess secretion and edema.

History and Physical

The history and physical examination should look for findings consistent with uncomplicated pharyngitis and exclude other potentially serious and life-threatening illnesses. Clinical manifestations frequently include fever, tonsillar exudates, painful cervical adenopathy, pharyngeal erythema, and ear pain. Uncomplicated infectious pharyngitis, both viral and bacterial, typically is self-limited to 5 to 7 days, is not progressive, is bilateral, does not have trismus, and does not have evidence of airway obstruction (stridor). 

If viral in etiology, associated symptoms often include coughing, rhinorrhea, conjunctivitis, headache, and a rash. Group A beta-hemolytic streptococcal pharyngitis typically has an acute onset, lacks signs of viral upper respiratory infection such as a cough or rhinorrhea, and is associated with fever, tonsillar exudates, and cervical adenopathy. Epstein-Barr virus, otherwise known as infectious mononucleosis,  can cause headaches, fever, tonsillar hypertrophy, lymphocytosis, atypical lymphocytes. Assess for hepatomegaly or splenomegaly. If a morbilliform rash develops after amoxicillin for presumed Group A beta-hemolytic streptococci, one should suspect Epstein-Barr virus.

A retropharyngeal abscess is characterized by neck stiffness and pain with neck extension. For epiglottitis, look for stridor as a symptom. F. necrophorum is the bacterium that causes Lemierre's syndrome, or internal jugular vein thrombophlebitis. If there has been orogenital contact by the patient, consider N. gonorrhoeae. Acute retroviral syndrome due to HIV may be associated with fever and non-exudative pharyngitis.

Evaluation

A variety of clinical decision rules have been developed to improve the diagnosis of Group A beta-hemolytic streptococcal pharyngitis and to guide testing and treatment. The Centor Score is one of the most commonly used, particularly for adult patients.[7][8]

Centor Criteria (1 point for each) for Group A Beta-hemolytic Streptococci:

  1. Tonsillar exudate
  2. Tender anterior cervical left mentoanterior
  3. History of fever
  4. Absence of a cough

More likely in 5 to 15 years of age and not valid under 3 years old.

Point Totals and Recommended Actions: 0-1: No testing or antibiotics.2-3: Rapid antigen test. 4: No testing, empiric antibiotics.

White blood cell counts have minimal value in the differentiation of viral versus bacterial etiologies of pharyngitis. A lymphocytosis (greater than 50%) or increased atypical lymphocytes (greater than 10%) may suggest infectious mononucleosis.

Rapid antigen detection tests (RADT) are very specific for Group A beta-hemolytic streptococci, but their sensitivity varies widely, from about 70% to 90%. If the test is positive, treatment should be initiated. If it is negative, particularly in children, a throat culture should be obtained and should guide treatment.

Throat cultures have been the ideal standard for diagnosis, but their sensitivity is variable and is influenced by many factors. These factors include the bacterial burden, site of collection (the tonsillar surface is best), culture medium, and culture atmosphere.

A heterophile antibody, or Monospot, test is 70% to 92% sensitive and 96% to 100% specific. This test for infectious mononucleosis is commonly available, but the ideal standard is to use Epstein-Barr virus serology. The test's sensitivity is lessened by testing early in the course of the illness (1 to 2 weeks) and by the age of the patient (less than 12 years).

For gonococcal origin, use a culture. Thayer-Martin agar is most commonly used. For Candida, test with a potassium hydroxide preparation or Sabouraud agar. 

A chest X-ray is not needed for routine cases. If airway compromise is suspected, a lateral neck X-ray should be obtained.

A CT scan may help identify a peritonsillar abscess.

Treatment / Management

Antibiotics for pharyngitis are usually used for patients with Group A beta-hemolytic streptococcal pharyngitis. Antibiotics may shorten the duration of symptoms by 16 to 24 hours and prevent rheumatic fever. Older data suggest 1 in 400 untreated cases of strep pharyngitis. Antibiotics should only be used for Group A beta-hemolytic streptococci-positive patients, particularly if they are children, based on a positive culture or a rapid antigen detection test.[1][9][10]

Treatment options for Group A beta-hemolytic streptococcal pharyngitis include oral treatment with penicillin V or oral amoxicillin. Cephalosporins, macrolides, and clindamycin may also be used. Intramuscular penicillin is also a treatment option. Resistance may develop during treatment with azithromycin and clarithromycin, and it is not considered a first-line antibiotic for this indication. The disease is no longer infectious after 24 hours of antibiotics.

Single dose corticosteroids like dexamethasone may be given to reduce the severity of symptoms, although the evidence for this approach is limited. Symptomatic treatment with gargles and acetaminophen or non-steroidal anti-inflammatory drugs should be recommended. Use caution in the setting of severe dehydration. For patients with infectious mononucleosis, recommend no contact sports for 6 to 8 weeks due to the risk of splenic rupture.

Differential Diagnosis

  • Airway obstruction from any cause
  • Allergic rhinitis
  • Cancer of the head and neck
  • Gastroesophageal reflux disease
  • Peritonsillar abscess
  • Diphtheria
  • Epiglottitis
  • Herpes simplex virus
  • Mononucleosis

Prognosis

In developing countries, over 20 million individuals are affected by group B streptococci and develop acute rheumatic fever. This disorder is the leading cause of death in young people. Other complications as a result of streptococcal pharyngitis include peritonsillar abscesses, acute glomerulonephritis, and toxic shock syndrome. Mortality from pharyngitis is rare but does occur if the airway is compromised.

Most cases of pharyngitis resolve within 7 to 10 days. Treatment failures are usually due to antibiotic resistance, poor compliance, and untreated close contacts.

Complications

Complications of bacterial pharyngitis include:

  • Epiglottitis
  • Otitis media
  • Mastoiditis
  • Sinusitis
  • Acute rheumatic fever
  • Post-streptococcal glomerulonephritis
  • Toxic shock syndrome

Postoperative and Rehabilitation Care

Household members of patients with group A streptococci should be treated with a full 10-day course of antibiotics without any prior testing only if they present with symptoms. Asymptomatic individuals require no treatment.

Deterrence and Patient Education

Patients must complete a full course of antibiotics, follow up with a primary care provider, wash their hands, rest, and remain hydrated.

Pearls and Other Issues

Antibiotics are typically overused in the treatment of acute pharyngitis. As most cases are due to a viral etiology, and antibiotics will not alter the patient's course.

Enhancing Healthcare Team Outcomes

The management of pharyngitis is multidisciplinary. Once the patient is discharged, follow up is required by the nurse, pharmacist or healthcare provider. Follow-up cultures are not necessary in patients without symptoms. All patients with pharyngitis should be educated on the use of antibiotics. Patients should be told not to use antibiotics empirically because the cause is most often viral. Hand washing and maintenance of good personal hygiene is important to prevent spread to others in the home. To prevent recurrence, immunization should be recommended against the flu virus and diphtheria. All patients must be told about the importance of compliance with antibiotic treatment. Further, patients should be told to use salt water gargles and adhere to a liquid diet until the symptoms subside. If the patient has a fever or pain, acetaminophen is recommended. Finally, parents should be told not to give young children aspirin for fever.[11][12] (Level V)

Outcomes

The majority of pharyngitis cases recover spontaneously within 7-10 days. Failures may occur if the cause is bacterial and antibiotics were either never prescribed, or there was the presence of antibiotic resistance, or there was a lack of patient compliance with treatment. Most cases of streptococcal pharyngitis improve within 24-48 hours of treatment. However, the flu-like symptoms may persist for 5-10 days. Mortality in the US is very rare but can occur from upper airway obstruction. Complications from pharyngitis are reported in less than 1% of patients and may include otitis media, pneumonia, nephritis, and meningitis. [13][14](Level V)


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Pharyngitis - Questions

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Which of the following is NOT part of the Centor criteria?



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A 4-year-old is brought in by his mother for a 1-day history of a sore throat. He has had associate periumbilical abdominal pain, an episode of emesis, and no signs of shortness of breath or a cough. On exam, he has a temperature of 102.5 degrees F, tonsillar erythema with exudate, and anterior cervical lymphadenopathy. What is his Centor criteria score?



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An 11 year old male presents with a 2 day history of sore throat, fever, a cough, and an erythematous rash. Which of the following would be most appropriate?



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A 17-year-old male presents with fever, sore throat, and an erythematous rash. A social history reveals he commonly has sexual relations with other males. His rapid antigen test for Group A beta-hemolytic streptococcus is negative. What is the next best step in the management of this patient?



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Pharyngitis - References

References

Frost HM,McLean HQ,Chow BDW, Variability in Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty. The Journal of pediatrics. 2018 Sep 5     [PubMed]
Alzahrani MS,Maneno MK,Daftary MN,Wingate L,Ettienne EB, Factors Associated with Prescribing Broad-Spectrum Antibiotics for Children with Upper Respiratory Tract Infections in Ambulatory Care Settings. Clinical medicine insights. Pediatrics. 2018     [PubMed]
Gottlieb M,Long B,Koyfman A, Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. The Journal of emergency medicine. 2018 May     [PubMed]
Brennan-Krohn T,Ozonoff A,Sandora TJ, Adherence to guidelines for testing and treatment of children with pharyngitis: a retrospective study. BMC pediatrics. 2018 Feb 9     [PubMed]
Faden H,Callanan V,Pizzuto M,Nagy M,Wilby M,Lamson D,Wrotniak B,Juretschko S,St George K, The ubiquity of asymptomatic respiratory viral infections in the tonsils and adenoids of children and their impact on airway obstruction. International journal of pediatric otorhinolaryngology. 2016 Nov     [PubMed]
Follmann D,Huang CY,Gabriel E, Who really gets strep sore throat? Confounding and effect modification of a time-varying exposure on recurrent events. Statistics in medicine. 2016 Oct 30     [PubMed]
Akhtar M,Van Heukelom PG,Ahmed A,Tranter RD,White E,Shekem N,Walz D,Fairfield C,Vakkalanka JP,Mohr NM, Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2018 Feb 22     [PubMed]
Yamamoto S,Gu Y,Fujitomo Y,Kanai N,Yamahata Y,Saito H,Hashimoto T,Ohmagari N, Development and efficacy of a clinician-targeted refresher course for treating nonpneumonia respiratory tract infections. Journal of general and family medicine. 2018 Jul     [PubMed]
Bird C,Winzor G,Lemon K,Moffat A,Newton T,Gray J, A Pragmatic Study to Evaluate the Use of a Rapid Diagnostic Test to Detect Group A Streptococcal Pharyngitis in Children With the Aim of Reducing Antibiotic Use in a UK Emergency Department. Pediatric emergency care. 2018 Jul 24     [PubMed]
Piltcher OB,Kosugi EM,Sakano E,Mion O,Testa JRG,Romano FR,Santos MCJ,Di Francesco RC,Mitre EI,Bezerra TFP,Roithmann R,Padua FG,Valera FCP,Lubianca Neto JF,Sá LCB,Pignatari SSN,Avelino MAG,Caixeta JAS,Anselmo-Lima WT,Tamashiro E, How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel. Brazilian journal of otorhinolaryngology. 2018 May - Jun     [PubMed]
Yoon YK,Park CS,Kim JW,Hwang K,Lee SY,Kim TH,Park DY,Kim HJ,Kim DY,Lee HJ,Shin HY,You YK,Park DA,Kim SW, Guidelines for the Antibiotic Use in Adults with Acute Upper Respiratory Tract Infections. Infection     [PubMed]
Norhayati MN,Ho JJ,Azman MY, Influenza vaccines for preventing acute otitis media in infants and children. The Cochrane database of systematic reviews. 2017 Oct 17     [PubMed]
Norton LE,Lee BR,Harte L,Mann K,Newland JG,Grimes RA,Myers AL, Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative. Pediatrics. 2018 Jul     [PubMed]
Sadeghirad B,Siemieniuk RAC,Brignardello-Petersen R,Papola D,Lytvyn L,Vandvik PO,Merglen A,Guyatt GH,Agoritsas T, Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ (Clinical research ed.). 2017 Sep 20     [PubMed]

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